When is health inequality acceptable? Appraisals of inevitability, complexity and causal explanations

Background: Health inequalities are typically presented with respect to separate groupings or bases of categorization , such as income-related health inequality or life expectancy by education. We sought to characterize the cognitive consequences of presenting health inequality by bases of categorization. Methods: : Across two studies (N = 1,321), UK and US participants made a number of judgments about life expectancy differences (including how acceptable they are and whether they should be addressed) attributed to distinct bases of categorization: income, education, social class, neighbourhood, lifestyle choices and genetics. Results: : Health inequality was perceived as least acceptable when attributed to the four socioeconomic bases, and most acceptable for lifestyle choices and genetics. Six appraisal dimensions – complexity, malleability, inevitability, extent driven by biological, psychological and sociocultural causes - varied with basis of categorization and predicted views on health inequality. These dimensions could explain the majority (47-57%) of the drop in acceptability for health inequality attributed to neighbourhood, social class and education differences relative to a condition with no categorization. Conclusions: : These findings illustrate for the first time some of the causal explanations and affiliated inferences that underpin views on health inequality, and the corresponding consequences for communicating about health and health inequalities.