Complexity of health inequalities: a refined conceptual framework

Background With persisting or widening health inequalities in many countries and stalling policies to tackle them, there is a growing interest in a more careful study of the many elements of complexity-generating socioeconomic inequalities in health. The aim of this paper is to present a refined conceptual framework for research and policy analysis which incorporates some recent complexity thinking and how it may improve our understanding of health inequalities, their development and policies to deal with them. Methods We start with the underlying disease progression mechanisms of the original Diderichsen conceptual framework, leading from individual social position to adverse health outcomes. We then refine the model first by adding elements of complexity, including emergence, non-linear interactions and feedback loops. Second, we introduce complexity thinking into the understanding of the societal forces which shape the working of the disease progression mechanisms and the distribution of involved exposures and services. Commercial and political drivers are employed as prominent examples operating at the societal level, illustrating the complexity of their sometimes synergistic but often antagonistic effects. Empirical examples are cited throughout. Conclusion The framework helps tease out the health inequalities impact of several mechanisms of complexity and policies, resulting from the interaction of political and commercial drivers.