A Thesis Submitted for the Degree of PhD at the University of Warwick Permanent WRAP URL: http://wrap.warwick.ac.uk/82163 Copyright and reuse: This thesis is made available online and is protected by original copyright. Please scroll down to view the document itself. Please refer to the repository record for this item for information to help you to cite it. Our policy information is available from the repository home page. For more information, please contact the WRAP Team at: [email protected] warwick.ac.uk/lib-publications Health inequity in a Neoliberal Society: Lifestyle Choices or Constrained Practices? By María Luisa Marinho Montero A thesis submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Social Policy Unive rsity of Warwick, Department of Sociology November 2015 T ABLE OF C ONTENTS L IST OF FIGURES ................................ ................................ ................................ ....................... V L IST OF TABLES ................................ ................................ ................................ ......................... V A CKNOWLEDGEMENTS ................................ ................................ ................................ ............ VII D ECLARATION AND INCLU SION OF MATERIAL FRO M A PRIOR THESIS ................................ .................... IX A BSTRAC T ................................ ................................ ................................ ............................... X C HAPTER 1 - I NTRODUCTION ................................ ................................ ................................ ...... 1 1.1 Background of the research ................................ ................................ ................. 1 1.2 Aims and Research Questions ................................ ................................ .............. 4 1.3 Theoretical Framework ................................ ................................ ........................ 6 1.4 Methodology ................................ ................................ ................................ ...... 10 1.5 Contributions to knowledge ................................ ................................ ................ 13 1.6 Thesis outline ................................ ................................ ................................ ...... 15 C HAPTER 2 - L ITERATURE R EVIEW AND C ONCEPTUAL F RAMEWORK : H EALTH CHOICES ACCORDING TO LIFE CHANCES ? ................................ ................................ ................................ ............................ 19 2.1 Introduction ................................ ................................ ................................ ........ 19 2.2 Literature Review ................................ ................................ ................................ 20 2.2.1 Individual responsibility: the behavioural approach ................................ .... 20 2.2.2 Social Determinants of Health: the importance of the social context ........... 31 2.3 Health choices according to health chances: Conceptual Framework .................. 40 2.3.1 Social position and the reproduction of social inequality .............................. 40 2.3.2 Is there space for agency? Analytical Dualism ................................ .............. 44 2.4 Connecting the Literature to the Research Framework ................................ ........ 48 2.5 Conclusion ................................ ................................ ................................ ........... 54 C HAPTER 3 - M ETHODOLOGY ................................ ................................ ................................ .... 56 3.1 Introduction ................................ ................................ ................................ ......... 56 3.2 Review of previous approaches and methods used in health - related research .... 57 3.2.1 The positivist approach and quantitative analysis ................................ ........ 57 3.2.2 The interpretivist approach and qualitative analysis ................................ ..... 63 3.3 Epistemological approach and research methods: Critical Realism and Mixed Methods ................................ ................................ ................................ ........................ 68 3.3.1 Critical Realism: stratified reality and generative mechanisms ..................... 68 3.3.2 Research methods: extensive and intensive research as complements ........ 73 ii 3.4 Design, data collection and data analysis ................................ .............................. 77 3.4.1 Chile: case study of a neoliberal society ................................ ....................... 78 3.4.2 Considering the health gradient: studying middle and lower socioeconomic groups ................................ ................................ ................................ ........................ 80 3.4.3 Data collection and analysis ................................ ................................ ......... 86 3.5 Conclusion ................................ ................................ ................................ ........... 99 C HAPTER 4 - C ONTEXTUAL ANALYSIS : I NEQUALITY IN A NEOLI BERAL COUNTRY ................................ .... 101 4.1 Introd uction ................................ ................................ ................................ ...... 101 4.2 Social Policies: the neoliberal experiment and the consolidation of inequality ... 102 4.3 Contrasting realities ................................ ................................ .......................... 110 4.3.1 Chile: A high - income country ................................ ................................ .... 111 4.3.2 And a highly unequal society ................................ ................................ ..... 113 4.4 Inequalities in Health - Relevant Dimensions ................................ ....................... 116 4.4.1 Hidden informality and low value of work ................................ ................. 116 4.4.2 Unequal educa tional opportunities ................................ ........................... 120 4.4.3 Residential Segregation ................................ ................................ ............. 125 4.5 Health inequality in Chile: healthcare and health outcomes ............................... 128 4.5.1 Patterns of health - related practices ................................ ........................... 137 4.6 Conclusion ................................ ................................ ................................ ......... 142 C HAPT ER 5 - L AY KNOWLEDGE OF HEAL TH : HOW MUCH CONTROL DO PEOPLE BELIEVE THEY HAVE OVER HEALTH OUTCOMES AND PRACTICES ? ................................ ................................ ........................ 146 5.1 Introduction ................................ ................................ ................................ ..... 146 5.2 What does ‘health’ mean? ................................ ................................ ................ 148 5.3 What affects health? Lay knowledge of the effect of structure and agency ....... 158 5.3.1 Ge neral socioeconomic, environmental and working conditions ............... 159 5.3.2 Social and Community Influences ................................ .............................. 171 5.3.3 Individual or Agency Factors ................................ ................................ ..... 1 76 5.4 Conclusion ................................ ................................ ................................ .............. 184 C HAPTER 6 - H EALTH - RELATED PRACTICES AN D ECONOMIC CAPITAL ................................ ................. 187 6.1 Introduction ................................ ................................ ................................ ...... 187 6.2 The effect of unequal income ................................ ................................ ............ 188 6.2.1 Commodification of health: ‘if yo u want good things, you have to pay for them’ ………………………………………………………………………………………………………………… 189 6.2.2 The cost of health - related practices ................................ .......................... 198 iii 6.3 Employment inequality ................................ ................................ ..................... 207 6.3.1 The working conditions of the middle socioeconomic group ..................... 207 6.3.2 Labour characteristics from the lower socioeconomic group ..................... 215 6.4 Conclusion ................................ ................................ ................................ ........ 222 C HAPTER 7 - H EALTH - RELATED PRACTICES , SOCIAL AND CULTURAL CAPITAL ................................ ....... 225 7.1 Introduction ................................ ................................ ................................ ...... 225 7.2 Social Capital: neighbourhoods , social relations and health - related practices ... 227 7.2.1 Residential segregation ................................ ................................ ............. 227 7.2.2 Habitus and ‘normality’ ................................ ................................ ............. 230 7.3 Social norms and hea lth - related practices ................................ ......................... 247 7.3.1 Middle socioeconomic group: Moderation and Refinement ...................... 248 7.3.2 Lower socioeconomic group: enjoyin g the moment ................................ ... 256 7.3.3 Gender: the construction of masculinity and femininity .............................