Chronic disease and healthy ageing at the intersections: social locations, biomarkers, and health practices;

Chronic diseases entail huge personal and societal costs and pose a significant challenge for public health. Furthermore, they are key drivers of inequalities in later life (50+) health. So far, health inequalities research has tended to focus on how health varies according to single categories of difference, such as gender or socioeconomic status. Yet in the real world we know that any given person is not just a man or woman, poor or rich, etc., but a combination of attributes, so that we might describe an older, poorer, ethnic minority man, for example (or any other combination that exists).

This project takes up a theory which addresses this complexity called intersectionality. In particular, it focuses on how each of the combinations possible from the interaction of gender, age, socioeconomic status, and ethnicity (and in ageing research, also typically retirement and marital status), is associated with a particular location in the social structure, which brings with it particular (yet overlapping) resources, policy effects, processes, and types of discrimination. In turn, each position is associated with a particular (yet overlapping) set of social determinants of health, with differential consequences for chronic disease outcomes. Different intersectional positions might also entail different cultural and social identities. For example, there might be distinctive aspects to the identity of a younger unemployed man that cannot be reduced to age, employment status, or gender alone.

In this project, we are particularly interested in the chronic diseases of type 2 diabetes, heart disease and obesity. These conditions are highly prevalent and have shared social determinants. We will analyse survey data from the English Longitudinal Study of Ageing, the Survey of Health, Ageing and Retirement in Europe, Understanding Society and the UK Biobank to identify which intersectional positions are at particular risk of these conditions. We will then investigate which factors might lead to this excess risk. We plan to focus on two types of factors. The first is events over the lifecourse, since we know that dis/advantage from womb to tomb is crucial to later life health outcomes. The second is health practices (i.e. health behaviours in social context) since there is strong evidence that these influence chronic disease outcomes. We will use a newly developed multilevel modelling technique and growth curve models; these methods allow for socially 'mapping out' health outcomes, and examining how they vary on time.

In this work, we plan to analyse biomarker data which is increasingly collected in inter/national surveys. Biomarkers are objective measures of underlying pathology. Commonly-known biomarkers include blood pressure, BMI, and for diabetes, HbA1c. The advantage is that biomarkers are objective, valid measurements of health. Furthermore, by analysing biomarker outcomes at intersectional positions, we are advancing a highly novel biosocial approach, bringing together sociological theory with medical measurements. In effect, we will be able to see how social disadvantage 'gets under the skin' where factors such as gender, age and ethnicity interact with each other.

What is the benefit of this research? It will highlight fine-grained inequalities that have previously escaped attention. It will suggest new ways to design, target and tailor public health policies and interventions. Academically, it takes up and runs with a theory which is currently seen as holding great promise to move health inequalities research forward. It will generate new conceptual, methodological and empirical knowledge which will be of substantial interest to the research community across multiple disciplines. Ultimately, the project offers a significant opportunity for a new approach to tackle the growing chronic disease burden negatively affecting the lives of many older people, but especially those in particularly deprived positions.

New forms of knowledge are needed to tackle the challenge of chronic diseases in older age, and their inequalities, to help ensure that all members of society can age healthily. The proposed research offers a novel interdisciplinary, biosocial approach that is directly geared to generating such knowledge. In the process, it aims to shift the conversation around risk, vulnerability and disadvantage in older age. Accordingly, non-academic beneficiaries fall into two main categories.

First are practitioners and policy makers in the fields of public health and gerontology, especially those with an interest in health inequalities and social determinants. Here the goal is instrumental impact. These stakeholders will benefit because the project will generate evidence relevant to more sophisticated and nuanced approaches to designing interventions and policies on health inequalities. Ultimately, the aim is to effect an equitable change in the public health.

Second are those who use concepts around health inequalities and healthy ageing (this also includes the first group), chiefly ageing and chronic disease charities and NGOs. Here the goal is conceptual impact. These stakeholders will benefit because they regularly use concepts and methods concerning health inequalities in older age. Adding the concept of intersectionality to the conversation will highlight fine-grained inequalities that have previously escaped attention. Consequently, these organisations will be more equipped to use the concept of intersectionality.

Stakeholders will be involved right from the beginning of the project in co-design activities. An online survey will be disseminated which will ascertain views on what is important in analysing inequalities in chronic conditions and healthy ageing. Topics will include awareness and understanding of the concept of intersectionalities and related terms (risk, subgroup, disadvantage, vulnerability).

A co-design workshop will explore with stakeholders the utility of intersectionality for understanding inequalities in chronic disease. The workshop will be highly interactive and will invite participants to consider how the 'classic four' socio-demographic factors of socioeconomic position, age, gender, and ethnicity, as well as other factors, might together socially drive illness in later life. The workshop will also discuss current issues in intersectional theory and challenges to its application for policy-making and practice.

The public health elements of the project relate to the focus on health inequalities and producing evidence regarding targeted and tailored interventions and policies. The research team will utilise the public health networks they are members of and also seek to join new networks as appropriate in order to disseminate the project as widely as possible and maximise impact. This will help to increase participation in the other planned activities.

An end of project conference will take up the twin foci of conceptual and instrumental impact by aiming to share understanding of intersectionalities stakeholders as well as having a dedicated session on policy and practice significance. It will also be an opportunity to disseminate the findings, as well as inviting leading intersectionality researchers from Europe and the US to maximise productive knowledge exchange.

Finally, the project will publish both academic and non-academic blog posts and maintain a social media presence. Research briefs will distil papers into key results with clear illustration for stakeholders. These will be distributed to the identified stakeholders through e-mail lists and the final conference.