Why object to inequalities in health and wellbeing? A mixed-methods exploration of inequality aversion with members of the general public

Distributional cost-effectiveness analyses (DCEAs) help decision-makers incorporate equity considerations in healthcare resource allocation. Public aversion to health inequalities is well documented, but underlying reasonings are rarely explored. Existing studies often elicit inequality aversion across socioeconomic groups, potentially conflating aversion to inequalities in health with inequalities in household finances or wellbeing. Additionally, online surveys systematically exclude people who do not use the internet, a disadvantaged group.

Objectives

To examine whether: i) reasoning for distributional preferences depend on the domain of inequality; ii) reasoning for distributional preferences are affected by cause of inequality; iii) participants provide and explain responses that violate ‘monotonicity’ (the welfare economics principle that, other things being equal, social welfare improves when at least one person is better-off); and iv) the above vary across the digital divide.

Methods

We employed mixed-methods to collect qualitative and quantitative data, via online discussion groups with a survey (11 groups, n=53), and telephone interviews (n=15) with digital minority individuals. Participants considered scenarios comparing equal and unequal health and wellbeing outcomes for an imaginary island. Wellbeing was framed as ‘equivalent income’ (described to participants as household spending money, with other life aspects being good).

Results

Distributional preferences varied by domain and cause of inequality but not digital status. Health inequality caused by financial inequality was widely unaccepted. Some preferred equal distributions, even when violating ‘monotonicity’, citing fairness and social cohesion.

Conclusions

Recruiting across the digital divide and using mixed-methods enriches inequality aversion research, enhancing the inclusivity and legitimacy of DCEA.