1. Senior Lecture in Public Health
Health inequalities
Dr Yoga
Senior Lecture in Public Health
GEMS UL

2. LO & Outline
LO = Outline the major forms of inequalities in health, and the general categories of explanation put forward to explain them
Social determinants of health
Social determinants of health inequalities
Discuss health inequalities
Inequalities in Ireland

3. Determinants of health

4. Social determinants of health
Income, access to decent, affordable food, education, housing, transport, safe and pleasant environment, clean water (protection from alien invasions!!), access to health and social services.
Also not depicted, good family and social relationships, cultural life, leisure time etc

5. Social determinants of health inequalities
Complexity of social structure:
Bigger picture of society - culture, power, history
Opportunities, assumptions, discrimination, social mobility
Social structure that favours higher social status, individualism and wealth and disadvantages poorer, dependant groups

6. Social inequalities and health
Inequalities in social position
Inequalities in access to determinants
Inequalities in health
Social structure

7. Perception “health inequalities”? Difference or unfairness?
What comes to mind when I say
“health inequalities”?
Difference or unfairness?
Differences, e.g. between numbers of men and women who smoke
Unfairness, e.g. higher cost of fresh fruit in poorer areas

8. E.g. Height
Being short as an adult could be due to genetics, ante-natal difficulties such as blood vessel malformation, physical illness or condition as a child, such as polio or cystic fibrosis
Or, poor maternal nutrition, lack of access to food as an infant, poor nurturing relationship etc, i.e. as a result of poverty and disadvantage
Being short could disadvantage social progress, or not
For any factor where there are differences or a social hierarchy, there could also be unfairness

9. Theories for health inequality
Relative poverty
Absolute poverty
Culture and behaviour
Biological responses to stress
Lifecourse effects starting from early years
Social stratification and discrimination

10. Health policies say that health inequalities are related to:
Environment
Poverty
Geography
Individual differences
Combined social circumstances
Deprived areas
Social inclusion
Lifestyles
Ethnicity
Gender
Disability
Opportunities
Discrimination
Personal choices
Age

11. In practice Health inequalities can be seen as an outcome of
Social Inequalities

12. Early life is key to the future
Healthy early years development is the foundation for later school achievement, economic productivity, responsible citizenship and successful parenting
Very early life is crucial but different skills mastered at different stages are equally important
Interventions important at all stages

13. A question
From what you’ve heard (and what you know), what do you think should be the two main priorities to address in order to reduce the inequalities gap in children’s health and well-being?

14. Two priorities
Reduce poverty
Improve educational attainment

15. Who can fix it?
Societal problem therefore society has to change (economic policies, diversity, social welfare etc)
Public sector is part of society – major employers, service providers, big contribution to health
Planning and practice for health inequalities
Irish policy emphasis on health inequalities - not entirely clear about specific action

16. Three approaches
Taking into account the complexities around health inequalities, academics suggest three interlinked approaches which all need to be addressed but will require different aims and actions:
Targeting worst off
Closing the gap
Reducing the gradient

17. Target the worst off Examples of actions: Regeneration, employability,
Aim
Examples of actions:
Regeneration,
employability,
targeted health improvement,
services for vulnerable children

18. Reduce the gap
Aim
Examples of actions: increase minimum wage alongside a millionaire prevention programme, re-allocation of resources from affluent to poor areas

19. Reducing the gradient
Reducing systematic inequalities for income, gender, ethnicity, disability etc i.e improve access and opportunities, inequalities sensitive practice

20. DVD on The Great Health Divide

21. Health Issues in the UK-Inequalities
1. Your Health
There are many influences on an individual’s health. These are often categorised into:
Biological Factors
Personal Lifestyle
The Physical and Social Environment
Health Services
Health Issues in the UK-Inequalities

22. 2. Inequalities in Health
It is now generally recognised that there are many reasons for health inequalities. People can suffer health inequalities for many reasons, due in the main to:
The geographical area they live in.
The racial group they belong to.
Their gender
And, perhaps most importantly, their social class.
The common denominator of all these factors is that they all link to POVERTY
Health Issues in the UK-Inequalities

23. 4. Ethnic Health Inequalities
Today, ethnic minorities make up about 6% of the UK population
* There is variation in health amongst various racial groups.
* For example,Asians are more prone to heart disease and Caribbeans have a higher incidence of mental problems
* However, one of the main reasons for ill-health inequalities amongst ethnic communities seems to arise from RACISM and DISCRIMINATION
* Poor “life chances” often leads to poor educational, employment and housing opportunities.
* This leads to POVERTY and increased chances of illness and disease.
Health Issues in the UK-Inequalities

24. Health Issues in the UK-Inequalities
6. Gender Inequalities
The GENDER you belong to can also be a contributory factor to the amount of health you enjoy
Due to 3 main factors:
Biological - Women’s role in reproduction can cause ill-health
Material - Women still seen as ‘carers’ - commitments often force them to take low paid /part time jobs - can lead to POVERTY and ill-health
Ageing - Women live longer more prone to ill-health connected to old age.
* Women tend to live longer than men
* But they suffer from more illness during their lives
Health Issues in the UK-Inequalities

25. 7. Inequalities in Social Class
In the UK the SOCIAL CLASS you belong to seems to be influential in determining your health.
BLACK REPORT (1980) concluded that while the health of the nation as a whole had improved, inequalities in health had not been eliminated.
In fact, Black stated that the ‘Health Gap’ between higher and lower social classes was widening.
He claimed that this was as a result of differences in social and economic conditions.
He said that people from lower social classes tend to drink and smoke more, exercise less and have poorer diets than those in higher social classes.
These poor habits can be traced back to POVERTY.
Health Issues in the UK-Inequalities

26. Health and Lifestyle Issues (1) - Poor Eating Habits and Obesity -
It is generally recognised that Western lifestyle is bad for your health……….
Fat seems also to be a class issue. It seems the lower the class you belong to, the greater the incidence of obesity
Over 50% of Britons are overweight and the number of overweight children is a growing phenomenon in the Western World
Some proposals to stop children eating junk food have been controversial - In 1998 James Report suggested banning sweets and fizzy drinks from schools
Often opposition from the food industry where a large % of profits can be made from junk food profits
Health Issues in the UK-Inequalities

27. Health and Lifestyle Issues(2) - Smoking -
Generally that smoking damages health in the form of cancers and heart disease
Smoking seems to link to ill health and is also a class issue
By 1990s, professional classes had listened to advice and had cut down on smoking.
The habits of lower classes changed little during this time.
Young women are especially vulnerable, especially teenage girls.
Girls 20 years behind men in smoking habits
Health Issues in the UK-Inequalities

28. Approaches to Solving Health Inequalities (1)
There are two major approaches to tackling inequalities in health:
THE COLLECTIVIST APPROACH
THE INDIVIDUALIST APPROACH
Health Issues in the UK-Inequalities

29. Health Issues in the UK-Inequalities
Approaches to Solving Health Inequalities (2) >THE COLLECTIVIST APPROACH<
This approach to solving inequalities is based on the view that differences in health are beyond the ability of the individual to change
Subscribers to this view feel that improvements will only come by concerted government action centering on anti-poverty strategies
The view is that differences in health are due to major economic and social problems in society - eg. poor housing stock, unemployment, inflation
Idea first found favour in the Black Report (1980) and Acheson Report (1998)
These problems impact on different people in different ways - but poorer social classes suffer most.
Health Issues in the UK-Inequalities

30. Health Issues in the UK-Inequalities
Approaches to Solving Health Inequalities (3) >THE INDIVIDUALIST APPROACH<
This approach is based on the belief that health inequalities are the result of how INDIVIDUALS choose to lead their lives
Government action should centre on high-profile health advertising campaigns etc. Approach favoured by Tory Government in early mid 1990s.
There seems to be differences in health habits between different social classes
Idea is that people should be largely responsible for monitoring own health
People of lower social class seem to; smoke and drink alcohol more often, exercise less and have less healthy diets
Health Issues in the UK-Inequalities

31. Other mortality gradients
Urban-rural differences
Urban excess in most causes of death except influenza and transport accidents
Gender difference in favour of females
Males
54% higher for all causes
61% higher for circulatory
45% higher for cancers
48% higher for respiratory
169% higher for injury/poisoning
Institute of Public Health 2001

32. Gradient also in illness levels determinants of health
Hospitalisation for mental illness among unskilled workers is 6x higher than for skilled
The average suicide rate in economically deprived areas is 2x that of non-deprived areas in N. Ireland
Children in first year of life have more ear, chest and GIT infections (Dundee study)
determinants of health
37% of women with medical cards smoke during pregnancy vs 12% of mothers without
27% of babies born to unemployed mothers were breastfed vs 67% of babies born to higher professional women
Cervical screening uptake > 60% in most affluent EDs,<40% in least affluent EDs in Limerick

33. Breastfeeding variation across 3 Mid-West Counties 1997

34. Milestones in Irish approach to health inequality
1838 Poor Law structures
1851 Dispensary service
1972 GMS
1994 Shaping a Healthier Future - health strategy introduces equity concept
1999 Institute of Public Health (North-South body with focus on tacking inequalities)
2001 Extension of GMS eligibility to all over 70’s
2008 Removal of above

35. If your only tool is a hammer, all your problems will be nails”
Interventions
Whitehead(2005) suggests a typology of actions to reduce health inequalities:
Strengthening individuals
Strengthening communities
Improving working and living conditions
Promoting healthy macro-policies
If your only tool is a hammer, all your problems will be nails”
Mark twain

36. What does this mean for your current PBL case?
Mr Power has an illness which has both modifiable and un-modifiable risk factors
? “Social determinants”
What can you as his doctor do to help him?
Prevention
Primary
Secondary
Tertiary