1. The wider determinants of health: Theory into practice Inequalities in Health: trends, causes and policy Joop ten Dam PhD NIGZ Support centre for Community Health (NSCH) www.slag.nu jtendam@nigz.nl

2. Contents ► Inequalities in health:  Facts and trends  Causes  Policy

3. ► Inequalities in health  Facts and trends  Causes  Policy

4. Increase in life expectancy between 1960 and 2000 Source: Eurostat. 2000

5. Life expectancy trends for men and women in various EU countries in the period from 1970 to 2000 As well as the Netherlands and the EU average (EU-15), the most and least favourable countries are shown (Source: WHO-HFA, 2002).

6. Estimated disability-adjusted life expectancy, 2001 72.8 years 50.1 years

7. Black Report (1980)

8. Solid Facts (second edition), WHO 2003 Occupational class differences in life expectancy, England and Wales, 1997-1999

9. Inequalities in health (1)

10. Inequalities in health (2)

11. Life expectancy and disability-free life expectancy according to educational level for Dutch men and women, 1995-1999 elementary tertiary elementary Men Women

12. Inequalities in health (3) ► Cities less healthier ► Concentration of poor health in deprived neighbourhoods. ► Differences in life expectancy between neighbourhoods more than 10 years ► Poor health an extra element in accumulation of problems

13. Inequalities in health (4) ► Exist in all Western countries ► Decreasing over the centuries ► Increasing since + 1950 (at the same time as the developing welfare state)

14. The Widening Mortality Gap Between the Social Classes Tackling Health Inequalities. A Programme for Action UK Department of Health 2003

15. ► Inequalities in health  Facts and trends  Causes  Policy

16. Lalonde Model (1974) ► Biological factors (gender, age, ethnicity) ► Physical environment (living, working) ► Social environment (social position, friends, family) ► Life style (nutrition, exercise, smoking, drinking) ► Health care (access, price, quality)

17. SES Health Determinants: environment and behaviour Health Selection Causes

18. Causes: life styles

19. Percentage smokers in men; 1990-2000 Source: RIVM 2002

20. Youth is investing in future ‘bad health’ Present levels of unhealthy behaviour: smoking (15-19)45% alcohol use 50-59% physical inactivity49% low consumption vegetables and fruit85-95% overweight7-16% Trends in the past decade: smokingunfavourable alcohol useunfavourable consumption vegetables and fruitunfavourable overweightunfavourable Source: RIVM 2002

21. Overweight more prevalent and in younger age groups Health on Course? RIVM 2002

22. Contribution (in per cent) of eight significant determinants to mortality, loss of quality of life and burden of disease (disability-adjusted life-year (DALY)) in the Netherlands.

23. Solid Facts (second edition), WHO 2003 Socioeconomic deprivation and risk of dependence on alcohol, nicotine and drugs, Great Britain, 1993

24. Mortality from coronary heart disease in relation to fruit and vegetable supply in selected European countries Solid Facts (second edition), WHO 2003

25. ► Inequalities in health  Facts and trends  Causes  Policy

26. Starting point ► Structural inequalities in health collide with the democratic principle of equal opportunities ► So decrease avoidable inequalities in health

27. What it’s all about... ► By the year 2020, the health gap between socio-economic groups within countries should be reduced by at least one fourth in all member states, by substantially improving the level of health of disadvantaged groups (Health 21 WHO / EURO)

28. Conditions for policy ► Effective interventions: ► attack crucial factors ► are effective ► Effective implementation: ► have sufficient support ► use long term investments ► monitor results

29. Possibilities for policymaking 1 ► Decrease differences in SES: ► Income policy ► Poverty policy ► Policy on education ► Labour market policy ► “Seduce” people into a healthy living style; ► Building a healthy physical environment

30. Possibilities for policymaking 2 ► Extra facilities in health care ► Keep the health care affordable ► School approach (smoking, fruit) ► Reduce absence through illness ► Medical indication for financial support to families and children with health problems ► Support the chronic patients: remove thresholds to work and income

31. Key interventions that will contribute to closing the life expectancy gap ► reducing smoking in manual social groups ► preventing and managing other risks for coronary heart disease and cancer such as poor diet and obesity, physical inactivity and hypertension through effective primary care and public health interventions – especially targeting the over-50s ► improving housing quality by tackling cold and dampness, and reducing accidents at home and on the road UK Inequalities in health programme for action (UK Department of Health 2003)

32. Actions likely to have greatest impact over the long term ► improvements in early years support for children and families ► improved social housing and reduced fuel poverty among vulnerable populations ► improved educational attainment and skills development among disadvantaged populations ► improved access to public services in disadvantaged communities in urban and rural areas, and ► reduced unemployment, and improved income among the poorest UK Inequalities in health programme for action (UK Department of Health 2003)

33. Community-approach  Traditional health campaigns and health promotion activities often fail to reach people with a low SES in an adequate way.  If health activities are to reach these people, they should be implemented closer to them, to the places where they live and work. This means that the programmes should be implemented at a local level.  So, a new paradigm is needed.  This change of paradigm is now taking place: from health education to a community-approach

34. Change of paradigm: from health education to community-approach

36. Improving Health Promotion Furthermore health profits from: Implementation of locally successful initiatives Stimulating of prevention within health care Using the ‘well-known’ insights: Prevention fitted to target groups: - youngsters, lower socio-economic groups Prevention within existing settings: - school, work, leisure time Prevention by combining methods: - health education, laws and regulations, etc. Structural prevention: - no project financing, but structural budgets Bron: VTV 2002

37. NIGZ - Support centre for Community Health (NSCH) ► NSCH supports organisations that strive to reduce health inequalities in a local context and takes care of the implementation of effective interventions.

38. NSCH offers several services : ► Developing new methods to address health issues at a local level while sharing existing methods and adapting them to local conditions. ► Direct support to pilot projects and publishing the results for broader use. ► A network of professionals sharing information, analysing projects, and contributing to the development of new methods and policies. ► Access to international information on good practices to local workers.

39. The wider determinants of health: Theory into practice Inequalities in Health: trends, causes and policy Joop ten Dam PhD NIGZ Support centre for Community Health (NSCH) www.slag.nu jtendam@nigz.nl