Dr Yoga

Senior Lecture in Public Health

GEMS UL

LO = Outline the major forms of inequalities in health, and the general categories of explanation put forward to explain them

Social determinants of healthSocial determinants of health inequalitiesDiscuss health inequalitiesInequalities in Ireland

* 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

Social

structure

Inequalities in social position

Inequalities in access to determinants

Inequalities in health

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

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

Relative poverty Absolute poverty Culture and behaviour Biological responses to stress Lifecourse effects starting from early years Social stratification and discrimination

EnvironmentEnvironment PovertyPoverty GeographyGeography Individual Individual differencesdifferences

Combined social Combined social circumstancescircumstances

Deprived areasDeprived areas Social inclusionSocial inclusion LifestylesLifestyles

EthnicityEthnicity GenderGender DisabilityDisability OpportunitiesOpportunities

DiscriminationDiscrimination Personal choicesPersonal choices Age Age

Health inequalities can be seen as an outcome of

Social Inequalities

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

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?

Reduce poverty

Improve educational attainment

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

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

Aim

Examples of actions: Regeneration, employability,

targeted health improvement, services for vulnerable children

Aim

Examples of actions: increase minimum wage alongside a millionaire prevention programme, re-allocation of resources from affluent to poor areas

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

Health Issues in the UK-Inequalities 21

There are many influences on an individual’s health. These are often categorised into:

Biological Factors

The Physical and Social Environment

Personal Lifestyle

Health Services

Health Issues in the UK-Inequalities 22

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 The common common denominatodenominator of all r of all these these factors is factors is that they all that they all link to link to POVERTYPOVERTY

Health Issues in the UK-Inequalities 23

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

The GENDER you belong to can also be a contributory factor to the amount of health you

enjoyDue 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

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

It is generally recognised that Western lifestyle is bad for your health……….

Over 50% of Britons are overweight and the number of overweight children is a growing phenomenon in the Western World Often opposition from the food industry where a large % of profits can be made from junk food profits

Fat seems also to be a class issue. It seems the lower the class you belong to, the greater the incidence of obesity Some proposals to stop children eating junk food have been controversial - In 1998 James Report suggested banning sweets and fizzy drinks from schools

Health Issues in the UK-Inequalities 27

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

There are two major approaches to tackling inequalities in health:

THE COLLECTIVIST THE COLLECTIVIST APPROACHAPPROACH

THE THE INDIVIDUALIST INDIVIDUALIST

APPROACHAPPROACH

Health Issues in the UK-Inequalities 29

This approach to solving inequalities is based on the view that differences in health are beyond the ability of the individual to change

The view is that differences in health are due to major economic and social problems in society - eg. poor housing stock, unemployment, inflation These problems impact on

different people in different ways - but poorer social classes suffer most.

Idea first found favour in the Black Report (1980) and Acheson Report (1998)

Subscribers to this view feel that improvements will only come by concerted government action centering on anti-poverty strategies

Health Issues in the UK-Inequalities 30

This approach is based on the belief that health inequalities are the result of how INDIVIDUALS choose to lead their lives

There seems to be differences in health habits between different social classes

People of lower social class seem to; smoke and drink alcohol more often, exercise less and have less healthy diets

Idea is that people should be largely responsible for monitoring own health

Government action should centre on high-profile health advertising campaigns etc. Approach favoured by Tory Government in early mid 1990s.

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

Urban-rural differences Urban excess in most

causes of death except influenza and transport accidents

Institute of Public Health 2001

illness levels 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

0

510

15

2025

30

35

4045

50

Commenced on discharge at 2 weeks at 6 weeks at 4 months at 6 months+

Tipp NR

Limerick

Clare

MWHB

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

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

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