joop ten dam phd nigz support centre for community health (nsch) slag.nu [email protected]
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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 [email protected]. Inequalities in health: Facts and trends Causes Policy. Contents. - PowerPoint PPT PresentationTRANSCRIPT
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The wider determinants of health: Theory into practice
Inequalities in Health: trends, causes and policy
Joop ten Dam PhDNIGZ Support centre for
Community Health (NSCH)www.slag.nu
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Contents
► Inequalities in health:
Facts and trends
Causes
Policy
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► Inequalities in health
Facts and trends
Causes
Policy
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Increase in life expectancy between 1960 and 2000
Source: Eurostat. 2000
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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 leastfavourable countries are shown (Source: WHO-HFA, 2002).
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Estimated disability-adjusted life expectancy, 2001
72.8 years
50.1 years
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Black Report (1980)
0
20
40
60
80
100
120
140
160
180
I II IIIN IIIM IV V
SMR Mannen
0
20
40
60
80
100
120
140
160
180
I II IIIN IIIM IV V
SMR Vrouwen
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Solid Facts (second edition), WHO 2003
Occupational class differences in lifeexpectancy, England and Wales, 1997-1999
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Inequalities in health (1)
SES low high Birth weight 3190 3424 (grams) Body length 175 180 (grown men) Chron. diseases 46 29 (number per 100 pers.) Disabilities 19 6 (% persons with > 1) Disablement 18 3 (%) Psych. soc. complaints 8.4 5.2 (mean number)
(Netherlands)
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Inequalities in health (2)
SES low high diff women
Lif e expectancy 79,5 82,1 - 3 Without health restrictions 64,7 73,3 - 9 Experienced as healthy 54,2 68,2 - 14
man
Lif e expectancy 73,1 78,0 - 5 Without health restrictions 63,8 73,7 - 10 Experienced as healthy 52,9 68,7 - 16 Source: RI VM 2002
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Life expectancy and disability-free life expectancy according to educational level for
Dutch men and women, 1995-1999
elementarytertiary tertiary
elementary
Men Women
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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
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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)
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The Widening Mortality Gap Between the Social Classes
Tackling Health Inequalities. A Programme for ActionUK Department of Health 2003
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► Inequalities in health
Facts and trends
Causes
Policy
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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)
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SES
HealthDeterminants:
environment and behaviour
Health
Selection
Causes
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Causes: life styles
low high
smoking man women
47 36
33 21
inactive man women
54 60
31 32
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Percentage smokers in men; 1990-2000
25
30
35
40
45
50
55
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
jongeren ouderen lage seshoge ses totaal
rokers (%), mannen
Source: RIVM 2002
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Youth is investing in future ‘bad health’
Present levels of unhealthy behaviour:smoking (15-19) 45%alcohol use 50-59% physical inactivity 49%low consumption vegetables and fruit 85-95%overweight 7-16%
Trends in the past decade: smoking unfavourablealcohol use unfavourableconsumption vegetables and fruit unfavourableoverweight unfavourable
Source: RIVM 2002
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Overweight more prevalent and in younger age groups
Health on Course? RIVM 2002
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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.
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Solid Facts (second edition), WHO 2003
Socioeconomic deprivation and risk of dependence on alcohol, nicotine and drugs, Great Britain, 1993
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Mortality from coronary heart disease in relation to fruit and vegetable supply in selected European
countries
Solid Facts (second edition), WHO 2003
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► Inequalities in health
Facts and trends
Causes
Policy
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Starting point
► Structural inequalities in health collide with the democratic principle of equal opportunities
► So decrease avoidable inequalities in health
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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)
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Conditions for policy
► Effective interventions:►attack crucial factors►are effective
► Effective implementation:►have sufficient support►use long term investments►monitor results
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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
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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
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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)
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Actions likely to have greatest impact over thelong 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)
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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
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Change of paradigm: from health education to community-approach
health promotion community- approach
method educate, convince support, empower
starting point percieved will to change living conditions of the people
theme narrow: behavior broad: healthy lifestyle, environment, health care
approach closed: a risk factor open
agenda health educator debate with all actors
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Change of paradigm: from health education to community-approach
health promotion community- approach
scale national, regional local, setting
production bureau en pretest co-operation with actors
type planning “healthy chaos”
aim healthy lif estyle quality of lif e, health
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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
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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.
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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.
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The wider determinants of health: Theory into practice
Inequalities in Health: trends, causes and policy
Joop ten Dam PhDNIGZ Support centre for
Community Health (NSCH)www.slag.nu