The wider determinants of health: Theory into practice Inequalities in Health: trends, causes and policy

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The wider determinants of health Theory into
practiceInequalities in Health trends,
causes and policy

• Joop ten Dam PhD
• NIGZ Support centre for Community Health (NSCH)
• www.slag.nu
• jtendam_at_nigz.nl

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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)
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Occupational class differences in
lifeexpectancy, England and Wales, 1997-1999
Solid Facts (second edition), WHO 2003
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Inequalities in health (1)
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Inequalities in health (2)
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Life expectancy and disability-free life
expectancy according to educational level
forDutch men and women, 1995-1999
elementary
elementary
tertiary
tertiary
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
Action UK 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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Causes
Selection
SES
Health Determinants environment and behaviour
Health
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Causes life styles
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Percentage smokers in men 1990-2000
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 unfav
ourable alcohol use unfavourable consumption
vegetables and fruit unfavourable overweight
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 andburden of disease (disability-adjusted
life-year (DALY)) in the Netherlands.
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Socioeconomic deprivation and risk of dependence
on alcohol, nicotine and drugs, Great Britain,
1993
Solid Facts (second edition), WHO 2003
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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 its 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
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Change of paradigm from health education to
community-approach
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Improving Health Promotion

• 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

• Furthermore health profits from
• Implementation of locally successful initiatives
• Stimulating of prevention within health care

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
practiceInequalities in Health trends,
causes and policy

• Joop ten Dam PhD
• NIGZ Support centre for Community Health (NSCH)
• www.slag.nu
• jtendam_at_nigz.nl