Health Inequalities and Health promotion

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Health Inequalities and Health promotion

• Dr. Steve Brindle

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Lecture plan

• Basics of inequalities - perspectives
• How is this linked to health promotion?
• What could be done to change the situation?
• Examples (inc from Scotland)

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Fundamentals

• Health and wealth linked - but how/why?
• Other inequalities
• - gender
• - race/ethnicity
• - age
• - disability, etc
• Inverse care law

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Fundamentals (cont)

• Inequalities often multiple not singular, e.g.
  gender and age
• In general the aging process affects women more
  because
• they live longer
• society has a gender-based view of older people.
• (Earl and Letherby 2008)

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Deprivation and health (1)

• Deprivation in itself is harmful
• People are trapped in health damaging
  circumstances by poverty and low income, e.g.,
• housing, transport, diet, exercise,
• participation, empowerment

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Deprivation and health (cont)

• What else is intrinsic about health inequalities
  that is linked with health promotion?
• Poor response to health campaigns
• Potentially damaging social norms

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Lower socio-economic groups and health promotion

• Lower socio-economic groups less responsive to HP
  campaigns, e.g. on
• Smoking cessation
• Cervical smear campaigns
• Testicular cancer awareness
• campaign (inc Marks Spencer)
• Exercise
• Diet

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Lower socio-economic groups and health promotion
(cont)

• Culture as an influencing factor, e.g. food as
  cultural identifier
• In developed countries the poverty gap is
  also a cultural one and food is one way that
  people can feel isolated from the cultural
  mainstream a family may be well nourished
  nutritionally but still experience deprivation
  through lack of access to valued foods, preferred
  foods or consistent amounts of food (Crotty,
  1999). (Caraher. 200248)

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Lower socio-economic groups and health promotion
(cont)

• Lay beliefs (and links with other types of
  inequality)
• Definitions of good diet
• Middle-class moderate and balanced
• Working-class meat, potatoes and greens
• Definitions of bad food
• Middle-class Processed and pre-packaged
• Working-class fatty (Povey et.al. 1998171)

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Lower socio-economic groups and health promotion
(cont)

• Cultural pressures vs realist needs
  Breastfeeding among poorer rural Kenyan women.
• Breastfeeding not socially acceptable, but
• Bottled milk too expensive
• (Ferguson 2007)

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Wider Inequalities issues Whitehall study

• 10,000 British civil servants, followed for 20
  years. Much data produced.
• age-standardised mortality over 10 year period
  for males aged 40 to 60 - three and half times
  higher in clerical and manual grades, as in
  senior admin. Grades
• Gradient in mortality

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Wider Inequalities issues Whitehall study (cont)

• However, no-one in the study was actually
  deprived
• So common interpretation that health and wealth
  linked cannot explain all
• Focus on poverty can block deeper understanding

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Smoking and Whitehall study

• Top people smoke less
• Death from smoking related diseases correlates
• But gradient also there for non smoking related
  diseases (smoking therefore may be an effect as
  much as a cause)
• Is there some underlying causal process
  associated with a hierarchy? (all societies have
  hierarchy)
  (Smith et.al. 1992)

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Whitehall Study II

• Looked at employment
• Stress and general ill health related
• Stress related to job positioning and lack of
  control
• (Marmot 1994)

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What is the problem?

• HP is not just health education and lifestyle
  approach. However, HP message sometimes removed
  from social context (e.g. relationship between
  smoking and stress)
• Responsibility for health is individual and
  societal
• HP must address broader inequalities?

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What is the problem? (cont)

• More facilities/education targeted at those who
  need them - is this the answer?
• Need to redistribute wealth and power, but how?
• Is inequality inevitable?

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How to address inequalities

• Government national policy
• some countries do much better than UK with less
  money
• Income Distribution Rising incomes can mean
  poorer health, if wealth is more concentrated
• Money is like muck - not good unless it is
  well spread (Sir Francis Bacon)

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How to address inequalities (cont)

• local policies
• reduce stress - support the vulnerable
• Increase/improve coping skills
• empowerment, participation
• - voluntary sectors, self help groups

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Scotland

• Report of Scottish Royal Colleges Working Party
  on Inequalities in Health 2000
• Refers to White paper Towards a healthier
  Scotland 1998
• - a three level national government strategy to
  reduce inequalities in life circumstances,
  lifestyles and loss of health

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Three Level National Government Strategy

• Improving Life Circumstances Social inclusion,
  job, income, housing, education, environment.
• Tackling Lifestyles Poor diet, lack of exercise,
  tobacco, alcohol/drugs misuse
• Tackling what can be prevented Heart disease,
  cancer accidents, improving child, mental, oral
  and sexual health.

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Scotland (cont)

• Uptake of breast cancer screening 20 lower in
  Depcat 7 than Depcat 1
• Rural issues
• Recommendation that extra efforts should be made
  to achieve greater uptake and use of services by
  those whose health is worse (see Acheson 1998)

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Scotland (cont)

• Time taken to achieve measurable changes is long
  - governments change
• - effective education to influence lifestyle
  changes can take 10 years to have visible impact
• But single most important strategy to reduce
  heart disease will be integrated and local
  initiative to confront relative deprivation
  (SNAP 1998)

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Public Health Institute of Scotland

• Established following the recommendations of the
  Review of the Public Health Function in Scotland
• To protect and improve the health of the people
  of Scotland by working with the relevant agencies
  and organisations to increase our understanding
  of the determinates of health and ill health

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Evans and Stoddart model
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Cure or sticking plaster?

• No redistribution of wealth
• still takes lifestyle approach, albeit based on
  settings programme
• GPs to give opportunistic advice - further
  burden on them
• focus on medical education re. inequalities

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References

• Acheson, D. 1998. Independent Inquiry into
  Inequalities in Health Report. London HMSO.
• Caraher, M. 2002. Food and Health national and
  international policy perspectives. in Adams, L.,
  Amos, M., and Munro, J. (eds) 2002. Promoting
  Health. London Sage.
• Earle, S, and Letherby, G. (eds). 2008. The
  Sociology of Healthcare. Basingstoke Palgrave
  MacMillan.
• Ferguson, J. 2007. Dilemmas in infant feeding for
  HIV positive mothers in a resource poor setting
  views from above and below BSc Dissertation
  University of Aberdeen.

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References

• Macdonald T. 1998. Rethinking Health Promotion.
  Routledge.
• Marmot 1994. Marmot MG. Social Differentials in
  Health Within and Between Populations. Daedalus
  123197-216.
• Povey, R., Conner, M., Sparks, P., James, R., and
  Sheperd, R. 1998. Interpretations of health and
  unhealthy eating, and implications for dietary
  change in Health Education Research. Vol.13
  No.2. 171-183. SNAP. 1998. Coronary Heart
  Disease. PHIS publications.
• Smith, G. D., Shipley, M. J., Marmot, M. G.,
  and Rose, G. 1994. Plasma cholesterol
  concentration and mortality. The Whitehall
  Study. JAMA Vol. 267. No. 1.

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Recommended Reading

• Adams, L., Amos, M., and Munro, J. 2002.
  Promoting Health Politics and Practice. London
  Sage. (Part 4)
• Doyal, L. 1997. Gendering health Men, women and
  wellbeing in Sidell, M., Jones, L., Katz, J.,
  and Peberdy, A. (eds) 1997 Debates and Dilemmas
  in Promoting Health A Reader. Milton Keynes
  Open University press.
• Leon, D., Morton, S., Cannegieter, S., and McKee,
  M. 2003. Understanding the Health of Scotlands
  Population in an International Context. London
  London School of Hygiene Tropical Medicine.
• Macintye, S. 2007. Inequalities in Health in
  Scotland What are they and what can we do about
  them? Glasgow Medical Research Council.
• Stafford, M., Nazroo, J., Popay, J.M., Whitehead,
  M. 2008. Tackling inequalities in health
  evaluating the New Deal for Communities
  initiative. in Journal of Epidemiology and
  Community Health 200862298-304.
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