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Health Inequalities and Health promotion


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Title: Health Inequalities and Health promotion

Health Inequalities and Health promotion
  • Dr. Steve Brindle

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)

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

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

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

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

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

Lower socio-economic groups and health promotion
  • 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)

Lower socio-economic groups and health promotion
  • Lay beliefs (and links with other types of
  • 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 1998171)

Lower socio-economic groups and health promotion
  • Cultural pressures vs realist needs
    Breastfeeding among poorer rural Kenyan women.
  • Breastfeeding not socially acceptable, but
  • Bottled milk too expensive
  • (Ferguson 2007)

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

Wider Inequalities issues Whitehall study (cont)
  • However, no-one in the study was actually
  • So common interpretation that health and wealth
    linked cannot explain all
  • Focus on poverty can block deeper understanding

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
    (Smith 1992)

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

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
  • HP must address broader inequalities?

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?

How to address inequalities
  • Government national policy
  • some countries do much better than UK with less
  • 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)

How to address inequalities (cont)
  • local policies
  • reduce stress - support the vulnerable
  • Increase/improve coping skills
  • empowerment, participation
  • - voluntary sectors, self help groups

  • 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

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.

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)

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)

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

Evans and Stoddart model
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

  • 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
  • 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.

  • Macdonald T. 1998. Rethinking Health Promotion.
  • Marmot 1994. Marmot MG. Social Differentials in
    Health Within and Between Populations. Daedalus
  • 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.

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.