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SOCIAL

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SOCIAL & COMMUNITY PERSPECTIVES Inequalities in Health and Health Care (2): 4th February 2003 – PowerPoint PPT presentation

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Title: SOCIAL


1
SOCIAL COMMUNITY PERSPECTIVES
  • Inequalities in Health and Health Care (2)
  • 4th February 2003

2
Objectives
  • To reflect on evidence of inequalities in health
    from last week
  • To reflect on different explanations for
    inequalities in health

3
Black Report Explanations
  • Artefactual
  • Social Selection
  • Behavioural/Cultural
  • Materialist

4
Artefactual
  • Health and class are artificial variables
  • Registrar Generals classification is flawed and
    may be circular
  • Numerator/denominator bias 
  • Lowest social class groups shrinking ? widens
    apparent inequalities

5
Social Selection
  • Health determines social class through a process
    of Health-related social mobility
  • Healthy move up social hierarchy and unhealthy
    move down (Downward drift).
  • Some evidences that serious illness in childhood
    can affect occupational class, e.g people with
    mental health problems tend to drift down social
    ladder.
  • However not explain all class gradient. e.g.
    children/women, different diseases.

6
Behavioural/ Cultural
  • Social class determines health through social
    class differences in health damaging/promoting
    behaviour
  • These are at least in principle are subject to
    individual choice
  • Smoking, diet, exercise, alcohol consumption,
    infant feeding practices all vary by class.
  • BEWARE OF VICTIM BLAMING Need to be aware of
    social/economic context in which these behaviours
    occur.

7
Smoking
  • From 1974 to 1994 smoking in professional groups
    decreased by ½., however, by only a 1/3 in
    unskilled manual groups.
  • By 1994 smokers in a minority in all social
    classes, however, unskilled manual workers were
    2-3 times more likely to smoke than those in
    professional groups
  • Explanations
  • 1
  • Self-medication - managing stress?
  • Gives people some space?
  • 2
  • Culture of smoking?
  • Less motivated to give up?

8
Diet
  • Availability at small local shops
  • Problems with transport.
  • Difficult to have a good diet on a low income.
  • Cheaper food often over-refined and processed.

9
Not all behaviour.
  • Risk factors such as smoking, drinking and diet
    only explain 1/3 of class gradient.
  • Diet and smoking behaviour in S Asian population
    is better than white population but excessive CHD
    in this former group.

10
Materialist
  • Social class determines health through social
    class differences in the material circumstances
    of life.
  • Material aspects of living conditions affect
    health.
  • Asset based measures strongly associated with
    mortality rates.
  • Type of employment and level of employment
    influence health.
  • Differences in working conditions, unemployment,
    housing, and diet, is the main cause of illness
    and disease not genetics and lifestyle.
  • Poverty is never officially recorded as a cause
    of death, but clearly one of the most important
    determinants of our health status.

11
Most Plausible Explanation?
  • BR emphasises materialistic
  • Need to see how material circumstances influence
    behaviour and affect life generally

12
Another Explanation
  • Variations in health can be explained by
    variation in quality of and access to health
    services.
  • Poorer people consult GPs more often BUT
    relatively less compared with need
  • Massive under-utilisation of preventative
    services by people in lower socio-economic
    groups.
  • More deprived often get less provision in
    relation to their need.
  • Average costs of prescriptions is higher in
    affluent areas.

13
Tudor-Hart (1971) Inverse Care Law
  • the availability of good medical care tends
    to vary inversely with the population served.
  •  
  • Access
  • Quality
  • Uptake.

14
Access
  • Poorer areas have services, which are more
    difficult to reach compared with affluent areas.

15
Quality
  • More poorly resourced practices in inner city
    areas.
  • Under-provision of GPs compared to average in
    more deprived areas

16
Under Uptake
  • Under utilisation of preventative services
    antenatal, dentistry, immunisation, cervical
    smears.
  • Paradox lower social classes have worst health
    but use services less why?

17
Explanations for inequalities between men and
women
  • Consider differentials in
  • Health behaviour
  • Consultation patterns

18
Narrowing gap may be explained by
  • Improved social circumstances improve womens
    healthsame for men?
  • Stricter laws on drinking and driving, compulsory
    seat-belts
  • Changes in patterns of work
  • Decline in male employment sectors traditionally
    associated with fatal injuries
  • Work in female dominated service sector may be
    just as unhealthy ? chronic not terminal

19
Smoking
  • 1948 approx 65 of men smoke - approx 40 women
    now nearly equal proportions of women and men
    smoke.
  • US 1980s substantial increase of female mortality
    from lung cancer and COAD
  • UK - male deaths from lung cancer ? female deaths
    ?

20
Womens cigarette smoking by social class
21
Womens cigarette smoking by age
22
Smoking patterns among Black and minority ethnic
groups in England
23
Data from British Household Panel Survey (Graham
and Der, 1999)
  • Women on means-tested benefits 33 more likely to
    smoke than those not on benefits
  • Women in rented accommodation are twice as likely
    to smoke than women in owner-occupied
    accommodation
  • For women, not having a car in household
    increased risk of smoking by 66

24
Smoking and caring
  • Women with children are more likely to be smokers
    and heavier smokers than those without children
  • Those with heavy caring burdens tend to be
    heavier smokers
  • Womens smoking is tightly woven in with coping
    strategies
  • Smoking plays a contradictory role in womens
    lives is health promoting and health damaging
    (Graham, 93)

25
Consulting patterns
  • Higher proportion of women as consumers of health
    care.
  • On average women visit their GP 6xs/year and men
    4xs/year.
  • Working women consult slightly less than
    housewives Easier to visit doctor ?
  • Housewives are less likely to define themselves
    as being in excellent health. - under
    reporting

26
Provision of services
  • Health service generally focused on biological
    difference
  • Womens reproductive role ? specialist services
    focusing on reproduction 
  • Well woman clinic developed around distinct
    biology (screening)
  • Less specialist health care focused on men
    fewer well man clinics and screening for
    prostate and testicular cancer

27
Are women sicker?
  • Hospital admission, GP contact and community
    surveys tend to reveal higher rates of
    psychosocial ill health among women.
  • GP data - women suffer more from mental
    disorders, osteoarthritis, migraine, obesity and
    iron deficiency anaemia (men consult more for
    heart attack and angina)

28
Need to be careful when looking at data
  • 1994 exactly same number of men and women
    reporting long-standing illness,
  • Female excess only found consistently across the
    lifecourse in psychological manifestations of
    distress, less apparent or reversed, for number
    of physical symptoms

29
Explanations for different patterns of
consultation
  • Higher rates of milder physical problems women
    greater likelihood to seek help?
  • Doctors more likely to define women as ill?
  • Differences in mild illnesses artefact of
    gender-related health attitudes and behaviours?
  • Male stoicism, it might be suggested, is
    complemented by the cultural acceptance of
    vulnerability and sensitivity to symptoms (linked
    to the caring role) within women (Annandale,
    1998)
  • Difficult to ascertain whether women over-report
    and men under-report ill health who can act as
    objective arbiter of experience?
  • Research suggests women not over-reporting illness

30
Macintyre (1993)
  • 1700 males and female - MRC Common Cold Unit
    rated presence/absence/ severity of cold.
  • Both men and women likely to over-rate severity
    compared to clinical observer.
  • Men 1.6 times more likely to over-rate symptoms
    and to complain at any level
  • Doctors more likely to observe and diagnose
    symptoms in women
  • Concluded at a given level of clinical signs men
    and women equally likely to report related
    symptoms- men more likely to report severe
    symptoms

31
Explanations for inequalities in ethnicity and
health
  • Artefactual lots of problems with data
  • Language
  • Significant number of South Asian (particularly
    Bangladeshi women) and Chinese find it more
    difficult to communicate with GP.
  • However.. problem with communication in
    consultations generally, but by making it
    language makes it an ethnic problem (Sheldon
    Parker,1992).

32
Geographic location
  • Unhealthy areas
  • Benefits of being concentrated in large numbers ?

33
Cultural difference in expression of
symptoms/accessing care ?
  • Many women from minority ethnic groups prefer to
    see female GP (preferably same ethnic
    background).
  • Ethnocentric western diagnostic approach may be
    inappropriate for some groups (especially with
    regard to mental illness).

34
Migration effects?
  • More healthy more likely to migrate?
  • Environmental conditions in country of birth, or
    mothers country of birth
  • Stress
  • Little difference between migrants and those born
    in UK.
  • Scotland migrants from Punjab health
    deteriorated with time spent in UK
    (Williams,1993)

35
Cultural difference in health related behaviour
  • Health behaviour e.g. smoking
  • Diet and exercise patterns
  • Culture changes over time and according to gender
    and class.

36
Genetics
  • Haemoglobinopathies related to genetic factors
    vary across but not exclusive to particular
    ethnic groups.
  • Research continuing re diabetes, coronary heart
    disease and hypertension

37
The problem of emphasising Cultural difference
  • In this perspective, racialized inequalities in
    both health and access to health care are
    explained as resulting from cultural differences
    and deficits. Integration on the part of minority
    communities, and cultural understanding and
    ethnic sensitivity on the part of the health
    professional, then become the obvious solution
    personal and institutional racist and racial
    discrimination have no part to play in this
    equation
  • Ahmad W.I.U. (eds) (1993)
  • Race and health in contemporary Britain

38
The problem of emphasising Cultural difference
  • Class and consumption only partly explain
    inequalities need to look at other social
    disadvantage i.e. racism
  • Tendency to explain inequalities by focusing on
    cultural differences and deficits (Ahmad, 1993).
  • Results in unmet need e.g. elderly South Asian
    patients
  • Tend to ignore healthy cultural practices e.g.
    lower alcohol consumption and smoking in Asian
    women

39
Sheldon and Parker (1992)
  • Often race used to explain problems e.g.
    Glasgow early C20th
  • Research focused on nutritional deficiency
    diseases, tuberculosis, haemoglobinopathies.
  • Risk of blaming the individual and culture which
    is alien and/or deviant.
  • Focus on ethnicity may mask other wider
    differences related to socio-economic status.

40
  • When we make links between race and health
    status it is notsomething that is inherent to
    black people which shapes their health
    trajectory, but something inherent to the social
    context within which they must live their lives.
    (Nettleton,1995,189)

41
Impact of racism
  • 1/8 minority ethnic people experienced some form
    of racial harassment in last year.
  • ¼ fearful of racial harassment.
  • White minority groups e.g. Irish also face
    extensive racial harassment.
  • White respondents admitted racial prejudice (26
    against Asians, 20 Caribbean, 8 Chinese)
  • Institutional and societal racism minority
    ethnic groups over-represented in disadvantaged
    sectors of society.
  • Psychological effects of racism makes people ill
     
  • Ethnocentrism in health services
  • Experience racism when receiving health care

42
Benzeval et al (1995) argue we need to be aware
of
  • How socio-economic circumstances, ethnicity and
    racial harassment and/or discrimination interact
  • Impact of material and social circumstances on
    health
  • Impact of racial harassment

43
Conclusion
  • Illness does not strike purely at random.
  • Strong correlation between health and social
    class makes assumptions to the contrary difficult
    to sustain.
  • Combination of explanations

44
Way forward social class?
  • Encourage changes in personal behaviour.
  • Improve working conditions.
  • Elimination of poverty.

45
Way forward Gender
  • Gender sensitivity and awareness in policy and
    practice need to be aware of how gender, age,
    ethnicity, class impact on each other
  • Ensure equality of healthcare provision for men
    and women
  • Reduce the high mortality rate for young men
  • Improve material circumstances of lone mothers
  • Policies to minimise the impact of impairment in
    older women
  • More research on inequalities in womens health
    and in older people

46
Way forward ethnicity
  • Policies to eliminate poverty and unemployment
  • Improving housing stock
  • Urban regeneration
  • Policies which take into account variety of
    households
  • Anti-discrimination policies
  • Support primary care
  • Address language and advocacy needs.
  • Cultural competency should be core part of health
    workers training.
  • Supporting doctors from minority ethnic groups

47
So what can be done?
  • Improving accessibility of health care provision.
  • Encouraging groups with the greatest need to make
    use of services.
  • Improve living and working conditions.
  • EBP
  • Evaluate services
  • Needs assessments
  • Multi-agency working
  • Community participation
  • Involvement in decision making
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