Health Inequalities

Question 1

Health inequalities

Answer 1

Health inequalities (or health inequities) are systemic variations in health between groups defined by
- socioeconomic
- ethnic
- geographical characteristics
that are socially determined, modifiable, and, therefore, unfair (Whitehead & Dahlgren, 2006)

genetics,
behaviour
access to medical care

Question 2

Health inequalities: global level

Answer 2

Life expectancy at birth (WHO 2019 data):
50.7 years in Lesotho - 84.3 years in Japan

Healthy life expectancy at birth (WHO 2019 data)
46.4 years in Central African Republic – 73.6 years in Singapore

Maternal mortality ratio (WHO 2017 data)
2 women died per 100,000 births in Finland
1150 women died per 100,000 births in South Sudan

Under five mortality rate (WHO 2019 data)
2 per 1000 live births average in Iceland
117 per 1000 live births average in Somalia

Question 3

Health inequalities: national level

in uk (london vs. blackpool)

Answer 3

10.5 years (Westminster = 84.9 years, Blackpool = 74.4 years)

Question 4

contribution of health behaviours to social inequality in mortality? (stringhini et al., 2010)

Answer 4

More senior people = healthier diet

Usually focus on individual health behaviour however, socioeconomic postion may also affect this

Question 5

‘Social determinants of health’ (WHO, 2022)

Answer 5

Income and social protection
Education
Unemployment and job insecurity
Working life conditions
Food insecurity
Housing, basic amenities and the environment
Early childhood development
Social inclusion and non-discrimination
Access to affordable health services of decent quality.

Question 6

Social determinants of health – a major driver of health inequalities

Answer 6

housing,
income,
education,
social isolation,
disability

Unequal distribution of money, power and resources

Social and economic inequalities - unequal daily living conditions

Health inequalities

Question 7

the covid-19 pandemic and health inequalities

Answer 7

Poorer existing health status, ↑ NCDs (risk factors for COVID) as a result of inequalities in exposure to SDH:

Employment - adverse working conditions concentrated in lower-skilled jobs, more likely to be designated key worker, not working from home (↑exposure)

Access to healthcare - reduced access in disadvantaged communities – may ↑ risk factors plus affect COVID outcomes

Housing - poor quality housing associated with certain health conditions, overcrowding ↑ infection rates, lack of outdoor space, plus psychosocial impact of high housing costs

Chronic stress of material/psychological deprivation is associated with immunosuppression
Unequal experience of lockdown measures (including financial)

Question 8

why act on health inequalities?

Answer 8

A matter of ‘social justice’ – health inequalities preventable by reasonable means are unfair (Marmot, 2010)

Reduction in premature deaths, increase in healthy life expectancy

Economic benefits

Question 9

Global: WHO Commission on Social Determinants of Health (2008)

Answer 9

Overarching recommendations:
Improve daily living conditions (circumstances in which people are born, grow, live, work and age)

Tackle the inequitable distribution of power, money and resources (structural drivers e.g. macroeconomic and urbanisation policies)

Measure and understand the problems and assess the impact of action (e.g. workforce trained in SDH, raise public awareness, scaled up and systematic action, proportionate to the disadvantage)

Question 10

Global: Sustainable Development Goal 10

Answer 10

Position in 2022 (UN, 2022):
Encouraging steady progress on narrowing income inequality appear to be reversing due to COVID, and

slow recovery of developing economies is widening disparities between countries

Record numbers of refugees worldwide (↑44% since 2015) including 6 million refugees from Ukraine, with high numbers of migrant deaths

Relative poverty increased in many – but not all – countries

Question 11

National: Fair Society, Healthy Lives (‘The Marmot Review’ 2010)

6 policy objectives

Answer 11

Six policy objectives with action across the life course:

• Give every child the best start in life
• Enable all children young people and adults to maximise their capabilities and have control over their lives
• Create fair employment and good work for all
• Ensure healthy standard of living for all
• Create and develop healthy and sustainable places and communities
• Strengthen the role and impact of ill health prevention

Question 12

Health equity in England: the Marmot review 10 years on (2020a)

Answer 12

‘We have lost a decade. And it shows’.

Improvements in health slowed markedly between 2010-2020
Stalling life expectancy from 2010

Health inequalities widened since 2010, meaning higher inequalities in society

Life expectancy for women and men living in the most deprived areas outside London dropped.

Stresses marked regional differences in life expectancy, particularly in more deprived areas

Some changes as a direct result of government policy (e.g. austerity - reductions in public expenditure - highest in most deprived areas)

Question 13

UK government policy to reduce health inequality

Answer 13

‘Causes for concern’ (Ralston et al., 2022)
persistence of an individualistic, medical model of health (e.g. focus on changing behaviours rather than changing the environment)

terminology ‘health disparities’ lacks the moral & political dimensions of referring to ‘inequalities’ and positioned as stemming from unhealthy lifestyle choices of those living in areas with poorer health
lacking specific target for ‘narrowing the gap’ in healthy life expectancy

greater local decision making unlikely to make much difference unless cuts to public health spending are reversed

no specific focus on inequalities in health by ethnic group

Question 14

can public health interventions increase health inequalities? (lorenc et al, 2013)

Answer 14

Some effective public health interventions (that improve health overall) may increase inequalities by disproportionately benefiting less disadvantaged groups

Question 15

Tentative pattern in the public health interventions that are effective in reducing health inequalities across all 5 intervention types

Answer 15

Taxes and food subsidies reduce inequalities by improving the health/health behaviours of the most vulnerable

For regulation, evidence of effectiveness of water fluoridation

For education policies, evidence of effectiveness of toothbrushing and targeted nutrition education programmes

Some interventions with overall benefit have no impact on health inequalities (e.g. free fruit in schools)

Most interventions are targeted to only most vulerable compared to least vulerable - none used gradient approach

Question 16

UK food security report 2021 (defra, 2021)

Answer 16

Overall, in 2019-20 food was the 4th highest cost for households, an average of 10.8% of expenditure

The poorest 20% of households spent a higher proportion of their income on food – more impacted by changes in food prices

Question 17

level of food security in the UK (Defra, 2021)

definition
A, A, U

Answer 17

Food security as a concept defined as ‘access by all people at all times to enough food for an active, healthy life’

affordability – financial means to meet nutritional requirements

access – physical access to buy healthy, nutritious food (shops, delivery)

utilisation – ability and opportunity to prepare foods within households (considering disabilities, lack of storage and prep facilities, energy costs, lack of time/skills to cook)

plus stability of the consistency with which these can be met

In UK surveys, a member from each household is asked about experiences in past 30 days
gives details of overall household financial situation and access to food
does not give information about individual experience of food insecurity for household members, or measure hunger

Question 18

DWP family resources survey 2020-21 (DWP, 2022)

WHERE ARE THERE HIGH AND LOW LEVELS OF FOOD SECURITY?

Answer 18

Geographical differences (higher food security in Wales than England and Scotland; higher food security in SE England than in NE England)

Higher levels of food security:
with higher income
where head of household is aged 65+
where head of the household has higher level of qualification
amongst Indian households than Black households

Lower levels of food security:
single adult households with children
households in social renting sector

Question 19

inflation in food prices 2021-2022

Answer 19

Food inflation = 14.6% from Sep 2021 to Sep 2022

Higher than overall inflation in this period = 10.1%

Food currently the second biggest contributor to inflation

Driven by range of factors including high input costs (energy, fertiliser, CO2) and the war in Ukraine

Question 20

cost of an adequate diet?

Answer 20

Increase in ‘Basic basket’ (reasonably costed adequately nutritious diet) increased by 15% over 6 months
£45.55 for woman
£49.36 for men

Question 21

food foundation/YOU GOV food insecurity tracking (2022b)

Answer 21

September 2022 results (n=4280 adults)
18.4% households (9.7m adults) experienced food insecurity in the past month; over half of households (53.8%) on Universal Credit
One in four households with children (25.8%) experienced food insecurity in the past month
Food insecurity increased more in households with children than without (16.0%)
Regional inequalities (27.8% food secure in NE England, 14.1% in SW England)

Question 22

Affordability of a healthy diet

Answer 22

Diets meeting recommendations for fruit and veg, oily fish, sugars, fat, saturated fat and salt 3-17% more expensive

Diets meeting recommendation for red/processed meat 4% less expensive

Diets meeting the recommendations for fibre = cost neutral

Conclusion: food costs may be a population level barrier to adopting dietary recommendations in the UK

Question 23

food security and compromise in diet quality

Answer 23

Houses who are more food insecure are cutting back on healthy food such as fruit and veg

Question 24

how do diets differ between socioeconomic groups?

food eaten

indicators

Answer 24

Socio-economic dietary inequalities in UK adults (Maguire & Monsivais, 2015) using NDNS data 2008-2011

fruit & veg, red & processed meat, oily fish,
saturated fat, NME sugars

SE indicators = income, occupation, educational qualifications

Found consistent socio-economic gradients in consumption of all 3 foods by income, occupation and education level

Higher SE groups consumed ↑ fruit & veg, ↓red & processed meat and NME sugar, more likely to eat oily fish (no significant difference for saturated fat)

Conclusion: aligning dietary intakes with public health guidance many require interventions specifically designed to reduce health inequalities

Question 25

income analysis of NDNS results (PHE&FSA, 2019)

Answer 25

↑total fruit and veg, % meeting 5 a day recommendation,
↑fruit juice consumers, oily fish consumers
↓sugar sweetened drink consumers (most groups)
↔ meat, red/processed meat, total fish

“Although those on higher incomes were closer to meeting some recommendations, overall where diets failed to meet recommendations this was the case across the range of income.”

Question 26

national food strategy independent review (2021)

Answer 26

Included 4 recommendations to reduce diet-related inequality:

Extend eligibility for free school meals

Fund the Holiday Activities and Food (HAF) programme for the next three years

Expand the Healthy Start scheme

Trial a ‘Community Eatwell’ programme (including prescription of fruit and veg, food-related education and social support) supporting those on low incomes to improve their diets

Question 27

free school meals (FSM) in England

Answer 27

All KS1 (infant) pupils eligible for free school meals in England
KS2 and secondary pupils – eligibility based on household income (annual income of <£7,400 after tax and in receipt of qualifying benefits)
2021/22: 22.5% pupils in England eligible for FSM (1.9m children)
an increase from 20.8% in 2020/21

Not all children living in poverty are eligible for free school meals – Child Poverty Action Group estimated in June 2022 that 800,000 children classed as living in poverty were not entitled to free school meals

Question 28

rationale for extending FSM eligibility (national food strategy, 2021)

Answer 28

Ensures free school lunches are available to a higher proportion of children in low income households

To reduce harmful effects of hunger on children’s behaviour and educational achievement

To reduce inequalities in diet quality for children from low income families –simplest, least intrusive way to ensue all children have at least one well-balanced, healthy meal each day

UK research has consistently shown school lunches to be healthier than packed lunches, including research specifically focusing on children from low income households (Stevens & Nelson, 2011)

Has public support (Lasko-Skinner & Sweetland, 2021):

Question 29

impact of FSM pilots in England (kitchen et al., 2013)

Answer 29

Most pupils took up universal offer (around 90% compared with 60% in non-pilot areas), ↑ for pupils previously eligible and not eligible for FSM
Shift in types of foods eaten at lunchtime from packed lunch foods to hot meal foods (↑veg, pasta, water ↓crisps, fruit, soft drinks)
Few significant impacts on overall consumption of individual foods
Significant positive impact on attainment at KS1 & KS2 (pupils in pilot areas on average 4-8 weeks more progress than in non-pilot areas), with impact appearing to be greatest in lowest income/previously lowest attending

Wolverhampton
Did not significantly increase take up of school meals in Wolverhampton secondary schools (stigma? Unaware of entitlement? Food choice available?)

Little impact on children’s diet and eating habits

Did not significantly affect attainment for primary or secondary pupils

No significant change

No evidence of change to BMI or other health outcomes

Question 30

Review of international universal FSM impact (Cohen et al., 2021)

Answer 30

Benefits to students, particularly those who are food insecure and/or near to eligibility cut off

Majority of studies found that UFSMs associated with increases in participation, improved diet quality and food security, no change/improved BMI

Further research needed into how optimal participation and benefits can be achieved

With presence of strong nutrition guidelines UFSMs have multiple potential benefits for students and schools

Question 31

impact of FSM on dietary quality? (Parnham et al., 2022)

Answer 31

UIFSM led to:
↑ infant schoolchildren having a school meal (from 47.4% to 80.5%)

No impacts seen on key food groups (fruit and veg, sweetened drinks)

Evidence of lowered consumption of foods associated with packed lunches (crisps) and some nutrients (fat, sodium), but not sugar

Impacts differed by income group, with larger effects in low-income children

Conclusion: Some improvements demonstrated in dietary quality, but findings suggest that school meal quality needs to be improved to fully realise the benefits (schools not complying with school food standards?)

Question 32

does improving school food improve educational outcomes? (belot and james, 2011)

Answer 32

Results – the campaign in Greenwich coincided with:
Improvements in educational achievement (e.g. ↑ % children reaching level 5 in Maths, English and Science) relative to other areas (more pronounced in higher SE groups)

↓14% authorised absence (likely to be due to illness) relative to other areas, but no change in unauthorised absence