Health Inequalities Flashcards
Health inequalities
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
Health inequalities: global level
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
Health inequalities: national level
in uk (london vs. blackpool)
10.5 years (Westminster = 84.9 years, Blackpool = 74.4 years)
contribution of health behaviours to social inequality in mortality? (stringhini et al., 2010)
More senior people = healthier diet
Usually focus on individual health behaviour however, socioeconomic postion may also affect this
‘Social determinants of health’ (WHO, 2022)
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.
Social determinants of health – a major driver of health inequalities
housing,
income,
education,
social isolation,
disability
Unequal distribution of money, power and resources
Social and economic inequalities - unequal daily living conditions
Health inequalities
the covid-19 pandemic and health inequalities
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)
why act on health inequalities?
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
Global: WHO Commission on Social Determinants of Health (2008)
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)
Global: Sustainable Development Goal 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
National: Fair Society, Healthy Lives (‘The Marmot Review’ 2010)
6 policy objectives
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
Health equity in England: the Marmot review 10 years on (2020a)
‘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)
UK government policy to reduce health inequality
‘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
can public health interventions increase health inequalities? (lorenc et al, 2013)
Some effective public health interventions (that improve health overall) may increase inequalities by disproportionately benefiting less disadvantaged groups
Tentative pattern in the public health interventions that are effective in reducing health inequalities across all 5 intervention types
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
UK food security report 2021 (defra, 2021)
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
level of food security in the UK (Defra, 2021)
definition
A, A, U
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
DWP family resources survey 2020-21 (DWP, 2022)
WHERE ARE THERE HIGH AND LOW LEVELS OF FOOD SECURITY?
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
inflation in food prices 2021-2022
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
cost of an adequate diet?
Increase in ‘Basic basket’ (reasonably costed adequately nutritious diet) increased by 15% over 6 months
£45.55 for woman
£49.36 for men
food foundation/YOU GOV food insecurity tracking (2022b)
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)
Affordability of a healthy diet
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
food security and compromise in diet quality
Houses who are more food insecure are cutting back on healthy food such as fruit and veg
how do diets differ between socioeconomic groups?
food eaten
indicators
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
