Health Inequalities Flashcards
what typically determines health inequalities
determined by socioeconomic circumstances and determinants
what is used to measure socioeconomic factors that impact health inequalities
measured in epidemiology mainly by education, income, occupational social class, and area-measures.
equalities domains (equality act 2010)
protected characteristics - Age - Disability - Gender reassignment - Marriage and civil partnership - Race - Religion or belief - Sex - Sexual orientation
inequalities primary definition
socioeconomic SES measures: - Education - Income - Occupational social class - Housing - Area-based measures
SES means
socioeconomic status
SES measures
- Education - Income - Occupational social class - Housing - Area-based measure
5 class groupings in Registrar General’s Social Class Groupings
I. Professional II. Managerial and Technical III. N Non-manual Skilled III. M Manual Skilled IV. Partly Skilled V. Unskilled then unemployed
Registrar General’s Social Class Examples I. Professional
accountants, engineers, doctors, dentists
Registrar General’s Social Class Examples II. Managerial and Technical
teachers, journalists, nurses, managers
Registrar General’s Social Class Examples III. N Non-manual skilled
clerks, shop assistants, cashiers
Registrar General’s Social Class Examples III. M Manual skilled
carpenters, van drivers, cooks
Registrar General’s Social Class Examples IV. Parly Skilled
security guards, machine tool operators, farm workers
Registrar General’s Social Class Examples V. Unskilled
building and civil engineering labourers, cleaners
difference of Great British Class Survey 2011 BBC
161,400 web respondents, as well as a nationally representative sample survey, inc unusually detailed questions asked on social, cultural and economic capita thus three dimension of Class UK – Economic, Social and Cultural
new classes as defined by Great British Class Survey 2011 BBC 7
elite established middle class technical middle class new affluent workers traditional working class emergent service workers premarital, or precarious proletariat
new classes as defined by Great British Class Survey 2011 BBC ELITE
the most privileged group in the UK, distinct from the other six classes through its wealth. This group has the highest levels of all three capitals
new classes as defined by Great British Class Survey 2011 BBC ESTABLISHED MIDDLE CLASS
the second wealthiest, scoring highly on all three capitals. The largest and most gregarious group, scoring second highest for cultural capital
new classes as defined by Great British Class Survey 2011 BBC TECHNICAL MIDDLE CLASS
a small, distinctive new class group which is prosperous but scores low for social and cultural capital. Distinguished by its social isolation and cultural apathy
new classes as defined by Great British Class Survey 2011 BBC NEW AFFLUENT WORKERS
a young class group which is socially and culturally active, with middling levels of economic capital
new classes as defined by Great British Class Survey 2011 BBC TRADITIONAL WORKING CLASS
scores low on all forms of capital, but is not completely deprived. Its members have reasonably high house values, explained by this group having the oldest average age at 66
new classes as defined by Great British Class Survey 2011 BBC EMERGENT SERVICE WORKERS
a new, young, urban group which is relatively poor but has high social and cultural capital
new classes as defined by Great British Class Survey 2011 BBC PREMARITAL, or PRECARIOUSL PROLETARIAT
the poorest, most deprived class, scoring low for social and cultural capital
areas - rich (affluent) or poor (deprived)? People or place?
People - social environment, culture, community, networks, Physical environment - services, safety, transport, parks/recreation, safety, air quality,
SIMD
Scottish Index of Multiple Deprivation (2020) area-based index (6976 data zones – neighbourhoods of 800 people) range of domains inc data from a range of sources inc eg census: - employment - Geographic access to services - Income - Crime - Health - Housing Education, skills, training Deciles (tenths) or Quintiles (fifths) - 1 is most deprived (poorest) - 5 or 10 is least deprived (richest)
SIMD divisions in
Deciles (tenths) or Quintiles (fifths) - 1 is most deprived (poorest) - 5 or 10 is least deprived (richest)
most extreme SIMD difference Glasgow
Drumchapel (28th poorest) vs Bearsden 60th (richest) – out of 6976
Global inequalities can be
between countries (high, middle, low income) or within countries Relates to income of country (GDP) or distribution of income in country
how can countries reduce inequality?
Sweden – high tax, levels down society – more contribution from higher paid Japan – has fairer pay – less discrepancy
health inequalities in (3)
Access and uptake to health services – inverse care law [Tudor-Hart] Health behaviours – smoking, diet, alcohol, exercise, etc Health and disease outcomes thus life-expectancy
scotland health inequalities dental decay
dental decay levels in children in Scotland have improved overall - good news! But inequalities between those children in our most deprived communities and those in the most affluent have not budged to the same degree - bad news - The problem of dental decay seems increasingly and stubbornly polarised to the poorest in society.
scotland health inequalities mouth cancer
mouth cancer rates, over the past 10 years, have increased up to nearly 700 cases per year. And we have also seen widening inequalities which began in early 1980s but continue to this date. Such that the risk associated with low socioeconomic position is double that of higher positions and this risk remains when you take into account smoking, alcohol, and diet behaviours.
scotland health inequalites alcohol related facial injuries
GDH found that the risk of being admitted to hospital with an alcohol-related facial injury was seven times greater if you lived in the most deprived areas compared to the most affluent. This is a scar across the face of Scotland is a physical scar yes, but also a social one
trend of health inequalities
more deprived = poorer health outcomes
good guide to oral health indicator
number of teeth fewer teeth in most deprived
NDIP is
national dental inspection programme
oral cancer in health inequality
Widening socioeconomic inequalities Males and females age-standardised incidence rate of oral and oro-pharyngeal cancer by Carstairs deprivation least and most deprived quintiles 1976-2002. - highest in most deprived males - more deprived of both sexes higher than less deprived As you know descriptive epidemiology only goes so far – hypothesis generating
measurement of inequality
Absolute measures (difference) Relative measures (ratio / gradient) Simple measures Complex measures
NDIP example % 5 year olds no obvious caries experience
Absolute inequalities (SIMD 5 – SIMD 1) 2008 73.1 – 42.2 = 30.9% 202086.9 – 58.1 = 28.8 % - i.e. V small reduction in (absolute) inequalities / differences difference between most and least deprived Relative inequalities (Relative Index of Inequality RII; weighted regression analysis of the gradient) 2010 1.58 2020 1.70 - i.e. Inequalities are stubbornly persistent - inequality has improved but gradient between worst and best has worsened ideal improve and level up, not widen
mortality causes in younger ages
driven by inequalities - iceberg of inequalities e.g. suicide, drug use
inverse care law
“The availability of good medical care tends to vary inversely with the need for it in the population served…” eg. - Deprived areas have fewer GPs - GPs have more patients, less time and resources
issue with biomedical perspective on improving health
Biomedical Perspective - Oral hygiene - Sugars consumption - Smoking and alcohol - Exposure to fluoride - Use of dental services thus Lifestyle / behaviour / Victim blaming Too reductionistic - Our research and Australian shown that behaviours alone account for limited degree of inequalities - Need to explore and uncover broader agenda
social determinants on inequality
Structural determinants - Power - Money - Wealth Conditions of daily life Political thus community / policy levers
fundamental aspect of health promotion
aims to empower people to have more control over the aspects of their lives that effects health (the wider social determinants of health)
example social determinants of health
social gradient, early years, work, social support, food, stress, social exclusion, unemployment, addictions, transport
health seen as
a resource for everyday life, not the objective of living, it is a positive concept emphasising social and personal resources, as well as physical capacities perspective is derived from a conception of ‘health’ as the extent to which an individual or group is able, on the one hand, to realise aspirations and satisfy needs, and on the other hand to change or cope with the environment
influences of why people smoke (8)
Age, sex and hereditary factors - Individual Life style factors and social and community networks – smoking is part of the social norm for some groups – e.g. young females, lone parents. People experiencing mental health problems, lower SES, Availability Education – do people know it’s bad for them Work environment – how many people smoke, the norm, social scene- outside smoking, smoking bans on premises, Stress Living Conditions – Horrible living conditions, alternative coping mechanism Unemployment – Nothing else to do but smoke, either that or worse Health Services – Any services available to help, is the GMP screening and recording the habit, providing brief intervention, offering help Socio – economic, cultural and environmental – in Scotland part of our culture, part of everyday routine
impact of social and welfare policies to promote health and wellbeing in population
impact positively or negatively how engaged the Government is Wider factors- environment, affects behaviours which impact on individual. No money to get to surgery- no self care- no control, blame society
social determinants of Oral health (based on Marmot Model)
economic, political and environmental conditions -> social and community contect -> oral health related behaviour -> individual
economic, political and environmental conditions determinants of oral health
poverty housing sanitation leisure facilities shopping facilities employment work/educational environment income policy (international, national, local) commercial advertising
social and community context determinant on oral health
social norms peer groups social capital cultural identity religion
oral health related behaviour determinant on oral health
diet hygiene smoking alcohol injury service
individual determinant on oral health
sex age genes biology
socio-economic, environmental and political conditions influence… effect on oral health inequalities
psychosocial factos (STRESS) influence behavioural factos influence biological factors which ultimately influence oral health inequalities
complex influences on health
wider influences -> lifestyle factos -> health (individuals and communities)
health inequalities - the causes: inequalities in the distribution of
income wealth power
health inequalities have implication on
health improvement
effective policies to reduce inequalities
Structural changes in environment Legislative and regulatory controls Fiscal policies Starting young Community action Improving accessibility of services Prioritizing disadvantaged population groups Reorientate health services
what ultimately solves health inequalities
ACTIONS Intervention (education) introduced a significant difference (p<0.05) in OH and gingival health between deprived and non-deprived schools. -> widened inequalities i.e. Better-off are better able to act on health promotion messages Hence, need care in implementing Health Promotion Interventions
ineffective interventions (increase inequalities)
Information based campaigns (mass media programmes) Written materials (leaflets and posters) Campaigns reliant on people taking the initiative to opt in Health education campaigns designed for the whole population Approaches which involve significant costs or other barriers need ACTIONS
what are the primary determinants of disease
mainly economic and social, and therefore its remedies must also be economic and social - they cause the causes of disease
Commission on Social Determinants of Health (CSDH) 3 principles of action
Improve the conditions of daily life Tackle the inequitable distribution of power, money and resources – globally, nationally and locally Measure the problem, evaluate action, expand the knowledge base, develop the work force
marmot’s 6 key policy objective of fair society, healthy lives
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
upstream- downstream interventions
upstream - healthy public policy to downstream - health education and clinical prevention - national and/or local policy initiatives - legislation/regulation - fiscal measures - healthy settings (HPS) - community development - training other professional groups - media campaigns - school dental health education - chair side dental health education - clinical prevention
upstream oral health examples
policies - Smoking ban in public spaces - School food policy - Sugar tax? - Minimum wage / income taxation
midstream oral health examples
Community development / engagement Social prescribing / community link workers / dental health support workers
downstream oral health examples
Chair-side clinical prevention Smoking cessation services
arnstein’s ladder of citizen participation (top to bottom)
Community control/leadership Delegated control Partnership / co-operation Participation Consultation Informed Placated / manipulated Increasing community/public participation, empowerment and control
reorientation of health services impact
Need to support and encourage dentists and their staff to be effective in prevention - Dentist not as available in areas of greatest need - Targeted – deprived access allowance policy So between 2006 and 2012 improved access to dental services in deprived areas
inverse care law
e.g. GPs
Not the difference between good and bad care
But issue of resource / service allocation.
Still an issue today, e.gs
- Deprived areas have fewer GPs
- Those on low incomes more dependent on public transport to access services
- People in manual work more likely to lose pay / or not allowed to take time off work
- Poorer educated people less knowledgeable about health / health services / less assertive when dealing with doctors.
- Poorer people do not have the money to jump NHS waiting lists by using private services
e.g.
smoking
UPSTREAM measures
LEGISLATIVE and fiscal levels
- Smoking bans – in certain places, cars with kids
- Plain packaging
- bans on advertising and sponsorship
- Unseen in shops
- Tax/cost
- Reducing cigs per pack
- raising age from 16 to 18
- test-purchasing to ensure law upheld
- limit on how many packets can but at once
e.g.
smoking
MIDSTREAM measures
COMMUNITY
- Help support groups for smokers
- School talks and posters
- socal marketing approaches/campaigns
- e-cigs
- smokefree workspaces
e.g.
smoking
DOWSTREAM measures
- Chairside personalised talks
- Referral to stop services
- advising
- signpositing
- NRT
social determinants of health (10)
- social gradient
- early years
- work
- social support
- food
- stress
- social exclusion
- unemployment
- addictions
- transport
impact of wider social deteminants of health
looking at the major determinants of health- including the social, economic and environmental aspects that are often outside individual or collective control.
Therefore a fundamental aspect of health promotion is that it aims to empower people to have more control over the aspects of their lives that effects health.
4 categories of socail determinants for oral health
- individual
- oral health related behaviour
- social and community context
- economic, political and environmental conditions
economic, polital and environmental conditions that are social determinants on oral health
- poverty
- housing
- sanitation
- leisure facilities
- shopping facilities
- employment
- work/educational environment
- income
- policy - international, national, local
- commercial
- advertising
social and community context that are social determinants of oral health
- social norms
- peer groups
- social capital
- cultural identity
- religion
oral health related behaviour that are social deteminants of oral health
- diet
- hygiene
- smoking
- alcohol
- injury
- service
individual factors that are social deteminants of oral health
sex
age
genes
biology
ineffecitve health interventions
- Information based campaigns (mass media programmes)
- Written materials (leaflets and posters)
- Campaigns reliant on people taking the initiative to opt in
- Health education campaigns designed for the whole population
- Approaches which involve significant costs or other barriers
INCREASE INEQUALITIES
- ACTIONS – SOLVE INEQUALITIES
absolute measure
describe the size of the difference
relative measure
show proportional differences between groups being compared
range
the difference between the values of the most and least advantaged groups.
unweighte - doesn’t take in consideration the size of the population of each group.
can be expressed in absolute and relative terms
absolute range
the difference between most and least disadvantaged
relative range
least disadvantaged divided by the most disadvantaged.
advantage of range
straightforward and easy to explain and understand
disadvantage of range
- Only uses the groups with the minimum and maximum values and therefore does not take into account any intermediate groups
- Inequalities will be greater and more disaggregated the population ranking measure is
how to interpret absolute range
magnitude of the value represents the level of inequality.
A value of 0 would indicate no inequality and a higher absolute value indicates greater inequality
how to interpret relative range
value of 1 indicates no inequality and the higher the value the larger the inequality
population attributable risk aim
quantify how much of a health outcome can be explained by an inequalities characteristic
what is the population attributable risk
uses the least disadvantaged area (or the area with the best value for the measure studied) as a baseline and quantifies everything over this value as attributable to inequality.
- What baseline to use will depend on the objectives of the analysis.
allows us to understand how a particular health aspect could improve if all groups had the same level of outcome.
3 advantages of population attributable risk
- Easy to interpret results
- Can be used to establish reduction targets
- Takes into consideration the population size of each group
3 disadvantages of population attributable risk
- Uses the least disadvantages group as the reference point – which sometimes might not be desirable
- Population attributable risks for multiple exposures can sum to more than 100% which can make explanation difficult
- Population attributable risk makes the assumption that all of the association between the risk factor and health indicator is casual – in reality there could be a number of other factors influencing the trends observes
how to interpret population attributable risk
usually presented as a percentage that varies between 0 and 100.
A value of 0 would indicate that the factor assessed has no impact at all and that there is no inequality, and higher values would point to increased inequality.
