L21 Health Disparities

Question 1

In Australia, the better-off live, on average,

Answer 1

two years longer than the poor

Question 2

Why do women live longer than men?

Answer 2

– Findings that women live longer than men may be as much the result of social and psychological factors as biological ones.

Question 3

Are we equally healthy?

Answer 3

No there are Health differentials across whole populations both within and between countries
– In general, the richer the country, the longer its population lives and the longer its equivalent of full health is

Question 4

• Marmot, Davey-Smith & Stansfield (1991): car ownership?

Answer 4

– middle class executives who own one car are more likely to die earlier than equivalent earners with two cars. (households where two cars mean double income families and they have all the more resources that come with this)

Question 5

Homelessness in Australia

Answer 5

58% male, 42% female
– 20% Indigenous Australians
– 30% born overseas

Question 6

Where do people stay?

Answer 6

– Improvised dwellings, tents or sleeping out 7% (8,200) tip of the ice-burg
– “Severely” overcrowded dwellings 44% (51,088) major issue

Question 7

Recent evidence in UK on social determinants of health

Answer 7

1. There is a persistent North-South divide in health—particularly marked among younger people.
2. Health inequalities, which probably became smaller during the 2000s, have grown again since about 2012.
3. There is a persistent North-South divide in health—particularly marked among younger people.

Question 8

Within countries 2010-12 life expectancy for indigneous

Answer 8

Indigenous males 10.6 yrs lower than non- indigenous

– Indigenous females 9.5 yrs lower than non- indigenous

Question 9

Aboriginal and Torres Straits Islanders have

Answer 9

– Higher infant mortality rates
– Higher unemployment rates
– Lower weekly income than other Australians
– More health risk behaviours
– Poorer housing circumstances
– Less access to education and child and maternal health.
– Breast, prostate, colorectal and skin cancer are lower
– Cervical cancer Incidence in Indigenous Australians 2x non-indigenous • 20 vs 9/100,000, 4 x higher cervical cancer mortality

Question 10

Cervical screening

Answer 10

2-yr participation rates of women aged 20-69 for cervical screening, Whop, et al 2016
- Indigenous its 36, and dropping slightly over time, to 33 %. Non indigenous, consistent at 60%

Question 11

STIs

Answer 11

Further research has suggested that rates of STIs, as well as HIV/AIDS are also increasing in this population
– HTLV-1 virus, indigenous communities in central Aust. Highest in the world
– Associated with rapidly fatal forms of leukaemia, inflammation in organs, increased risk of other infections
– HOWEVER, may be to do with higher susceptibility rather than a higher number of sexual partners (Fairley, Bowden, Gay, Paterson, Garland & Tabrizi, 1997)
– Implications for the type of health interventions that get planned?

Question 12

– difficulties in doing research with Aboriginal and Torres Straits Islanders

Answer 12

Torzillo (1999):
– difficulties in doing research with Aboriginal and Torres Straits Islanders
– political climate should not detract from the need to do good quality research in the area.
– This position is supported by a systematic review of clinical trials in this population, which found that there was a lack of such research (Morris, 1999)

Question 13

USA rank on the OECD average for life expectancy Explanations include:

Answer 13

24th
some groups have extremely poor health
– more characteristic of poor developing countries
– The HIV epidemic caused higher proportion of death and disability among young and middle-aged Americans than in most other advanced countries.
– ‘War on drugs (zero-tolerance means can’t do harm minimization)
– USA is one of the leading countries for cancers relating to tobacco.
– The United States has high incidences of homicides compared to other industrial countries.

Question 14

Can genes play a role in health disparities between countries?

Answer 14

Yes – Possibly also genetic differences between groups

Question 15

Ethnic Minorities

Answer 15

– Migrants to Australia have lower rates of cardiovascular mortality than Australian born people.
– Deaths from lung cancer and breast cancer were higher in UK and Irish born residents than Australian born people but skin cancer was lower
– People born in Asia had significantly higher rates of mortality from infectious diseases, diabetes and homicide than the Australian born population.

The incidence of type 2 diabetes in Greek and Italian migrants to Australia is three times that of the Australian born population (Hodge, English, O’Dea & Giles, 2004)
– Incidence of cervical cancer is higher in groups of migrants from the former Yugoslavia (Fernbach, 2002) (there have not been screening programs, not part of their culture)

Question 16

The ‘Healthy Migrant’ effect

Answer 16

– In general what can be found in Australia is what is called the ‘health migrant effect’
– The majority of people who migrate to Australia are as healthy if not healthier that the Australian born population (Australian Institute of Health and Welfare, 2000)
(Reflect on our policies? Hard to convince others to include a less healthy population within our population)

Question 17

Social class and gender mortality

Answer 17

– Lawson and Black (1993) found that marked differences in death rates according to social class exist. Male’s in every SES group have much higher mortality than women.
– If men of all social classes had the same mortality experiences as higher social class men the overall death rates for Australian men would be reduced by 60% 
– They suggest that socioeconomic status is the most important indicator of health status among Australians
(the social gradient in Australian mortality, 2009-2011)

Question 18

Social causation vs social drift

Answer 18

Social Causation Model
– Low SES ‘causes’ health problems.
– There is something about occupying a low socio-economic group that negatively influences the health of individuals.
Vs.
Social Drift Model
– Health problems ‘cause’ low SES.
– When individuals develop a health problem, they may not maintain a job or the levels of overtime required to maintain their standard of living. They therefore drift down the socio-economic scale.
Those with significant chronic mental health problems likely most affected.

Question 19

Health selection explanations

Answer 19

– People are not sick because they are poor.
– Rather, poor health lowers income and limits earning potential.
– There is little empirical support for this explanation.

Question 20

Statistical artefact explanations

Answer 20

– The poorest in any society are usually the sickest.
– A society with high levels of income inequality has high numbers of poor and consequently will have more people who are sick.
– There is little empirical support for this explanation

Question 21

Explaining inequalities

Answer 21

– It is impossible to decide how much each of these causes is contributing to the gradients in illnesses and deaths
– Understanding the material, behavioural and locality-based causes, and the interactions between them is a priority
– Behavioural, material, and local circumstances vary with SES

Question 22

Explaining Health differentials: Different health behaviour

Answer 22

– For example, in Australia the most socially disadvantaged people were twice as likely to smoke as those in the least socially disadvantaged group (Australian Bureau of Statistics, 2004).
– Poorer Australians are more likely to eat a less healthy diet, and take less leisure exercise than the better-off (Australian Bureau of Statistics, 2004).
– However, these differences do not provide the whole explanation for the health differentials

Question 23

the impact of job level and health behaviour on health outcomes over ten years.

Answer 23

– Marmot, Shipley and Rose (1984) examined the impact of job level and health behaviour on health outcomes over ten years.
– Smoking, alcohol, obesity, cholesterol and blood pressure removed
– Occupational status still remained independently predictive of health status
Most effective thing you can do is help an ill person get back to work.

Question 24

Environmental insult

Answer 24

– Exposed to working in dangerous settings such as building sites
– Have more accidents
– Living in rented accommodation
– E.g. Only 30% of the indigenous population were home owners compared to non-indigenous Australians (Australian Bureau of Statistics, 2005).
– Stress, strain and depression

Question 25

Stress, strain and depression Carroll, Davey-Smith & Bennett (1996):
– Childhood?

Answer 25

– family instability
– Overcrowding
– poor diet
– restricted educational opportunities

Question 26

Stress, strain and depression Carroll, Davey-Smith & Bennett (1996)
Adolescence?

Answer 26

– family strife
– exposure to smoking and own smoking
– leaving school with poor qualifications
– experiencing unemployment or low-paid and insecure jobs

Question 27

Stress, strain and depression Carroll, Davey-Smith & Bennett (1996) – Adulthood?

Answer 27

working in hazardous conditions
– financial insecurity – periods of unemployment
– low levels of control over work or home life
– negative social interactions

Question 28

Stress, strain and depression Carroll, Davey-Smith & Bennett (1996)– Older age?

Answer 28

no, or small occupational pension
– inadequate heating
– inadequate food

Question 29

Hobfoll & Lilly: conservation of resources model 1993

Answer 29

– Mental and physical health are determined by the amount of resources available to the individual. – economic (e.g. job, income)
– social (e.g. family support)
– structural (e.g. housing)
– psychological (e.g. coping skills, perceived control).
Indigenous fit this model well

– High level of resources is health-protective.
– Low levels of resources place an individual at risk for health problems.

Question 30

– Access to health care services in Australia is mediated by

Answer 30

– availability of services, especially in rural and outer urban areas
– cost of health care services, especially services to which patients are referred from primary care
– waiting times especially allied health services (particularly allied health in regional areas)
– outpatient medical specialist services
– elective procedures (Harris & Furler, 2002).
– Differences in response to unemployed patients with anxiety or depression
– being more likely to prescribe to people who are unemployed or low SES
– less likely to refer or offer non-pharmacological interventions
It would be nice if they also prescribed behavioural interventions about building skills.

Question 31

heart attack correlation?

Answer 31

– Low socioeconomic status was correlated with higher rates of admission for acute myocardial infarction, it was also related to low intervention rates (Beard, Morgan, Earnest, Summerhayes, Houlder & Dunn, 2006).

Question 32

Reducing Inequalities

Answer 32

– Strengthening individuals
– Strengthening communities
– Improving access to essential facilities and services
– Encouraging macro-economic and cultural change

Question 33

Incarceration

Answer 33

In 2013, indigenous Australians made up 23% of the prison population. With the juvenile system added, it would be much higher.
Twice as likely to experience high levels of distress.
3 x more likely hospitalised, self-harm

Question 34

Overarching recommendations closing the gap

Answer 34

– Improve daily living conditions
• Circumstances in which people are born, grow, live, work, age
– Tackle inequitable distribution of power, money, and resources
• Structural drivers of those conditions of daily life
– Measure and understand the problem and assess the impact of action
• Expand knowledge base, develop work force trained in SDH, raise public awareness