Session 3: Inequalities and Inequities in Health and Healthcare

Question 1

How can we measure (and compare the health of different groups)?

Answer 1

• By measuring mortality and life expectancy
• Self-report e.g. Surveys: Census 2011 e.g. how is your health in general? Very good/Good/Fair/Bad/Very bad
• Other useful sources of data? Diagnosis rates, QOF records from GPs, admission rates

Question 2

What patterns would you expect to find if we compared the health of people living in different regions of England?

Answer 2

• Kensington and Chelsea/Richmond area - life expectancy is up to 86
• In areas like inner city area Manchester, Tower Hamlets etc - life expectancy down to 79
• Census data can also give you idea of healthy years (years in good health) - range from up to 70 to down to mid 50s

Question 3

How can we measure (and compare) the health of people in different socioeconomic positions?

Answer 3

• [SES: Socioeconomic status]
• Measuring socioeconomic position - based on individual occupation
• Most commonly used measurement at the moment is National Statistics Socio-Economic Classification (NS-SEC)
• Census 2011: Q.26-38 (current and past work status, title, responsibilities, sector)
• Complex calculation

Question 4

How could you measure deprivation - based on geographical residential area?

Answer 4

• Index of Multiple Deprivation
• Calculated from Census data on 7 domains (Income, Employment, health and disability, Education skills and training, barriers to housing and services, living environment, crime)
• Small areas (~1500 residents/650 households) (Lower Layer Super Output Areas) ranked to allow comparisons.

Question 5

What patterns would you expect to find if we compare the health of people in different socioeconomic positions?

Answer 5

• Census 2011 showed the lower the SES, the higher the porportion of people reporting ill health and disease (stepwise increase).
• Rates of infant mortality such as still birth, perinatal, neonatal, post-neonatal and infant all decrease the higher the socioeconomic position.
• Life expectancy and disability-life expectancy is lower in more deprived areas - a lot of people from the more deprived areas are have more years below the pension line spent in hell health.
• Summary: in the UK, health inequalities are evident between AND within regions. Deprivation is strongly assoicated with (ill) health:

**The more deprived a person is, the larger the proportion of their life will be spent in ill health, and the more likely they will die at a younger age. **

Question 6

What explanations are there for inequalities in health?

Answer 6

• A long history. Census data from 1911 onwards allowed occupation-based comparisons on death rates.
• Black Report (commissioned by Department of Health): a landmark text; outlined 4 explanations (initially suppressed by conservative government).
• ‘Acheson’ Report (Labour government), 1998: inequalities had widened since Black Report
• Whitehall Studies, 1967; 1985-present: cohort study of civil servants (health and risk factors, job grade etc)
• ‘Marmot Report’ Fair Society, Healthy Lives, 2010: review of evidence-based strategies for tackling inequalities. *More than 30 years after the Black Report, inequalities were worsening. *

Question 7

What are the Explanations, theories and pathways for Inequalities in Health?

Answer 7

The Black Report provided 4 different explanations and put inequalities on the political and research agenda

1. Artefact
2. Social Explanation
3. Behavioural-cultural
4. Materialist

In addition there is also research evidence to support psychosocial explanations and income distribution theory

5. Psychosocial
6. Income distribution

Research continues e.g. Institute of Health Equity

Question 8

Describe the Artefact Explanation

Answer 8

• = Health inequalities are evident due to the way statistics are collected (re measurement of class).
• Concerns about quality of data and method of measurement (of social class and health)
• Numerator: based on occupational distribution of those who die during the period considered.
• Denominator: occupational distribution at the most recent Census
• *Potential problem that death rates in the lower socioeconomic positions were being artificially elevated because people may not have been reporting correctly in the census data. *
• Mostly decredited as an explanation.
• If anything, data problems lead to underestimation of inequaltities.

Question 9

Describe the Social Selection Explanation (Black Report)

Answer 9

• Health determines social position rather than social position influencing health through the process of social mobility (up and down the hierarchy) = Direction of causation is from health to social position.
• Sick individuals move down social hierarchy, health individuals move up (e.g. due to not being able to work).
• However chronically ill and disabled people are more likel to be disadvantaged.
• However huge social health differences in a children (who have no prospensity for social mobility).
• Plausible explanation but studies suggest that, at most, social-selection makes only minor contribution to social explanation differences in health and mortality (doesn’t provide whole picture).

Question 10

Describe the Behavioural-Cultural Explanation (Black Report)

Answer 10

• = Ill health is due to people’s choices/decisions, lack of knowledge (e.g. about long term effects) and goals
• People from disadvantaged backgrounds tend to engage in more health-damaging behaviours, while people from advantaged backgrounds tend to engage in more health-promoting behaviours.
• Useful explanation (some merit) - e.g. for health education.

Limitations:

• It is too simplistic to consider health behaviours as always determined by our choices - we need to consider wide social environment when choices are not always possible e.g. cost and accessibility of healthy food.
• Behaviours are outcomes of social processes, not simply individual choice.
• “Choices” may be difficult to exercise in adverse conditions
• “Choices” may be rational for those whose lives are constrained by their lack of resources

Question 11

Describe the Materialist Explanation (Black Report)

Answer 11

• = Inequalities in health arise from differential access to material resources (focuses on lack of choice) - low income; unemployment; work environments; low control over job; poor housing conditions.
• Lack of choice in exposure to hazards and adverse conditions e.g. less access to green space and exercise facilities
• Accumulation of factors across life-course (not taken into account by the Behavioural-Cultural explanation)
• Most plausible

Limitations

• Further research needed as to precise routes (pathways) through which material deprivation causes ill-health

Question 12

Describe Psychosocial Explanation(s)

Answer 12

• Psychosocial pathways act in addition to direct effects of absolute material living standards - not just economic and environmental factors that impact our health. Stress is also influential.
• Data from Whitehall studies (e.g. Marmot 1991) - social gradient of psychosocial factors.
• Some stressors are distributed on a social gradient - e.g. negative life events, social support, autonomy at work; job security.
• Bio-Psycho-Social model
• Stress impact on health via different pathways:
• Direct (physiological, immune system)
• Indirect (health related behaviours, mental health)

Question 13

Describe the Income Distribution Explanation (Wilkinson)

Answer 13

• Relative (not average) income affects health .
• Countries with greater income inequalities have greater health inequalities.
• It is not the richest, but the most egalitarian societies that have the best health
• Health and social problems are not related to average income in rich countries.
• Health and social problems are worse in more unequal countries.
• The larger the income gaps within a country, the worse the worse the country performs on these health and social problems.
• Why? Associated with psychosocial explanation (increased social inequality => increased social-evaluative threat => increased stress => decreased health)
• Redistributive policies: reducing income inequality in a society can improve social well-being and in turn many other health and social factors.

Question 14

How can we measure ACCESS to healthcare?

Answer 14

• Utilisation studies measure receipt of services. But what about people who don’t access care because they can’t/don’t know how?
• Evidence about Utilisation is contradictory and difficult to interpret

Question 15

What is the difference between Inequality and Inequity?

Answer 15

• Inequality: when things are different (not equal)
• Inequity: inequalities that are unfair and avoidable (or not accounted for by clinical need) - e.g. when 2 different groups have the same clinical need but only one of them has access to the health services for that clinical need.
• You can have inequality without inequity

Question 16

Describe Deprivation and Patterns of Access

Answer 16

More deprived groups seem to have:

• Higher rates of use of GP services and emergency services
• Under-use of preventive services (e.g. screening, asthma, outpatients) and specialist services (e.g. CABG and cancer treatments)

Question 17

Describe the theory and evidence behind Deprivation and access

Answer 17

• Tendency to manage health as a series of crises
• Normalisation of ill-health
• Event-based consulting may be required to legitimise consultations being ill but not wanting to have ill identitity
• Difficulty marshalling the resources needed for negiotiation and engagement with health services (requires a variety of sources - transport, social support to help patient get to GPs etc)
• Tendency to use more “porous” services e.g. GPs are perhaps easier to access.
• May reflect lack of cultural alignment between health services and lower SES
• Adjudications of technical and social eligibility by doctors affect referrals and offers.
• Inequities in access are mediated by complex forms of social advantage and disadvantage as well as differences in service use are associated with social disadvantage (+ ethnicity + gender)

Question 18

What factors relating to diversity are associated with inequalities in health?

Answer 18

• Ethnicity
• Gender
• Age
• Disability
• Homelessness

Question 19

Describe Ethnicity and Health

Answer 19

Lots of different patterns

• CVD: highest % prevalence in men of south Asian origin, also high rates in Irish men
• Cancer: generally lower % prevalence in BME (black and minority ethnic groups); exceptions include prostate cancer (higher in black men).
• Respiratory disease: BME groups lower than white british
• Liver disease: BME groups lower than white british; exceptions include Hep B conditions in chinese populations
• Health is patterned by ethnicity; minority ethnic groups are at risk of significant disadvantage across a range of circumstances and indicators. Complex patterns with many contributing factors

Question 20

Describe contributing factors in Ethnicity, SES and Health

Answer 20

• Many (but not all) minority ethnic groups face large SES inequalities but this is not the only factor impacting on health.
• Patterns of use of, and engagement with healthcare are different for different BME groups e.g. primary care use - higher rates by some SA groups, lower rates by chinese groups. Another example is lower receipt of some specialist services. Higher use of mental health consultations (South African Female Elders)
• Service provision: perhaps service needs are not being met in some BME groups - potential discrimination in service provision, diagnosis and treatment e.g. due to language barriers etc.
• Responsiveness: how well do services meet the needs of different groups? E,g. due to social disapproval of certain health issues such as people not seeking consultation on sexual activities, alcohol etc.
• Language and social networks may deter help-seeking.
• Stigmatisation and stereotyping. Association between ethnicity and socioeconomic status.

Question 21

Describe Ethnicity, Culture and Health

Answer 21

• Some (health-related) behaviours vary by ethnicity (some BME groups may be more likely to participate in some health behaviours than others).

BUT

• Significant herteogeneity within ethnic groups.
• Many minority groups do ‘better’ than majority WB in relation to key health risks (smoking, alcohol, diet).
• Behaviour patterns are heavily shaped by the socio-economic context.
• Impact of behaviours depends on the response from healthcare/systems - i.e. if behaviours regarded as ‘deviating’ from ‘the norm’.

AVOID ‘victim blaming’ when mkaing assoications e.g. ‘this particular behaviour is associated with that group’ - not thinking about how services could be adjusted to meet needs accordingly

Question 22

Describe how multidimensional Ethnicity and Health is

Answer 22

Question 23

Describe differences in gender and health. Consider gender vs. sex

Answer 23

• Males: higher mortality rates (e.g. more heart attacks), more suicide and violent death
• Females: higher life expectancy, higher reported (poor) mental health, higher rates of disability and limited longstanding illness. Women have higher use of primary care.
• Cultural expectations of what is gender appropriate
• ‘men die quicker, but women get sicker’

Gender vs, Sex:

• Sex: biological factors (hormonal, reproductive differences)
• Gender: social factors (roles, norms, discrimination). What is about being a woman/man that influences our health?
• Gender and SES: there are more men in Class 1 (higher managerial and professional) and large proportions of women in Classes 2, 3 and 6).

Question 24

Sum up Diversity and Inequalities in Health

Answer 24

• Inequalities in health are not only related to socioeconomic factors, but are also associated with diversity (including ethnicity, gender etc)
• Relationships between factors are complex
• The health of each individual patient that you meet is related to their socioeconomic status (and the constraints within with that hey live), ethnicity, gender and age

Question 25

Describe the measurement/classification of SES

Answer 25

Individual

• Registrar General Scheme
• NS-SEC

Area-based

• Townsend-Deprivation Score

Education

• Years / level reached

Income

• E.g. household

Question 26

Describe the Townsend Deprivation Score

Answer 26

• Census data
• 4 variables
• Unemployment
• Car ownership
• Overcrowded housing
• Housing tenure
• Limitations include heterogeneity and transient populations