Week 9 Flashcards
What do we mean by health inequalities
Health inequalities are avoidable, unfair and systematic differences in health between different groups of people. There are many kinds of health inequality and many ways in which the term is used. This means that when we talk about ‘health inequality’ it is useful to be clear on which measure in unequally distributed and between which people. (Kings fund 2020)
Health inequalities
Preventable and unjust differences in health status across the population and between specific population groups
Avoidable differences do not occur randomly or by chance
Socially determined circumstances often beyond control of the individual
Limit opportunities and healthy life expectancy
Health inequality factors that policy often considers
Socio-economic factors, for example, income
Geography for example, region or whether urban or rural
Specific characteristics including those protected in law such as sex, ethnicity or disability
Socially excluded groups for example people experiencing homelessness
(Kings fund 2020)
Intersectionality
People experience different combinations of factors
The way different health inequality factors interact with each other is called intersectionality
Life expectancy at birth
Key measure of health inequality
Linked to peoples socio economic circumstances
Deprivation is a common measure of socio economic circumstances
Index of multiple deprivation
Deprivation and health
Index of multiple deprivation :
-level of income
-employment
-education
-levels of crime
Social gradient in health is the systematic relationship between deprivation and life expectancy
Males living in least deprived areas live 9.4 years longer thank males in most deprived areas
Gap is 7.4 years for females
Healthy life expectancy
Good health is another key measure of health inequality
2 important measures:
-healthy life expectancy
-disability free life expectancy
Inequalities in avoidable mortality
Some deaths are avoidable
Dependent on the getting help with illnesses and disease
Long term health conditions
Major causes of poor quality of life
Is a barrier to amount of type of work
Correlated with lower socio economic groups
Tend to be more severe in those in lower socio economic groups
Deprivation linked to having more than one LTC
Prevalence of mental ill health
Difficulties with accuracy of figure
Being in a protected characteristic linked to mental ill health
Women more likely to experience CMD, 1/5 and 1/8
Young women in particular
Psychotic disorders and ethnicity
People who identify as LGBTQ+ experience higher rates of poor mental ill health and lower well being than those who do not identify
Among working age adults suicide rates among the most deprived were consistently double the rates than those who were the least deprived
Wider determinants of health
These are social, economic and environmental conditions
-income
-access to green space
-access to healthy food
-nature of work
-home you live in
Behavioural risk factors
A persons behaviour is a major determinant of how healthy they are
4 principal behavioural risks to health are:
-smoking, poor diet, physical inactivity and high alcohol consumption
These risk are higher in disadvantaged groups
Circumstances can make it harder to move away from unhealthy behaviours
Access and experience of health services
Refers to services that are timely appropriate and easy to use
Full range access refers to access to preventative interventions, social services as well as primary and secondary care
Inequitable access means a groups faces barriers accessing these services that they need
Interactions between factors
We can see a complex interaction between a
number of factors
-Quality of health and care services
– Individual behaviours
– The places and communities people live in
– Wider determinants like education, housing and access to green space
The inverse care law
Those who need care the most are least likely to get it and those who least need it tend to use health services more
Access and equity
Marmot review fair society, health lives 2010
Health equity in England: the marmot review 10 years on
The health gap has grown between wealthy and deprived areas
The amount of time people spend in poor health has increased across England since 2010
Impact of COVID-19 and health inequalities
Mortality rates higher in more deprived areas
2.6 times higher for the most deprived decile
Ethnic minority groups have experience higher mortality
Highest being bangladeshi, Pakistani and Caribbean groups also mortality rates from all causes were higher in these groups
Covid-19 and disabled people
Greater risk of dying from COVID
Risk of death 1.6 and 1.4 times greater for disabled women and men respectively (those who consider their daily life to be ‘limited a lot’)
Marmot 10 years on
As Marmot notes “if health has stopped improving it is a sign that society has stopped improving” what is government for it not to act on that (Marmot 2020)
Cultural blindness
Claiming not to see differences in race, culture, ethnicity
‘Treating everyone the same way’
-this one size fits all approach
-does not represent personal care
-does not give equal chance
Culture
What is culture:
-beliefs and behaviours that are learned and shared by members of a group
Cultural trait or personal idiosyncrasy?
Sub cultures- nursing and medicine are examples of 2 subcultures
The cultural iceberg
Visible aspects
Non visible aspects
So what is cultural competence and how am I going to get it?
Understanding your own culture and biases
Becoming sensitive to the cultures of others
Appreciating differences
Acquiring knowledge and understanding of others cultures especially values and beliefs
Applying your knowledge
Remember cultural competence care is patient centred care
Asking the right questions
Principles of culturally competent care should apply to all patients
Learn to ask the right questions the 4 Cs
-what do you call your problem
-what do you think caused your problem
-how do you cope with your condition
-what concerns do you have regarding your condition
Stereotypes vs generalisation
Difference lies not in the content
But in the usage of the information
Stereotype is an ending point
A generalisation is an beginning point.
Values
Values are things we hold important. Values exist at the individual and cultural level
Understanding values is the key to understanding Behaviour
Some examples of different values system:
-independence and autonomy
-privacy
-health and fitness, what is considered healthy
-physical appearance
Values and healthcare culture
Conflicts and misunderstandings can occur in health care between the values of the health care culture and that of the patient population
Autonomy and independence
Efficiency
Self control
Worldview
Second most important concept in understanding people’s behaviour is understating their world view
World views consists of peoples assumptions about the nature of reality
People often interpret events in a manner that is consistent with their beliefs
Emic and Etic perspectives
Emic account comes from within the culture
Etic account comes from the observer and tries to be culturally neutral
Prejudice and discrimination
Evidence from studies that those individuals and communities that have had experience of institutional discrimination and racism may distrust the health care system
Communication
Language issues:
-idioms
-differences in language terms even in English speaking countries
-for example the use of the terms negative and positive as applied to tests can be confusing
Names:
-when someone else answers for the patient
Interpreters:
Non verbal communication
Ethnocentricism and relativism
Refers to attitudes
Ethnocentrism
Cultural relativism
Most humans are ethnocentric
Western health care systems tend to be ethnocentric
Time orientation
A person focus regarding time varies in different cultures
Focus on past, present and future
Past time orientation
Present time orientation
Future time orientation
More key concepts
Hierarchical versus egalitarian cultures
Family of orientation versus family of procreation
Models of disease:
-biomedical model
-magico-religious model
-holistic model
Disease etiology
Pain
Expression of pain
Pain medication
religion and spirituality
Religious practices
Sacred symbols
Spiritual beliefs and practices
Family
Decision making
The role of the family
Men and women
Sex roles
Gender preferences
Female purity
Birth
Ante partum
Labour and delivery
Postpartum
End of life
Dying
Death
Race, culture and ethnicity
Race is seen to be characterised by physical appearance and is determined by genetic ancestry and is usually permanent
Culture is a set of behaviours and attitudes of a group and is often determined by your upbringing and choice and is changeable
Ethnicity is defined as sense of belonging and is a group identity determined by social pressures, psychological need and is partially changeable
Acculturation
When a person arrives to a new country they will begin a process of acculturation they may have already started this process before they’ve even arrived
Acculturation refers to the process of taking on the cultures of the host country in which you arrive
Assimilation
It’s a process where a person becomes fully integrated into a new country where their language and culture resemble that of host community
Integration
It’s a process where a person takes on the cultural norms of the new country but also maintain their original culture or that of their parents
Separation
It’s where a person maintains their original culture and rejects that of the country to which they have migrated
Marginalisation
It’s when a person rejects their original culture and the new culture
Factors of health of populations
Genetic factors
Social factors
Environmental factors
Human discovery factors
Social causation
Stipulates that poorer people are more vulnerable to adversity and stress and this in turn makes them more vulnerable to developing a psychiatric illness
Social selection
Postulates that those who are mentally ill have impaired upward social mobility and therefore they drift into a lower socioeconomic status and neighbourhood
Social constructivism
This approach takes the view that reality of society is socially created and so are the labels that we assign people and the definitions that we create for behaviours that do not fit into what society defines as acceptable behaviour
Unacceptable deviants (termed as deviants) become noticed and pathologised and given labels which creates stigma for individuals
Under a label, will be set of stereotypical behaviours typical of a person with this label, the person who is labelled begins to internalise these expected behaviours and behaves in the expected way. These labelled deviants are rewarded by society for playing the stereotyped deviant role. Under this theoretical framework the concept of “lay appraisal” has emerged, this is the term given to the general population’s understandings about mental illness. A person who might display certain behaviours that are not deemed as “normal” will come to the attention of their family and friends who will appraise these signs and make decisions about symptoms and treatment even before the person has come to the attention of the clinician. It is argued that societies hostility towards the mentally ill by seeing them as “other” leads to stigma and prejudices and leads the person to take on the “sick” role to cope with such a hostile environment.
Critical theory/anti-psychiatry
Thomas Szasz is one of the main contributors to critical theory also sometime called anti- psychiatry. Szasz believed that the term “mental illness” was socially created in the same way as social constructivism states above. He argued it is a metaphor that describes a behaviour or action that other don’t like and come to describe it as an illness and go on to give it a label such as schizophrenia. He saw labels given as “fake” diseases. He proposed that these labels were given to support the use of power by psychiatric authorities to detain and treat people sometimes against their will. He also argued that drug addiction was not a disease but a social habit. Critical theory highlights the problem of coercion in psychiatry and how in other fields of medicine, coercion is rare and in psychiatry it is used on a daily basis. It also highlights the lack of control the patient has and the paternalistic role the doctor takes as having the right to treat the patient. These debates are still currently alive and well in mental health services and similar discussions are held in local mental health user groups who aim to improve mental health services and their own experiences.
