Health Inequalities & CLAHRC (SY)

1. Health Inequalities & CLAHRC (SY) Sarah Salway On behalf of the Inequalities Implementation Theme

2. CLAHRC (SY)Inequalities ImplementationTheme • Lead: Dr Liddy Goyder, ScHARR, UoS • Representatives from Public Health sections of PCTs - Sheffield, Barnsley, Rotherham, Doncaster • Academic researchers at UoS and SHU • 3 Research Facilitators one each at Sheffield, Barnsley, Rotherham PCTs • 2 PhD Students one each at SHU and UoS

3. Overall aim To build on existing public health programmes that target deprived communities to promote evidence-based public health interventions that will improve health outcomes and reduce inequalities across South Yorkshire

4. Overview of talk • What do we mean by 'health inequalities'? • Why are we concerned about health inequalities? • What does health-related research have to do with health inequalities? • Attention to inequalities within CLAHRC (SY):- Inequalities Implementation Theme- Linkages with other Themes

5. What are 'health inequalities'? Systematic disparities in health status between groups with different levels of underlying social (dis)advantage including wealth, power or prestige [Exworthy et al.,2006 after Braveman & Gruskin, 2003]

6. Defining /describing 'health inequalities' • Differences between 'groups' • Gaps, disparities, inequities (unfair / avoidable) • Several 'axes' of health disadvantage: gender, class, ethnicity, age, disability, geography • Axes also demarcate 'difference' and social hierarchy • In UK, predominant focus has been socioeconomic and geographical • Separate strands of policy activity around race/ethnicity and to a lesser extent disability and gender • Variety of measures relating to: health outcomes; receipt of services in relation to need; quality of services (e.g. satisfaction) etc. • Also sometimes expressed in terms of 'gradients' across whole population

7. Age standardised death rates per 100,000 population for circulatory diseases under 75 by area of deprivation

8. Proportion of people reporting a long-term health condition among four Census 2001 ethnic categories

9. The health gradient High Health state Low Low High 'Social advantage' (e.g. income, education)

10. The health gradient 'Paradox' - while the health of the population as whole may be improving, the health of the least well off improves more slowly or in some cases gets worse in absolute terms (Graham & Kelly, 2004) 1990s High Health state 1970s Low Low High Social advantage

11. Shifting the health gradient High Health state Low Low High Social advantage

12. Local illustrations • Barnsley: People living in poorer areas are twice as likely to die prematurely as those in the more affluent areas. • Sheffield: 14 year difference in life expectancy between the best and worst off neighbourhoods. • Compared to White British majority, Black and Ethnic Minority (BME) communities in South Yorkshire have:- much higher rates of diabetes and CHD- greater levels of emergency admissions to hospital - lower uptake of screening and preventive services(though variation between and within groups too)

13. Why are we concerned with 'health inequalities'? • Moral imperatives: concern for fairness or justice • Policy imperatives at national and international level • Legal requirements • Poor health of large sections of the population is problem for everyone (e.g. worklessness, spiralling NHS costs, exclusion) • Targets and priorities for whole populations • Alignment of efficiency and equity agendas

14. DH position "Health is profoundly unequal. Health inequality … exists between social classes, different areas of the country, between men and women and between people from different ethnic groups. The story of health inequality is clear: the poorer you are, the more likely you are to be ill and to die younger. That is true for almost every health problem" "Health inequalities are unacceptable. They start early in life and persist not only into old age but subsequent generations. Tackling health inequalities is a top priority for this Government, and it is focused on narrowing the health gap between disadvantaged groups, communities and the rest of the country, and on improving health overall."

15. What has our research got to do with health inequalities? • Tend to associate inequalities with public health and social determinants, 'caused by society not health services' • But, the health system can mitigate or, more often, exacerbate inequalities • Health services often mirror and (re)create the same hierarchies of exclusion as wider society - persistent inequalities in access and quality of curative and rehabilitative care • Preventive and health promoting interventions increasingly prioritised - commissioning health rather than healthcare • Healthy cities, health-promoting environments, healthy choices - health and health inequality is increasingly everybody's business • Much more has been done to document and describe inequalities than to understand causes or solutions • Huge need for research evidence that can inform policy and practice to improve health of most disadvantaged sections of society

16. Research must address difference and disadvantage Research Governance Framework: 'Research, and those pursuing it, should respect the diversity of human society and conditions and the multi-cultural nature of society, Whenever relevant, it should take account of age, disability, gender, sexual orientation, race, culture and religion in its design, undertaking and reporting. The body of research evidence available to policy makers should reflect the diversity of the population' World Class Commissioning: 'Commissioning decisions should be based on sound evidence… In particular, world class commissioning will ensure that the greatest priority is placed on those whose needs are greatest'

17. Findings overlook processes of disadvantage / support the status quo → inequalities remain Research does not pay attention to inequalities Knowledge translation process considers inequalities issues → may lead to reduced disparities in longer term Findings inform new intervention that benefits better off → inequalities grow (IGIs)

18. K Findings reinforce processes of disadvantage / support the status quo → inequalities remain or even grow Research does pay attention to inequalities:- direct focus- indirect (inclusion) Findings inform new intervention that benefits worse off → inequalities decrease Inequalities Theme aims to encourage and support considered and careful attention to inequalities wherever appropriate

19. Attention to inequalities within CLAHRC (SY): Theme-based activity • Evidence-based but also attention to practicality, feasibility and acceptability in the local context • Community engagement • Practitioner engagement - front line staff • An action research model:identification of issue►review evidence & local context ►design & implement strategy►evaluate & disseminate • Build on existing public health programmes across South Yorkshire, focus on interventions with direct patient benefits within the 3-5 year timeframe • Currently identifying potential areas for attention e.g. screening; self-care/self-management for BME groups. • Aim to develop of a culture of shared learning from the development and evaluation of evidence-based strategies to reduce inequalities

20. Attention to inequalities within CLAHRC (SY): Linkages to other Themes • Aiming for wider, more systemic influence within CLAHRC (SY) • Internal Independent Scientific Review - prompts to alert researchers to inequalities issues • Briefing Papers: Why? and How? • Support to other Themes at various stages within the research cycle:- research question formulation- methodology (inclusive approaches)- translation or application of findings (wide and equitable impact)

21. Contact details: • Liddy Goyder: e.goyder@sheffield.ac.uk • Sarah Salway s.salway@shu.ac.uk Thank you