Inequalities in health : theory and evidence

1. Inequalities in health : theory and evidence Siobhan Adams Interim Deputy Director of Public Health, North Wales Public Health Wales

2. Outline • What is health? • What are health inequalities? • Determinants of health • Inequity across the world • The life course approach • Addressing Inequalities • The future Inequalities in Health January 2017

3. What is health? Definitions and determinants of health and well-being

4. Definitions of health Positive definitions “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” WHO 1948 Inequalities in Health January 2017

5. Definitions of health health is "a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities." Ottawa Charter 1986 Inequalities in Health January 2017

6. Inequality or inequity? • A health inequality is a difference in health or healthcare that people experience and is not necessarily unfair or unjust. • A health inequity is an unnecessary, avoidable, unfair and unjust difference between the health or healthcare of one person, and that of another. Inequalities in Health January 2017

7. Key reports • Black report (1980) • Acheson report (1998) • Marmot report (2010)

8. Black report (1980) • Investigate inequalities in health in the UK • Generally the health of the nation had improved ; but the improvement had not been equal across the social gradient • Gap widening between most / least deprived

9. Acheson report (1998) • Independent study into health inequality • Findings ‘mirrored’ Black report ; root cause of inequalities in health was poverty • Gap between richest and poorest in UK society ‘had to be reduced’

10. Marmot report (2010) • Reducing health inequalities is a matter of ‘fairness’ and ‘social justice’ • Action is needed to tackle the social gradient in health • ‘Proportionate universalism’ • Action on health inequalities requires action across all

11. Determinants of health (1)

12. What are social determinants of health? Structural determinants and conditions of daily life constitute the social determinants of health and they are crucial to explaining health inequities. More specifically these include distribution of power, income, goods and services, globally and nationally, as well as the immediate, visible circumstances of peoples lives, such as their access to health care, schools and education; their conditions of work and leisure; their homes, communities, and rural or urban settings; and their chances of leading a flourishing life WHO Commission on Social Determinants of Health 2008 Inequalities in Health January 2017

13. Life Expectancy Life Expectancy: Average number of years that a newborn is expected to live if current mortality rates continue to apply Healthy Life Expectancy: Average number of years that a person can expect to live in "full health" by taking into account years lived in less than full health due to disease and/or injury. (WHO) "Poor people are ill more often and die sooner, and that's the greatest inequality of them all: the inequality between the living and the dead." Frank Dobson, Secretary of State for Health, UK, 1998

14. Inequality gap very wide in healthy life expectancy in Wales Produced by Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD/WHS(WG)

15. Welsh Index of Multiple Deprivation Income, housing, employment, access to services, education, health, community safety and physical environment

16. Maps of Birmingham illustrating mismatch between CHD registration with GP (left) and CHD mortality (right)

17. Infant mortality by fifth of deprivation, Wales, rate per 1,000 births, 2006-2010 Produced by Public Health Wales Observatory, using ADBE & ADDE (ONS), WIMD 2011 (WG) Public Health Wales Observatory

19. IMR’s for selection of European countries for 2011 (taken from Eurostat data) (per 1000) • Czech Republic – 2.7 • Germany – 3.6 • Estonia – 2.5 • Ireland – 3.5 • Greece – 3.4 • Slovenia – 2.9 • Finland – 2.4 • Sweden – 2.1 • Iceland – 0.9 • England – 4.2 • Wales – 4.4

20. Four major models: • Behavioural model: Social class differences in health damaging or health promoting behaviours • Materialist model: Poverty exposes people to health hazards. although inequalities in health tend to follow a steady gradient • Psycho-social model: Social inequality may affect how people feel which in turn can affect body chemistry. • Life-course model: The chances of good or poor health are influenced by what happens in-utero and in early childhood. Disadvantages are likely to accumulate through childhood and adulthood. Relatively recent. Inequalities in Health January 2017

21. Life course Early years are crucial

22. United in Health Improvement

23. Inequality in early cognitive development of children in the 1970 British Cohort Study, at ages 22 months to 10 years Inequalities in Health January 2017

24. Buddsoddi yn y Blynyddoedd CynnarInvestment in Early Years

26. Adverse Childhood Experiences

27. Prevalence

28. The Increased Risk

29. The Critical Years - make the difference • In the first 2 years a baby’s brain grows from 25% to 80% of its adult size • Development continues in childhood learningempathy, trust and community

30. The Impact of ACEs on Brain Development • Chronic Stress from ACEs over-develop ‘life-preserving’ part of the brain • In School - anxious, disengaged, poor learner always prepared to fight or flee Fight or Flight Fixed Allostatic load Healthy response Exhausted Recovery Threat ACEs Tau et al, 2010; Mercy, Butchart, Bellis et al, 2014 At Rest At Rest Inequalities in Health January 2017

31. England: Individuals Never Diagnosed with a Major Disease by Age (%) 0 ACEs 4+ ACEs Major Diseases Cancer Stoke Type II Diabetes Cardio Vascular Disease Digestive/Liver Disease Respiratory Disease 50% Disease Free 20% Disease Free Differences remain after adjusting for Deprivation Aged 18 to 69 years; (n = 3,885) Bellis et al, Journal of Public Health, 2014

32. Adverse Childhood Experiences ACEs - The Life Course DEATH Developed from Felitti et al. 1998 LIFE COURSE Early Death Non Communicable Disease, Disability, Social Problems, Low Productivity Adopt Health Harming Behaviours and Crime Social, Emotional and Learning Problems Disrupted Nervous, Hormonal and Immune Development ACEs Adverse Childhood Experiences BIRTH

33. Cycle of Violence – ACEs run in families Inequalities in Health January 2017

34. Smoking Prevalence • 33 % before, during throughout pregnancy • 16 % throughout pregnancy • 14% least deprived • 40% most deprived UK infant feeding survey Smoking in Pregnancy – Impact, challenges and opportunities

35. Impacts of Inequality – Low Birth Weight One of the key indicators of the health of a population Understanding our population

36. Reducing Low Birth Weight Primary Risk Factors Lifestyle Factors Groups highest risk Deprived Communities Young people Those in manual / repetitive work or who have never worked

37. Models for Access to Maternal Smoking Cessation Support (MAMSS) • What is MAMSS? • Smoking cessation support for pregnant smokers • Adherence to NICE ‘opt out’ referral pathway • Support closely aligned to Maternity Services • Woman centred approach with flexibility in delivery Qualitative Results

38. PreventionCampaign - Ymgyrch Atal Smygu

39. TargetingParents – Targedu rhieni

40. Inequalities in Health January 2017

41. The Future Inequalities in Health January 2017

42. Levels of intervention Cost Impact

43. Models to analyse and intervene (4) • Asset based approach • salutogenesis

44. Policyresponse Inequalities in Health January 2017

45. WHO Social Determinants of Health report 2008 • Three principles of action • Improve the conditions of daily life. • Tackle the inequitable distribution of power, money, and resources • Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health. Inequalities in Health January 2017

46. Policy Response “Decades of experience tell us that this world will not become a fair place for health all by itself. Health systems will not automatically gravitate towards greater equity or naturally evolve towards universal coverage. Economic decisions within a country will not automatically protect the poor or promote their health. Globalization will not self-regulate in ways that ensure fair distribution of benefits. International trade agreements will not, by themselves, guarantee food security, or job security, or health security, or access to affordable medicines. All of these outcomes require deliberate policy decisions. Dr Margaret Chan, Director General WHO, 2010 Inequalities in Health January 2017

47. What can make a difference? • 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 Fair Society, Healthy Lives: The Marmot Review, England, February 2010 Inequalities in Health January 2017

48. Approaches • Focus on the poorest • Focus on the gap between the richest and the poorest • Focus on the gradient Inequalities in Health January 2017

49. Proportionate universalism • Interventions are delivered to the whole population, with the 'intensity' adjusted according to the needs of specific groups (for example, some groups may need more frequent help and advice). This type of approach can help to reduce the social gradient and benefit everybody. Inequalities in Health January 2017

50. Proportionate universalism Inequalities in Health January 2017