Which Tips for Health Really Matter? Don't smoke. If you can, stop. If you can't, cut down.

1. Which Tips for Health Really Matter? • Don't smoke. If you can, stop. If you can't, cut down. • Follow a balanced diet with plenty of fruit and vegetables. • Keep physically active. • Manage stress by, for example, talking things through and making time to relax. • If you drink alcohol, do so in moderation. • Cover up in the sun, and protect children from sunburn. • Practice safer sex. • Take up cancer screening opportunities. • Be safe on the roads: follow the Highway Code. • Learn the First Aid ABC: airways, breathing, circulation. • Foreward to Acheson Report

2. or • Don't be poor. If you can, stop. If you can't, try not to be poor for long. • Don't have poor parents. • Own a car. • Don't work in a stressful, low paid manual job. • Don't live in damp, low quality housing. • Be able to afford to go on a holiday and sunbathe. • Practice not losing your job and don't become unemployed. • Take up all benefits you are entitled to, if you are unemployed, retired or sick or disabled. • Don't live next to a busy major road or near a polluting factory. • Learn how to fill in the complex housing benefit/shelter application forms before you become homeless and destitute. • See Donaldson, L. (1999). Ten Tips For Better Health. On-line at http://www.official-documents.co.uk/document/cm43/4386/4386-tp.htm. • Gordon, D. (1999). An Alternative Ten Tips for Staying Healthy. Personal Communication, October 10, 1999.

3. Community Development Approaches to Tackling Health Inequalities • What are health inequalities? • What causes them? • How can we reduce them? • Can community development approaches reduce health inequalities? • Do you think your work reduces health inequalities? • Future work for CDHN. • Barbary Cook, Director, 2nd March 2007

4. Community Development Approaches to Tackling Health Inequalities • Tackling health Inequalities is Really, Really, Really difficult. • People are still trying to work out what’s the best way to do it. • In community development and health we have to ask ourselves if we’re doing it in the most effective way we can.

5. Community Development Approaches to Tackling Health Inequalities • What are health inequalities? • People with no formal educational qualifications are half as likely as those with third level education to have excellent/very good health. • People who are unemployed are a third less likely than those in employment to have a high general mental health score. • People with the lowest income are half as likely as those with the highest income to be very satisfied with their health or have a very good quality of life. • People who rent in the public sector are nearly half as likely as those who own their own home to have a very good quality of life. • Balanda,K.,Wilde, J. (2003) Inequalities in Perceived Health: A Report on the All-Ireland Social Capital and Health Survey. Dublin: Institute of Public Health in Ireland.

6. Community Development Approaches to Tackling Health Inequalities • What are health inequalities? • Differences in health status/outcomes between two groups of people. • Often between the lowest and highest socio-economic groups. • Can be between genders, between different ethnicities etc. • When you talk about tackling a health inequality you have to think about who you are working with and what other group’s health status/outcomes you are comparing your group to. • That’s the gap you’re trying to close.

7. Community Development Approaches to Tackling Health Inequalities • Differences in lifestyle behaviour such as diet,exercise,tobacco use have been presented as the prime determinants of health. However according to WHO, 2003 these risk factors only account for a small proportion of variation in heart disease and cancers. • The evidence that the social determinants of health are more important than biomedical and lifestyle factors is clear. • According to WHO, 2003 despite this evidence people are told by the government, media and policy makers that lifestyle factors are both a threat and a salvation to their health. • Anna Cootes, Kings Fund on WHO, The Solid Facts (2003)

8. Community Development Approaches to Tackling Health Inequalities • How do the wider determinants cause health inequalities? • Material (poverty, income distribution) or psycho-social (understand your status relative to other people) or a combination? • Influences at macro-social (e.g. public policy), meso-social (e.g. work environment) or individual level? • A life-course or longitudinal approach (e.g. critical early life experience or cumulative effects over time) • Cultural context (differences within and between countries)? • Determinants of Social Disadvantage, presentation by Prof. Cecily Kelleher, Health Research Board Unit for Health Status and Health Gain, 1999-2004, Combat Poverty Agency conference on the social determinants of health

9. Community Development Approaches to Tackling Health Inequalities • Labour Govt targets on health inequalities • Education; welfare to work; environment; housing and urban renewal & better transport • What has been done? • Minimum wage and tax credits • Community based interventions • 500 Sure start programmes £1.3 billion • New Deal £1.9 million • 26 Health Action Zone programmes £449 million • Healthy living centres 300 million • Local Strategic Partnerships £2 billion • Anna Cootes, Kings Fund

10. Community Development Approaches to Tackling Health Inequalities • Swedish Health Policy has six main actions. • Swedish Public health policy - these health goals are not very sophisticated, however the targets are formulated in terms of the determinants of health and there is a consensus on their importance • Increase social capital, decrease inequality and discrimination • Improve conditions for children and young people, better support for families • Promote healthy lifestyles, support the vulnerable • Provide good public health at all levels • Promote good working conditions • Improve the physical environment • Presentation, Anna Cootes, Kings Fund

11. Community Development Approaches to Tackling Health Inequalities • The result: • Sweden has low mortality rates, • high life expectancy, • and favourable health indicators across all groups • Reducing Inequalities in Health :a European Perspective (2002) Burgstrom et al

12. Community Development Approaches to Tackling Health Inequalities • Even though there is acceptance of the impact of wider determinants on health interventions still mostly revolve around individuals and lifestyles - Investing for Health etc focusing on smoking cessation, fitness, nutrition etc. • Why? - Asthana and Halliday say it’s because stronger evidence base for these interventions • Favour randomised controlled trials; research funding flows down existing policy priorities; medical epidemiology prefers linear causal relationships rather than possibly non-linear interplay of wider determinants; political will. • Response: need to strengthen the evidence base for community-development wider determinants interventions (poverty, education, focus on lowest socio-economic group, neighbourhood renewal).

13. Community Development Approaches to Tackling Health Inequalities • Rob Phipps, DHSSPS, Presentation to Belfast Healthy Cities Equity in Health course, i.e. from statutory point of view: • Interventions that target socio-economic disadvantage • Policies that promote educational achievement of children from lower socio-economic families • Taxation policies that reduce income inequalities • Benefit uptake schemes, transfer of extended benefits to particular groups.

14. Community Development Approaches to Tackling Health Inequalities • But what if everything depends on macro-level interventions?

15. Community Development Approaches to Tackling Health Inequalities • What can community development offer health inequality interventions? • Community-based • Empowerment – people who are experincing the inequality define the problem and design the solution • Responsive • Practical – can tackle the real problems people are experiencing • Can reach most disadvantaged groups • Can design solutions that are complex and deal with lots of different issues at the same time

16. Community Development Approaches to Tackling Health Inequalities • Rob Phipps, DHSSPS, presentation to Belfast Healthy Cities Equity in Health course • Correlates or causes • Partnership; empowerment; community-based; stakeholder involvement; targeted; integrated; pragmatic; realistic; informed (theoretically sound) • So community development has good process ingredients • Phipps asked are these variables necessary or sufficient – we would say necessary but not sufficient

17. Community Development Approaches to Tackling Health Inequalities • What do our interventions look like at the moment? • Turn to the person beside you and briefly describe one of the projects you’re working on. • Try and describe what health inequality it is tackling and how. • Feedback on flipcharts – common ingredients

18. Community Development Approaches to Tackling Health Inequalities • What do our interventions look like at the moment? • Do we intervene to tackle the symptoms or the causes of health inequalities in our community?

19. Community Development Approaches to Tackling Health Inequalities • Community development that moves from the individual to the system • Interventions based around service provision and health improvement pathways for individuals • Interventions are responsive, understand the impact of the wider determinants of health on that individual (education, poverty etc.), complex and people clearly benefit • However, even though we build the wider determinants into the intervention we still intervene to the individual • What would it look like to intervene against the wider determinants themselves? - Advocacy that moves beyond individual pathways to political problems?

20. Community Development Approaches to Tackling Health Inequalities • Future work for CDHN. • Strengthen the evidence base for community-development wider determinants interventions • Develop advocacy work on wider determinants • What else? • Thanks!