Health differences in Kainuu and other Europe

1. ”Medicine is a social science, and politics is nothing but medicine at a larger scale” -Rudolf Virchow, 1848 Health differences in Kainuu and other Europe -from global to local- DART inequalities 2012 / Kaikkonen

2. Description of Public Health • ”Medicine is a social science, and politics is nothingbutmedicine at a largerscale” • Rudolf Virchow, 1848 • Society´s obligation to assure the conditions for people´s health • Gostin 2001 • ”… yhteiskunnallisen edistyksen luonnollinen taipumus on saattaa henkisen ja ruumiillisen työn harjoittajat parempaan tasa-arvoon keskenänsä.” Societies develoment´s natural tendency is to bring the mental and physical work of practitioners to greater equality among each other • Yrjö-Sakari Yrjö-Koskinen 1874 DART inequalities 2012 / Kaikkonen

3. Life Expectancy: differences world-wide WHO 2008 DART inequalities 2012 / Kaikkonen

4. Income distribution GDP (at purchasing power parity) per capita, 2010–2011 World map showing countries above and below the world GDP (PPP) per capita, currently $10,700. Source: IMF (International Monetary Fund).Blue above world GDP (PPP) per capitaOrange below world GDP (PPP) per capita DART inequalities 2012 / Kaikkonen

5. More detailed in Europe: West, North, East DART inequalities 2012 / Kaikkonen

6. Differences in what? -examples from Welfarestate Finland DART inequalities 2012 / Kaikkonen

7. Life expectancy at birth (e0) in 1890–91, 1950–51 and 2000–2003 by gender and region Women Men Men living on the west coast and in Åland live 3–5 years longer than men living in the northeast; among women the difference is 2 years (Source: Koskinen and Martelin 2007)

8. Life Expectancy an PYLL differences in Finland: Kainuu region

9. Relative mortality by living arrangements and number of childrenaged 17 or less, persons aged 30–64 (standardized for age and socio-economic characteristics) Living with a spouse (in marriage) and having children is associated with low mortality (Source: Koskinen et al. 2007)

10. Life-expectancy trend among men and women at the age 35 during period 1988-2007 according to income fifths Tarkiainen et al. 2011 10 DART inequalities 2012 / Kaikkonen

11. POTENTIAL: Proportion (%) of selected public health problems that would be avoided in Finland if the prevalence of the problem in the rest of the population would be as low as among those with tertiary level of education Health problem Proportion (%) of cases avoided Respiratory deaths 50–75 Alcohol deaths 50–60 Need for daily help due to restrictions in functional capacity 50 Coronary heart disease deaths 30–50 Accidental/violent deaths 20–45 Diabetes 30 Back disorders 30 Osteoarthritis of knee/hip 30 Stroke deaths 20–40 Cancer deaths 20–30 Impaired vision/hearing 20 Disturbing allergy 10 Koskinen & Martelin 2007 DART inequalities 2012 / Kaikkonen

12. Riddle me this and riddle me that –but who is getting and what? One of the great riddles of public health: • despite prosperity, more equal income distribution, welfare state, equal access to health care, … • persisting, even widening health inequalities between socioeconomic groups (Mackenbach 2010, presentation in Helsinki) DART inequalities 2012 / Kaikkonen

13. Socioeconomic factors: what do they refer to? • Material well-being • income, assets, housing conditions etc. • Means to acquire material well-being • education, occupation, employment status • In addition to the material aspects, also life style and esteem associated with e.g. education and occupation have great importance in the background of health inequalities • High socioeconomic position improves the knowledge and economic prerequisites– as well as motivation– to choose health-promoting living conditions and behaviour patterns DART inequalities 2012 / Kaikkonen

14. We should influnce these in global and in local decision making Need for global and local information is obvious DART inequalities 2012 / Kaikkonen

15. Health inequalities in Europe DART inequalities 2012 / Kaikkonen

16. Several action plans to reduce inequalities in health –but more needed • Britain: Independent Inquiry (1998) etc. • Netherlands: Albeda committee (2001) • Sweden: Public Health Commission (2002) • Norway: National Strategy (2006) • Finland: National Action Plan (2008) DART inequalities 2012 / Kaikkonen

17. Relative Index of Inequality in 22 European countries: by education, Death (all cause) Mackenbach et.al 2008, NEJM DART inequalities 2012 / Kaikkonen

18. Relative Index of Inequality in 8 European countries: by occupational class, Death (all cause) Mackenbach et.al 2008, NEJM DART inequalities 2012 / Kaikkonen

19. Relative Index of Inequality in 22 European countries: by education, Self-rated health Mackenbach et.al 2008, NEJM DART inequalities 2012 / Kaikkonen

20. Health inequalities in Kainuu DART inequalities 2012 / Kaikkonen

21. Background: health inequalities • The overall status of health in Finland has improved significantly over the past decades. • However health inequalities have increased • Big differences in mortality between socioeconomic groups in Finland compared to many European countries • Government Resolution on the national 'Health 2015 public health programme' (2001) • One key target to reduce inequalities in mortality by a fifth by the year 2015 • The Ministry of Social Affairs and Health has published (2008) the National Action Plan to Reduce Health Inequalities 2008-2011 • Identification for relevance of area level information for decision makers and palnners (Kaikkonen et.al2008; Murto et.al2009) • Eye opening DART inequalities 2012 / Kaikkonen

22. Context: Finnish welfare state and responsibilities for THL and municipalities • Finland is a modern Nordic welfare that was build up to provide social security for the whole population, a safety network • However Finnish welfare state has not accomplished to reduce inequalities in health and welfare (Palosuo et. al 2009) • Moreover area level differences in health and welfare in Finland are still visible • National institute for health and welfare has obligatory resposibility to analyze and monitor the welfare of the population and health, the factors affecting them and their problems, prevalence of the problems and prevention opportunities, and develop and promote measures to promote health and well-being and reduce the problems. (Act of National institute for health and welfare § 2). • “Finnish municipalities and cities have broad responsibilities in providing their citizens with social and health care services, education and cultural services, in supervising activities affecting the environment, in promoting employment and commerce, and in arranging preventive work. Moreover, the 2006 revised Primary Health Care Act obligates municipalities to follow the health of their population and its subgroups.” (Kaikkonen et al. 2008) • Obligation revisited in Healthcare act 2010 (§12) DART inequalities 2012 / Kaikkonen

23. Socioeconomic inequalities in KAINUU: from gradle to grave DART inequalities 2012 / Kaikkonen

24. Kainuu has been a national pilot for local level information: available information • Various existing national register and survey data have been used in the report. Information on the working-aged population in Kainuu is most extensive but also children, adolescents and the elderly have been covered when possible. Actors in Kainuu have been interviewed to supplement the results. • The report also includes strategic guidelines to reduce socioeconomic health inequalities defined by the health and social sector of the Joint authority of Kainuu region. • The health of the Kainuu population has improved over the past decades but socioeconomic health inequalities are generally wider than in Finland on average. • Poor health and risky health behaviour are more common and mortality is higher among the lower educational groups. Kaikkonen et. al 2008 DART inequalities 2012 / Kaikkonen

25. Kainuu hasbeen a national pilot for locallevelinformation: sewinggaps • During years 2007–2008, was carried out by Institute for Health and Welfare (THL) Child Health Monitoring Development project (LATE) data collection of 10 child healthcare units and school health services in normal children health monitoring. • In addition, during the years 2007–2009 were collected also substudiesin the City of Turku and the region of Kainuu as part of joint project of THL’s and • In the data collection the target age-groups were half-, one-, three-, and five years of age, and from the school healthcare services of the first, fifth and eighth (or 9) grade students. In this report we use these data-sets to • To examine health and welfare inequalities among children and their families. Kaikkonen et. al 2012 DART inequalities 2012 / Kaikkonen

26. Flying finns… experiences from municipalitiesEvidence based policy TEROKA, INDI, ATH, LATE etc. We know from arealevel co-operation: • Area-level information (data) speaks to decision makers • Waking up with local info really works! • Easy reachable and understandable results are worthy • Co-operation and networks are possible over the normal structure using information , not only feelings • Goals go through to strategies • Commitment is possible DART inequalities 2012 / Kaikkonen

27. Overweight and obesity is a problem in Finland and in Kainuu DART inequalities 2012 / Kaikkonen

28. Mothers education is associated with it DART inequalities 2012 / Kaikkonen

29. Smoking: high schoolers and vocational education in Kainuu Kaikkonen et. al. 2008 DART inequalities 2012 / Kaikkonen

30. Parents education and 8/9th graders binge drinking at least once a month in Kainuu Kaikkonen ym. 2008 DART inequalities 2012 / Kaikkonen

31. Smoking by education in Kainuu and Finland DART inequalities 2012 / Kaikkonen

32. Quality of life (WHO-QOL-bref) by education in Kainuu and Finland DART inequalities 2012 / Kaikkonen

33. Old age and inequalities: serious problems coping with daily activities in Kainuu and Finland by education DART inequalities 2012 / Kaikkonen

34. Motivation • Local authorities need information by population group in order to be able to evaluate service needs, orient actions, allocate resources and monitor the attainment of goals. DART inequalities 2012 / Kaikkonen

35. AREAL, REGIONAL, LOCAL AND MUNICIPAL INFORMATION OF HEALTH AND WELLBEING • SERVICE SYSTEMS AND LOCAL DATA SYSTEMS • the use of services • the content of service • SURVEYS • -interviews • -self-rated health • -need for care (service) • -way of life, etc. • -examinations NATIONAL REGISTERS • population • Living cond. • etc. • COMBINING DATASETS • Registers and surveys INDICATORS metadata + interpretation EASY TO USE OPEN DISSEMINATION PORTAL ”Tip of the iceberg” Koskinen 2008, translation Kaikkonen 2009 DART inequalities 2012 / Kaikkonen

36. The current situation • National level monitoring with socioeconomic status is internationally comparable • Children’s (aged 0-13) health monitoring is lacking • Questionnaire-based data on lifestyles and citizens’ personal experiences are often not available at the local level or even at the regional level. • Monitoring data available, mainly derived from various data files and usually are not analysed by population group in the area level. DART inequalities 2012 / Kaikkonen

37. Regional Health and Well-being study ATH ATH:n motto: DART inequalities 2012 / Kaikkonen

38. National area level adult Health and Well-being survey, ATH • Area level monitoring is needed for effective national level policy making • Monitoring factors affecting the health and well-being in area level and local populations and their sub-groups, • Compare data with those of other regions or of the country as a whole, or against the goals set. • ATH will further collect monitoring information which is significant for the orienting of health promotion measures and the evaluation of their effectiveness • ATH will also improve the technical implementation of the stages of the questionnaire study, aiming at a process • minimising the requirement for manual labour and enabling rapid reporting. DART inequalities 2012 / Kaikkonen

39. Regional Health and Well-being study ATH • Pilot 34 000 Finnish age 20+ in Kainuu (9000), Turku (9000), Southern Ostrobotnia (8000), Keski-Satakunta (3000) and representative sample of Finland (5000) • THL will nationalize the ATH-study, years 2012–2014 • 150 000+ finns • Covering also ethnic groups 2014 (based on the maamu-study) • Areas can also add their samples to fill the needs DART inequalities 2012 / Kaikkonen

40. Metainformation for relevance and interpretation • Relevance and interpretation = Ilmiön merkitys ja tulkinta • Definition = Määritelmä • Effects to population wellbeing (inc. health) = Vaikutus väestön hyvinvointiin • Economical relevance (if known) = Taloudellinen merkitys • How can we affect = Miten ilmiöön kyetään vaikuttamaan • What should be done in the area level/municipa level = Mitä kunnassa/alueilla tulisi tehdä • Look also for following indicators = Katso ATH:sta myös seuraavat osoittimet • Keywords (for search machine’s) = Asiasanat • Technical documentation and additional information = Tekninen kuvaus ja lisätiedot • Calculation = Laskeminen • Backgroud variables = Taustamuuttujat, joiden mukaisissa ryhmissä tulokset esitetään • Update information = Päivitystiedot • Limitations and additiona information (about the indicator) = Lisätiedot ja käytön rajoitukset • Dataresource = Tietoaineisto • References = Viitteet • Availability, reliability and coverage = Tiedon saatavuus, luotettavuus, ajallinen kattavuus • Contact information (system) = Yhteystiedot • Contact information (dataresource) = Tietoaineiston yhteystiedot DART inequalities 2012 / Kaikkonen

41. Tacling health inequalities global to local: need for use of TEROKA 2012 unpublished DART inequalities 2012 / Kaikkonen

42. Messages • Health inequalities are important and won´t automatically go away –need for addressing • What went wrong? –why or what we do that increases but does not decrease the inequalities? What we should learn? • Comparing health inequalities across countries is difficult but we need also more area/local information concerning the determinants that can be adjusted by decision makers • LOCAL INFORMATION IS EYE OPENING! DART inequalities 2012 / Kaikkonen

43. Kiitos mielenkiinnostanne!Thank you for your attention! Risto Kaikkonen Development manager THL/ATH p. 029 524 8176 risto.kaikkonen@thl.fi DART inequalities 2012 / Kaikkonen