Inequalities In Health PDF

INEQUALITIES IN HEALTH Population Health and Healthcare Delivery (PHHD) Dr. Nitya Kumar PHHD Lead Image sources: foodsafety.net.au Feed my starving children. URL: http://schwonks.blogspot.com/...

INEQUALITIES IN HEALTH Population Health and Healthcare Delivery (PHHD) Dr. Nitya Kumar PHHD Lead Image sources: foodsafety.net.au Feed my starving children. URL: http://schwonks.blogspot.com/ 1  Learning outcomes You will be able to:  Explain the relationship between public health and medicine  Describe the main social determinants of health and how they interact with the environment  Briefly explain the pathways through which social determinants impact on health  Identify how social determinants can impact on individual health experience  Discuss how the climate change burden can exacerbate already existing health inequalities  Describe the actions that can be taken at a policy level to reduce inequalities in health 2 Medicine Epidemiology Population Health Patient Methods Population 3  Why Study Population Health? Healthca Public re Health Benefits seen on a population scale max 25% of health Reduces burden on healthcare outcomes Cascading effects e.g. herd immunity Address inequalities in health  everyone can reap the benefits  INEQUALITY versus INEQUITY Inequality in health1 Inequity in health2 Any measurable aspect of Differences in health health that varies across between groups which are individuals or according to unjust and could be avoided by reasonable socially relevant groupings. means. No moral judgement applied to those differences 1. Arcaya et al. (2015) Inequalities in health, definitions, concepts and theories. Global Health Action 8 27106 2. Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P. WHO European review of social determinants of health and the health divide. Lancet 5 2012; 380: 1011􀀁29.  Inequality and Inequity Upstream Equality Upstream in Equity in resources resources ↓ ↓ Downstrea Downstrea m equality m equality in in outcomes outcomes  ? Source: equitytool.org 6  Income inequality and health and social problems Income and health outcomes associated Association remains complex due to other variables Generally accepted that income and income inequality impact health problems. Source: Pickett and Wilkinson (2015) Social Science and Medicine. Vol 128 pp 316-326 Also see www.ted.com/talks/richard_wilkinson_how_economic_inequality_harms_societies?language=en 7  Earliest Evidence of Inequality in Health - I Whitehall 1 - 1967 study of British civil servants  steep inverse association between social class, (grade of employment), and mortality from a wide range of diseases. Whitehall 2 - 1985 and 1988  inverse association between employment grade and prevalence of angina, ischaemia, and chronic bronchitis. Employment grade differences in risk behaviours (smoking, diet, exercise) Michael Marmot et al. https://www.thelancet.com/journals/lancet/article/PII0140-6736(91)93068- K/fulltext 8  Earliest Evidence of Inequality in Health - II Promoted a global interest in health inequalities Identified that differences in health between groups were inequitable Identified policy approaches required to address inequalities. 9 What is the mechanism by which inequalities lead to poor health? 11 Theories on how inequalities lead to poor health 1.There aren’t any inequalities in health. We just don’t measure determinants and outcomes properly (artefact) 2. Selection theory (poor health  social slide) 3. Behavioral theory (underprivileged people  poor health behaviors) 4. Structural theories – (politics and policy make it difficult for underprivileged people to have healthy behaviors) 12 Theories on how inequalities lead to poor health Structural explanations fit best Behavioural theory relevant, but insufficient. Selection theory and Behavioral theory state underprivileged people are responsible for making poor health choices – this is tantamount to victim blaming. Health inequalities are also a factor of political decisions and political priorities. Health inequalities are not inevitable and have been lower in the past and are lower in other populations. 13 Social Determinants of Health (SDOH)  Several alternative models of the determinants of health  Michael Marmot and Richard Wilkinson identified the following: – Early life – Stress – Social exclusion – Working conditions – Unemployment – Social support – Addiction – Healthy food – Transport Some argue that INCOME is most important because others are a product of income or status Source: https://apps.who.int/iris/bitstream/handle/10665/108082/e59555.pdf?sequence=1&isAllowed=y  Social Determinants of Health Social gradient across these determinants contributes to health “Constitutional Factors” = recognizable factors that position individuals in a social class ⁻ Income ⁻ Gender ⁻ Race ⁻ Disability  How Social Determinants Impact Individuals Person Person X Y Born into Born into family from family from higher lower Socio- Socio- economic economic stratum stratum Poor Affluent neighborhoo neighborhoo d d Cycle repeats with subsequent generations of X and Y Key Determinants of Health: Stream Metaphor 1.Upstream 2.Mid- “Stream” metaphor = as one moves upstream, you get to stream the source 3.Downstrea m  Climate Change and Inequalities The impact of climate change on inequalities is of huge global concern. Climate change is a threat multiplier. How might drought, heat, floods and changes in disease vectors impact on health and Balochistan, Pakistan Sept 2022 disease? https://www.bbc.com/news/world-asia-62728678 How to reduce inequalities in health? 19 1. Health Services 20  Primary Prevention esi alit ine ial Safety net qu c So programs and secondary Plateau = Good prevention health Medical care and tertiary Jones, CP et al J Hlth Care Poor Underserved, 2009 prevention 2. Policy Interventions  Health Inequalities – policy interventions Identifying policy entry points to address health inequalities using Diderichson’s Conceptual Model Diderichson (2004) Resource allocation for health equity; issues and methods. HNP Paper. World Bank.  Conceptual model for studying pathways through which social position impact health I = different social position lead to: II = differential exposures lead to: III = differential vulnerability to disease leads to: IV = differential consequences of Diderichson’s Conceptual Model enables identifying policy entry points disease Diderichson (2004) Resource allocation for health equity; issues and methods. HNP Paper. World Bank.  Assessment of Population Health Needs is the central core of Population focus This is achieved using Health Needs Assessment (HNA)  EXAMPLE: Neonatal Mortality Upstream: Population policies and interventions that seek to reduce women’s risk of adverse birth outcomes prior to conception Mid-stream: Efforts to reduce the risk of adverse outcomes during pregnancy Downstream: intensive care that seeks to increase survival of high-risk neonates  Health Needs Assessment (HNA) – A way to incorporate population needs in Health Services Purpose - to aid decision making and to promote action so it is important that the emphasis is on what actions you recommend A systematic method of identifying unmet health and health care needs of a population and making changes to meet those unmet needs Is the back bone of public health work used to improve health, commissioning of healthcare and other service planning leads to agreed priorities and resource allocation that will improve health.  Health Needs Assessment steps 1. State your aim 2. Define the problem to be addressed 3. Describe the size and nature of the problem 4. Describe current services 5. Synthesize and summarize the evidence on interventions available 6. Summarize your findings from stakeholders 7. Summarize cost-effective solutions and resource implications 8. Recommendations for action 9. Identify the indicators and outcomes needed to evaluate change.  What can medical practitioners do? The Clear Toolkit https://www.who.int/workforcealliance/forum/2013/SE7-Han dout.pdf  Additional Resources https://www.cdc.gov/socialdeterminants/index.htm Thornton RL, Glover CM, Cené CW, Glik DC, Henderson JA, Williams DR. Evaluating strategies for reducing health disparities by addressing the social determinants of health. Health Affairs. 2016 Aug 1;35(8):1416-23. Schulz A, Northridge ME. Social determinants of health: implications for environmental health promotion. Health education & behavior. 2004 Aug;31(4):455-71. Braveman P, Egerter S, Williams DR. The social determinants of health: coming of age. Annual review of public health. 2011 Apr 21;32:381-98. Cockerham WC, Hamby BW, Oates GR. The social determinants of chronic disease. American journal of preventive medicine. 2017 Jan 1;52(1):S5-12. 31  Questions? Discussion Forum on VLE E-mail: [email protected] THANK YOU 32