Public Health Approach to Health Inequalities

Health
inequalities have been documented in various literatures for decades, but more
recently, the government have introduced specific policies to tackle health
inequalities. Marmot (2010)’s findings showed that people living in poorer
areas not only have a lower life expectancy, but experience health inequalities
from housing, income, education, social isolation and disabilities. Although
life expectancy in developed countries are now slowly improving, health
inequalities continue to occur (Crombie et al, 2005). The World Health
Organisation (WHO | Key Concepts, 2017) believe that social and economic
conditions and their effects on people’s lives determine their risk of illness.
These also effect the actions taken to prevent them becoming ill or treat an
illness when it occurs.  Marmot (2010)
supports the notion of social and economic conditions as they strongly suggest
the link between social conditions and health should be a priority, as society
would benefit in many ways if there was an improvement in well-being, better
mental health and disabilities.

These
socioeconomic factors come under the social determinants of health, which WHO |
Key Concepts (2017) state are “the conditions in which people are born, grow,
live, work and age”.   These issues occur regionally, nationally and
globally. The Marmot Review that looks into health inequalities in England proposes
an evidence based strategy to address the social determinants of health (LGA,
2017).

The
root causes of health inequalities are complex and varied, therefore broad
policies are required to tackle such inequalities in health (Crombie et al,
2005). Mackenbach (2002) suggests the most fundamental approach to reducing
such inequalities in health is to directly tackle the inequalities in
education, occupation and income.

Aims

This report begins by exploring what constitutes as
a health inequality, what are the underlying reasons and how do they manifest
themselves in people. Following this, the reports aims to discuss examples of
health inequalities and the reasons behind why they experience them. The report
further aims to critically examine the role public health play in
reducing health inequalities through findings of current data and the
evaluation of policies and strategies implemented to reduce health
inequalities.

The
report will conclude with a summarisation of the findings and where appropriate
provide recommendations for further actions.

 

What is a health inequality?

 

Health inequalities are defined in various ways. A
broad and common definition by Graham (2009) states “systematic differences in
health of people occupying unequal positions in society”. This term emphasises
the health differences associated to unequal socio-economic positions. World
Health Organisation (WHO | Health Impact Assessment, 2017) support this
definition by stating “health inequalities can be defined as differences in
health status or in the distribution of health determinants between different
population groups”. WHO | Health Impact Assessment (2017) explain that it may
not be possible to change some health determinants, resulting in some health
inequalities being unavoidable. However, uneven distribution is avoidable as
well as unfair, which then shows health inequalities also leading to health
inequity (WHO | Health Impact Assessment, 2017). However, to create health for
all additional support may be required to create equality. This may not always
be perceived as equity.

Social determinants of health

It is widely accepted that social determinants are
responsible for a significant number of health inequities. Whilst some health
inequalities are from natural causes or free choice, many are beyond individual
control and can’t be avoided (RCN, 2012). The social determinants of health
specifically look at; personal characteristics such as age, sex, ethnic group;
individual lifestyle factors such as level of physical activity and alcohol
use; social and community networks, living conditions and socioeconomic status,
cultural and environmental conditions (PHE, 2017). The Marmot Review “Fair
Society, Healthy Lives” states that to take action on health inequalities,
action must be taken across all social determinants of health (PHE, 2017).

Underlying reasons for health inequalities

The underlying causes of health
inequalities in the UK have been examined for decades, starting from the
release of The Black Report (1980) – a document published by the Department of
Health and Social Security on inequalities in health. Gray (1982) states The
Black Report includes details of the unequal distribution rates of ill-health
and death amongst Britain’s population. The Black Report propose four different
theories that could be the underlying cause of health inequalities: selection,
behavioural/cultural, structural and artefact (McCartney, 2013). The structural
theory is believed to provide the best explanation as it suggest that
socioeconomic circumstances such as wealth, power and access at all stages of
life are considered to be causing differences in population health (McCartney,
2013).  SHA (1980) explains the
socio-structural factors in distributing health and wellbeing to have many
different reasons from the role of economic deprivation, but focus on the
direct influence of poverty or economic deprivation has on mortality. BMA (2017) believe there is a social gradient in
health, where the lower the social position, the worse their health. By
expanding thoughts to address issues further than those requiring medical
attention, a lot of health inequalities were found. NHS Health Scotland (2018)
believe the fundamental causes of health inequalities are income, wealth and
power, as these factors the wider environmental issues on health and access to
services, shaping individual and population experiences which result in
inequalities.

How do health inequalities manifest themselves in
people?

Health
inequalities manifest themselves in people in a variety of ways with a number
of different indicators to measure inequalities within communities, such as looking
at mortality rates, health statuses, environmental factors and risk behaviours.
The purpose of health equalities
are to give everyone the same opportunities to lead a healthy life, no matter
where they live or who they are (Connolly et al, 2017), however, an difference
in health improvement will not always close the gap of health inequalities.

When
looking at inequalities, factors such as housing, jobs and geographical
disparity must be considered to explore how they affect health and life
expectancies (Newton, 2017).  Life expectancy at
birth in England has generally increased over years, however life expectancy is
not uniform across England and inequalities still exist (PHE | Inequality in
health, 2017). PHE | Inequality in health (2017) believe there is a social
gradient in life span, with people living in the most deprived areas in England
having on average the lowest life expectancy unlike those living in more
affluent areas having a higher life expectancy.

Children growing up in more
deprived areas often suffer disadvantages throughout their lives (Newton, 2017)
which could lead to adverse childhood experiences (ACEs). A study between Centres for Disease Control and
Prevention and Kaiser Permanente found that ACEs are very common and sometimes
come in clusters, showing 40% of their sample reporting two or more ACES, this
increasing the risk factors of disease, disability and early mortality (SAMHSA,
2017). Bellis et
al (2015) explains how experiences during childhood can affect health
throughout the life course. ACEs can also be
harmful for the development of a child’s brain, which could present academic
problems throughout their school years (ACEResponse, 2018). This can
lead to children who have experienced stressful or poor quality childhoods
becoming likely to adopt health-harming risk behaviours during adolescence such
as binge drinking, smoking and drug use (Bellis, 2015).

This emphasises on WHO (2000)’s findings on
sensitive developmental stages in childhood and adolescences such as cognitive
skills, coping strategies, attitudes and values being hindered in later life,
which follows from ACEs.

Reducing
health inequalities is one of Public Health England (PHE)’s main missions.
Connolly (2015) states that PHE understand that the social determinants of
health inequalities can be complex and as such, invest heavily into
understanding what can make a difference. An approach PHE take to reduce health
inequalities is supporting local authorities and local partners to use
resources they have put in place, such as opportunities for using Social Value
Act 2013, promoting good quality jobs, reducing social isolation and improving
health literacy (Connolly, 2015). Caldwell (2016) explains the public health
approach as defining health problems, identifying risks, developing
community-level interventions, implement interventions to improve the health of
the population and continue to monitor its effectiveness. 

An
example of this is Public Health Wales (PHW) who have undertaken new and
innovative approaches to ensure success in reducing health inequalities,
resulting in an understanding of resources and commitment required to reduce
inequalities (Public Health Wales | Strategic Plan 2017-2020,
2017). However, there is a clear view of challenges that PHW aim to prepare
for, as they believe that their systems approach of utilising and maximising
collective assets embraces the sustainability and unique opportunities
presented by the Well-being of Future Generations Act (Wales) 2015 (Public
Health Wales | Strategic Plan 2017-2020, 2017).

NHS
Health Scotland (2015) also believe inequalities account for a large element of
the increasing demands on public health services due to the cycle of
deprivation. They further believe children and young adults who have been
brought up in deprived circumstances are more likely to be deprived in later
life, which will then affect their children. There are various factors that cause recurring poverty,
such as irregular work, relationships, children being born into broken
households and intermittent health issues, which create a poverty cycle and
continue to experience inequalities (Goulden, 2010). This cycle of poverty is
costing the UK £78bn a year according to Joseph Rowntree Foundation (BBC News,
2016). NHS Health Scotland (2015) found The Christie Commissions Report
suggests that around 40% of the countries money is being accounted for by
interventions that could have been avoided had preventative approaches been
priorities.  With interventions in place,
Wickware (2017) quotes the chief executive of Public Health England Duncan
Selbie who believes that despite a large amount of funding provided to the NHS,
it will not improve healthcare inequalities and ‘it will never close the gap
between the affluent and the poor’. He believes that job creations is one of
the most important measures for improving health in the next 20 years, as no matter
how much money is put in, it will never change the health profile of the
country (Wickware, 2017).

Strategies and
Policies

Actions
towards tackling inequalities are based on evidence of need, understanding of
barriers to social opportunities and what is most likely to work (NHS Health
Scotland, 2015). The UK have had a keen interest in strategies and policies for
tackling health inequalities since they were first acknowledged in The Black
Report in 1980. The Black Report lacked
significant support due to change in government, as the paper was commissioned
by the Labour governments but reported by Conservative party, who dismissed the
report as they refused to address the socio economic and environmental factors
that health inequalities create (Marmot, 2001). 
The Black Report stated that they did not believe the persisting problem
of health inequalities was because of the NHS, but explained a materialistic
explanation of inequalities by looking at differences in health based issues on
different social classes and how they lead their lives (Marmot, 2001).  However, despite various studies and showing
the UK’s efforts to reduce health inequalities, it is questioned if more
practical policies would be more effective (Smith and Eltanani, 2014).  

The
Health of the Nation strategy (HOTN) created in 1992 was the first government
attempt to develop a strategy based on improving health inequalities in the UK,
however its main focuses were coronary heart disease and stroke, cancers,
mental health, sexual health and the accidents (Hunter et al, 2000). HOTN
emphasises mainly on issues requiring medical based interventions, without
considering socio-economic approaches therefore found that it failed to reduce
inequalities. Following the HOTN, the Labour Government in 1997 launched the
new strategy “Our Healthier Nation”, with intentions to also address
inequalities in health (Hunter et al, 2000), which accounts for Acheson
(1998)’s report, discussing inequalities in schools, workplaces and
neighbourhoods. Acheson made 39 recommendations, recognising that tackling
inequalities required action to address the broader layers (Nutbeam, n.d),
whilst evaluating all policies that are likely to have an impact on health
inequalities, to prioritise health of families with children and improve the
living standards of poor households to reduce health inequalities. Following
Acheson’s report it was noticed a decrease in child poverty and increased
income in lower socio-economic groups (Mackenbach and Bakker, 2002).  However, Acheson’s report was criticised for
its recommendations being vague and not providing detailed costs, making it
difficult for the government to assess if it would be cost effective (Asthana
and Halliday, 2006).

As
emphasized in this report, health inequalities begin from a young age and
continue to develop. Therefore, strategies have been implemented to reduce
inequalities throughout the life course. The life course approach emphasises on
social perspectives on life experiences across generations to find patterns in
health and diseases, whilst understanding that past and present experiences are
shaped by wider determinants (WHO, 2000). Supporting this, Kawachi (2002)
states that the life course approach refers to how health status at any age
reflects on contemporary conditions and prior living circumstances.
Socio-economic conditions throughout the life course can cause health damaging
or health enhancing opportunities in later life, and individual’s responses may
modify their impact of risk exposures in the futures (Kuh et al, 1997).  A recent strategy implemented to target early
years is NICE guidelines strategy of promoting health and wellbeing in under 5s
NICE (2016) created their quality standard to improve school readiness, child
development, antisocial behaviour, mental health and educational attainment.
They do so by introducing services to support wellbeing, such as home visits,
childcare, early intervention and early education. NICE quality standard has
based their aims and targets based on a Public Health Outcomes Framework (NICE,
2016).

NICE (2016) achievement levels are not yet
specified, however they explain they intent to drive quality of care forward to
100% success. Though the high aim, NICE understands and take into account that
not all situations may be appropriate in practise, therefore desired levels of
achievement may vary. The quality standard is in place alongside various
policies from the Department for Education, NHS, Ofsted, PHE and the Department
of Health (NICE, 2016). NICE (2016) believes a relationship between a child and
their main carer strongly influences the child’s development. Although most
parents in poorer social circumstances still provide nurturing environments for
their children, it is still strongly believed that children living in
disadvantaged homes are more likely to be exposed to risk behaviours.
Therefore, the aim of this strategy is to target early years with aims to
ensure a healthier development to adulthood. A development for later in life is
the Children and Young People’s Health Strategy 2015-2020 (CYPHS). This
strategy is shaped by a numerous factors as children and young people develop
with various strengths and vulnerabilities based on how they’ve grown up. CYPS
2015 – 2020’s main principles are to identify needs for interventions early,
create equal access to services, involve communities in promotion strategies to
better manage their own health and wellbeing and ensuring safeguarding is
strongly considered in all planning. Following early interventions from
under5’s, PHE believe partnership working has a large contribution for taking
action in reducing health inequalities as it can involve a range of
organisations for various sectors such as health services, schools and
employers (PHE | Health Equity Briefing10, 2014). PHE | Health
Equity Breifing3 (2014) have recognised the inequalities in young
people not in employment, education or training (NEET). They believe acting
early is the best approach to reduce the prevalence of young people NEET, as it
is should prevent it from happening at all. To support their opinions, the
ThinkForward programmes was created, with the aim to act early to ensure young
people are successful in the transition from education to employment by placing
coaches in schools and providing long-term support which includes linking young
people to services 

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