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08/10/2014

HEALTH PROMOTION

The Effects of Socioeconomic Influences of Health
LO1
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• The notes contained in this PowerPoint presentation will cover LO1 (1.1;1.2;1.3) • Please print notes prior to attending lectures

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Learning Outcomes (LO)
On successful completion of this lecture a learner will: LO1: Understand the socio-economic influences on health 1.1 explain the effects of socio-economic influences on health. 1.2 assess the relevance of government sources in reporting on inequalities in health. 1.3 discuss reasons for barriers to accessing healthcare.

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Unit Content (LO1)
Influences: social e.g. disposable income, unemployment, lifestyle choices, environment, access to healthcare facilities, access to information, citizenship status, discrimination.

Sources of information: reports and enquiries e.g. Black Report DHSS 1980, Acheson Report ‘Independent Inquiry in ‘Inequalities in Health’ 1998, Health and Lifestyle Surveys (HALS), Health Survey for England (HSFE), census data
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Definitions (Class participation Review) • What is health promotion? • What is public health? • What do we mean by determinant of health? • What do we mean by environmental factors?

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The main determinants of health
Dahlgren and Whitehead's model, 1992

Figure 1: adapted from Dahlgren and Whitehead

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Health Promotion

“The process of enabling people to increase control over, and to improve their health.”

- Ottawa charter

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Refocusing upstream
"I am standing by the shore of a swiftly flowing river and hear the cry of a drowning man. I jump into the cold waters. I fight against the strong current and force my way to the struggling man. I hold on hard and gradually pull him to shore. I lay him out on the bank and revive him with artificial respiration. Just when he begins to breathe, I hear another cry for help.

I jump into the cold waters. I fight against the strong current, and swim forcefully to the struggling woman. I grab hold and gradually pull her to shore. I lift her out on the bank beside the man and work to revive her with artificial respiration. Just when she begins to breathe, I hear another cry for help.
I jump into the cold waters. Fighting again against the strong current, I force my way to the struggling man. I am getting tired, so with great effort I eventually pull him to shore. I lay him out on the bank and try to revive him with artificial respiration. Just when he begins to breathe, I hear another cry for help. Near exhaustion, it occurs to me that I'm so busy jumping in, pulling them to shore, applying artificial respiration that I have no time to see who is upstream pushing them all in...."
Adapted from A story told by Irving Zola - but is used in an article by John B. McKinlay in "A Case for Refocusing Upstream: The Political Economy of Illness" McKinlay, J.B. (1981)
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Public Health
• The science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society.

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Influences

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1. Your Health
There are many influences on an individual’s health. These are often categorised into:

Biological Factors
The Physical and Social Environment

Personal Lifestyle

Health Services
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2. Inequalities in Health
It is now generally recognised that there are many reasons for health inequalities. People can suffer health inequalities for many reasons, due in the main to:

The geographical area they live in. The racial group they belong to. Their gender

And, perhaps most importantly, their social class.
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The common denominator of all these factors is that they all link to POVERTY

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4. Ethnic Health Inequalities
Today, ethnic minorities make up about 6% of the UK population
* There is variation in health amongst various racial groups. * For example, Asians are more prone to heart disease and Caribbean's have a higher incidence of mental problems

* However, one of the main reasons for ill-health inequalities amongst ethnic communities seems to arise from RACISM and DISCRIMINATION * Poor “life chances” housing opportunities. often leads to poor educational, employment and

* This leads to POVERTY and increased chances of illness and disease.
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Gender Inequalities
The GENDER you belong to can also be a contributory factor to the amount of health you enjoy
Due to 3 main factors:

 Biological
* Women tend to live longer than men * But they suffer from more illness during their lives

- Women ’ s role in reproduction can cause ill-health

 Material

- Women still seen as ‘ carers ’ commitments often force them to take low paid /part time jobs - can lead to POVERTY and ill-health
- Women live longer more prone to illICON COLLEGE (LO1) = TASK 1 health connected to old age. 14

 Ageing

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Incidence and Prevalence of Obesity in the UK according to year ( female vs male)

Figure 2: Prevalence of morbid obesity among adults aged 16+ years

Source http://www.noo.org.uk/NOO_about_obesity/morbid_obesity/ukprev
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Health and Lifestyle Issues (1)
- Poor Eating Habits and Obesity It is generally recognised that Western lifestyle is bad for your health………. Fat seems also to be a class issue. It seems the lower the class you belong to, the greater the incidence of obesity


 Over 50% of Britons are overweight and the number of overweight children is a growing phenomenon in the Western World  Often opposition from the food industry where a large % of profits can be made from junk food profits

Some proposals to stop children eating junk food have been controversial - In 1998 James Report suggested banning sweets and fizzy drinks from schools

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Health and Lifestyle Issues(2)
- Smoking Generally that smoking damages health in the form of cancers and heart disease


 Smoking seems to link to ill health and is also a class issue
 By 1990s, professional classes had

listened to advice and had cut down on smoking.
 The habits of lower classes changed

little during this time.
 Young

women are especially vulnerable, especially teenage girls.
 Girls 20 years behind men in smoking
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habits

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Approaches to Solving Health Inequalities (1)
There are two major approaches to tackling inequalities in health:

THE COLLECTIVIST APPROACH

THE INDIVIDUALIST APPROACH
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Approaches to Solving Health Inequalities (2) >THE COLLECTIVIST APPROACH<
This approach to solving inequalities is based on the view that differences in health are beyond the ability of the individual to change
 

Subscribers to this view feel that improvements will only come by concerted government action centering on anti-poverty strategies


The view is that differences in health are due  Idea first found favour to major economic and in the Black Report social problems in society (1980) and Acheson - e.g.. poor housing stock, Report (1998) unemployment, inflation  These problems impact on different people in different ways - but poorer social classes suffer ICON COLLEGE (LO1) = TASK 1 most. 19

Approaches to Solving Health Inequalities (3) >THE INDIVIDUALIST APPROACH<
 This approach is based on the belief that health inequalities are the result of how INDIVIDUALS choose to lead their lives Government action should centre on high-profile health advertising campaigns etc. Approach favoured by Tory Government in early mid 1990s.


There seems to be differences in health habits between different social classes


Idea is that people should be largely responsible for monitoring own health  People of lower social class seem to; smoke and drink alcohol more often, exercise less and have less healthy ICON COLLEGE (LO1) = TASK 1 diets


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KEY DEFINITIONS
• Social determinants of health - These refer to the social, economic, and political situations that affect the health of individuals, communities, and populations. • Health system and health-systems performance The health system as defined by WHO describes “all the activities whose primary purpose is to promote, restore, or maintain health.

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Social determinants of health

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Social Determinants
(refer to Dahlgren and Whitehead Model) • The social conditions in which people live powerfully influence their chances to be healthy.

• Indeed factors such as poverty, food insecurity, social exclusion and discrimination, poor housing, unhealthy early childhood conditions and low occupational status are important determinants of most diseases, deaths and health inequalities between and within countries’. (WHO 2004) ICON COLLEGE (LO1) = TASK 1 23

Social Determinants
• Health is influenced, either positively or negatively, by a variety of factors. Some of these factors are genetic or biological and are relatively fixed. • ‘Social determinants of health’ arise from the social and economic conditions in which we live and are not so fixed. • The kind of housing and environments we live in, the health or education services we have access to, the incomes we can generate and the type of work we do, for instance, can all influence our health, and the lifestyle decisions we make.
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Summary

1.Social determinants contribute to health inequalities between social groups. This is because the effects of social determinants of health are not distributed equally or fairly across society. 2. Social determinants can influence health both directly and indirectly. For example educational disadvantage can limit access to employment, raising the risk of poverty and its adverse impact on health. 3. Social determinants of health are interconnected e.g. poverty is linked to poor housing, access to health services or diet, all of which are in turn linked to health. 4. Social determinants operate at different levels.
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Inequalities in Health
A number of studies have been carried out by various groups over the years

Their reports revealed: • the nature of health inequalities • the scale of the health inequalities • the causes of these inequalities in the UK.

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Well established inequalities
1. 2. 3. 4. Income. Poverty. Education. Health.

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Multiple Causes
A range of factors contribute to health Inequalities: • Socio-economic or material factors such as government social spending and the distribution of income and other resources in society which influence the social and built environment. • Psychosocial factors such as stress, isolation, social relationships and social support. Behavioral or lifestyle factors.

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The following studies into health inequalities have found a causal link between social class and the incidence of ill health.

Reports

The Black Report (1980) The Health Divide (1987) Working Together for a Healthier Scotland (1998) The Acheson Report (1998)

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Social Class
To understand the link between social class and ill health, we need to be clear what is meant by social class. A person’s social class is based on a mixture of factors:

Occupation

Income level

Housing

Education

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Registrar General’s Classification of Social Class (RGCSC)
Class I II IIIa IIIb IV V Categories Higher managerial, administrative, professional. Accountant, bank manager, dentist, doctor, solicitor. Lower managerial, administrative, professional. Farmer, librarian, sales manager, teacher. Non-manual: Clerical and minor supervisory. Clerk, police officer, shop assistant Skilled manual: Clerical and minor supervisory. Electrician, mechanic, plumber. Semi-skilled manual. Assembly line worker, builder, lorry driver. Unskilled. Cleaner, labourer.
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Sources of Information (1.2)

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The Black Report (1980)Remit
1. To investigate the problem of inequalities in health in the UK. 2. To analyse the lifestyles and health records of people from all social classes (based on the Registrar General’s categories).
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The Black Report (1980)
Findings: • The health of the nation had improved generally but the improvement had not been equal across all the social classes. • Gap in inequalities of health between lower and higher social classes was widening.

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The Black Report (1980)
Findings • Health standards were directly linked to social class. • Ill health increased down the social scale. • The problem had little to do with the NHS. • Problems were linked with social and economic factors such as: 1. income 2. unemployment 3. poor environment 4. poor housing 5. education
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The Black Report (1980) Findings
Low income Sub standard housing

Unemployment

Poor education

Poor environment
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The Black Report (1980) Recommendations
• Report contained 37 recommendations which focused on two main areas:
Government should adopt a policy: aimed at reducing poverty in the UK of spending more money on health education and the prevention of Illness.
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The Black Report (1980) Reaction by Government
• When the Report was published there was a change of government. Conservatives were now in government and they criticised the Report.

Report did not explain inequalities in health. Spending more on health services would make no difference to health standards.
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Contrary to what the Report said, poor people did use health services.
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The Black Report (1980)
Problem was:
They wanted to reduce public expenditure

Took the individualist approach – people should eat, drink and smoke less

Government disagreed

Regarded the Report as old-fashioned, socialist explanations of ill-health

Argued that individual behaviour within social classes shaped health
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The Health Divide (1987) Remit
• This Report, also called the Whitehead Report, concentrated on social class as one of the main causes of inequalities in health. • The Report was commissioned by the Health Education Council (HEC) in 1987 and headed by Margaret Whitehead. • Her remit was to update the evidence on inequalities in health and to assess the progress made since the Black Report six years earlier.
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The Health Divide (1987)
• The HEC was a quango – a body set up by the government but able to work independently, in theory.
• a semi-public administrative body outside the civil service but receiving financial support from the government, which makes senior appointments to it.

• Findings Revealed that the gap between health standards and social class had widened since the publication of the Black Report. Restated the direct link between health and social class.

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The Health Divide (1987)
Government reaction
• • Just when the Report was being commissioned, government announced that the HEC was to be scrapped. the HEC was campaigning on alcohol, tobacco and diet issues which upset some of the government’s financial supporters – tobacco manufacturers gave a lot to party funds. One week before findings were due to be made public, a press conference was cancelled with no explanation. Clearly pressure had been put on the Chairman of the HEC to cancel because of the controversial nature of the report’s findings.



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The Acheson Report (1998)
• This was an independent study into health inequality. • It was commissioned by the new Labour government in 1997, under the chairmanship of a former Chief Medical Officer for England and Wales, Sir Donald Acheson. • Remit – to investigate health inequalities in the UK.
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The Acheson Report (1998)
• It was a very comprehensive survey of those in society described as disadvantaged. • Its findings mirrored those of the Black Report. • The root cause of inequalities in health was poverty. • It concluded that in order improve the health of millions, the gap between the richest and poorest in UK society had to be reduced.
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The Acheson Report (1998) Findings
  Children from poor families weighed on average 1.30gms less than those from wealthy families Infant mortality rates:  7/1000 – lower social classes

 5/1000 – upper social classes
 Long term illness  17% of profession men aged 45-64  48% of lower class men aged 45-64  Income levels  2.2 million children live on income levels 50% below the national average  Health campaigns  Higher uptake of screening amongst upper social classes – widened health gap
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The Acheson Report (1998) Findings
Social class I


Coronary heart disease Strokes

Poor men are 68% more likely to die in middle age than richer men.




Lung cancer Accidents & suicides Respiratory diseases

Poor women are 55% more likely to die young.
Health inequalities start before birth – A key factor in low weight babies is the mother’s birth weight and her pre-pregnant weight.

Social class V

Risk increases

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Scotland Health Survey 2003
Coronary Heart Disease and Deprivation Mortality Rates per 100,000, all ages

300.0 250.0 200.0 150.0 100.0 50.0 0.0 1 2 3 4 5 6 7 8 9 10
SIMD (Scottish Index of Multiple Deprivation)
(1 = least deprived and 10, m ost deprived)
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Crude Rate per 100,000 Population

Crude Rate per 100,000 Population

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Sources of Information (1.2) continued

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Health and Lifestyle Survey (HALS) (1)
Health and Lifestyle Survey carried out in 1991/2
•HALS1 was designed as a unique attempt to describe the selfreported health, attitudes to health and beliefs about causes of disease in relation to measurements of health (e.g. blood pressure. lung function) and lifestyle in adults of all ages and circumstances living in their own homes in all parts of Great Britain

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Health and Lifestyle Survey (HALS) (2)
1.
The principal aims of HALS2 were to record self-reported health, measured health, cognitive function, psychological well –being, lifestyle habits - diet, alcohol consumption, exercise and leisure activities – and social and demographic status in order to identify changes that had occurred in the seven years between the two surveys

1.

To investigate the extent to which changes in circumstances, lifestyle habits and health are associated

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Health and Lifestyle Survey (HALS) (3)
3. 4. To examine how beliefs about health and attitudes to health have changed with changing heath status. To investigate the relationship between life events (not recorded 10 the first survey) and physical and psychological morbidity.

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Significance to Health Inequality
•Most measurement of health inequality involves the use of indicators or indexes to measure health, but it also involves decisions on what groups or areas to compare. •Measuring inequality by health and disease categories (using data from surveys).

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Health Survey for England (1)
The Health Survey for England (HSE) comprises a series of annual surveys beginning in 1991.
• is a statistical survey which is conducted annually in order to collect information concerning health and health-related behavior of people living in private households in England.

http://www.dh.gov.uk/en/Publicationsandstatistics/PublishedSurvey/HealthSur veyForEngland/index.htm

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Health Survey for England (2)
• This survey is now commissioned and published by The NHS Information Centre. It is designed to provide regular information on various aspects of the nation's health. • All surveys have covered the adult population aged 16 and over living in private households in England. Children were included in every year since 1995.

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Key measures of health covered by the latest report include
1. 2. 3. 4. 5. 6. 7. 8. Kidney disease Diabetes Smoking Adult obesity Alcohol consumption Fruit and vegetable consumption Long standing illness Self reported general health and acute sickness
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Significance to Health Inequality 2009 (1)
•Significant health inequalities still exist between the country’s richest and poorest according to the latest findings from the biggest annual survey of health in England, The Health Survey for England. • showed that people in the lowest income households continued to experience much worse outcomes across key health measures than people in the highest income households.
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Significance to Health Inequality 2009 (2)



Men and women in the lowest income bracket are three times more likely than those in the highest income bracket to have kidney disease and to smoke. The disparity in health between England’s richest and poorest is particularly marked amongst women, with those in the lowest income bracket four times more likely to be diagnosed with diabetes and twice as likely to be obese than women in the highest income bracket.



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Significance to Health Inequality (2009) (3)

This important survey provides an annual health check for the nation, and shows that there are still marked inequalities in health between different socio-economic groups.

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Census data

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Group Discussion
• How do we use the census data in reporting on inequalities in health

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What are the inequalities?
Compare: health outcome or health related measure with measure of deprivation Examples Data: - Children: low birth weight, breastfeeding, hospital admissions, mortality, smoking in pregnancy, teenage pregnancy - Adults: deaths from heart disease, cancer, and other diseases, uptake for services, Measures of deprivation for geographical areas: e.g. DETR, Townsend, Jarman
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How do we measure socioeconomic health inequality?

• examine Index of multiple deprivation

• The Indices of Deprivation 2010 (ID 2010) is the collective name for several separate indices measuring deprivation within all local authority areas in England.

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How do we measure socioeconomic health inequality?
• The Index of Multiple Deprivation is based on the concept of measuring distinct dimensions of deprivation separately and then combining these to give an overall score. It is an area based measure, rather than an individual based measure, so it looks at the extent of each type of deprivation within the area and then combines these to give a figure taking into account the extent of each type of deprivation. It does this by using statistical techniques to combine information on economic and social issues to produce scores for small areas across the whole of England





.
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` Domains’ of deprivation included in the IMD2010,
1.

Income deprivation Employment deprivation Health deprivation and disability

2. 3.

4.
5. 6. 7.

Education, skills and training deprivation
Barriers to housing and services Living environment deprivation Crime

.
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Life Expectancy at birth by deprivation quintile in North Somerset
85.0 83.0 81.0 79.0 77.0 75.0 73.0 71.0 69.0 67.0 65.0 I - Most Affluent II III Deprivation Quintile IV V - Most Deprived

years

Males Females

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Townsend Score
Provides a material measure of deprivation and disadvantage. The index is based on four (4) different variables taken, originally from the 1991 Census.
The four variables that comprise the Townsend Index are: 1. Unemployment as a percentage of those aged 16 and over who are

economically active. 2. 3. 4. Non-car ownership, as a percentage of all households. Non-home ownership as a percentage of all households. Household overcrowding.

The four variables combine to form an overall score. The higher the
Townsend Index score, the more deprived and disadvantaged an area is thought to be. This allows different areas to be ranked in relation to one another.
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Townsend Score
The four variables combine to form an overall score. The higher the Townsend Index score, the more deprived and disadvantaged an area is thought to be. This allows different areas to be ranked in relation to one another.

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Townsend Score
• Ranking system, based on Census Data • Most commonly used in routine analysis of health inequalities

Pros: • It can be used to look at small areas • Highly correlated with measures of ill health, e.g. limiting long-term illness

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Class participation Review) • What was the objective of the Black Report? (1980) • What was the objective of the Health Divide Report ? (1987) • What was the objective of the Acheson Report? (1990) • Using Dalghren and Whitheads model , What do we mean by determinant of health?
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Access to Health Care

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Access to Health Care (1)

What are some barriers to accessing health care and WHY?

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ACCESS TO HEALTH SERVICES factors and who (1)
Julian Tudor Hart’s “Inverse Care Law”: People who need health services the most are the least likely to get them Why? Because of barriers to access: (Factors) 1. Financial barriers e.g. unable to pay, cannot afford to take time off from work to see the doctor 2. Geographic barriers e.g. too far to travel; safety and costs 3. Cultural barriers (i.e. staff attitudes) 4. Can you think of any other barriers?
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ACCESS TO HEALTH SERVICES other factors and who (2)
1. social, political, cultural and institutional

factors. 2. Ethnicity 3. economic empowerment and education are critical to access to healthcare 4. groups such as women and girls (gender) or the very poorest and marginalised.

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Who is Marginalized?
Marginalized women are women whose access to health is limited by their access to the social determinants of health, such as: 1. 2. 3. 4. income and social status social support networks education and literacy employment/working conditions

Marginalized women also experience discrimination based on their ability, race, gender sexual orientation, class, etc.
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The next slides will highlight from research how groups (women , people of colour) are marginalised in society

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Women and Stroke
According to the Heart and Stroke Foundation of Canada:
• • • • Women have 60% of 50,000 strokes yearly. More women than men die as a result of stroke There are risk factors and symptoms of stroke specific only to women. Women are less likely to receive the right treatment. (2007 Report on Canadians' Health, Heart and Stroke Foundation of Canada, 2007)

Furthermore, twice as many women die from stroke as breast cancer.

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Example of a Marginalised group (1)
Refugees may experience many barriers when trying to access health care. For example: 1. They may not speak or understand English

2. They may not be familiar with health practices in England. Health care systems differ around the world. Some refugees may have unrealistic expectations of the health service in the UK, having gained a distorted view of the NHS when in their home country.
3. They may not know where to go, who to see or whether they have to pay for health care or medicines.

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Example of a Marginalised group (2)
4.They may not understand appointment or referral systems, waiting lists or letters from doctors or hospitals. 5.They may not have had proper access to health care services in their own country. 6.Some refugees, because of their experiences, may view health professionals with mistrust.

7.Some health care service staff may be unaware of refugees’ entitlements.
8.Some GPs may only see refugees as temporary patients. 9.Some health care service staff may be prejudiced against refugees.

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Ethnic Disparities in Patient Recall of Physician Recommendations of Diagnostic and Treatment Procedures for Coronary Disease

• Despite the proven benefits of many cardiac procedures, some are used less frequently for African American than for white patients with known or suspected coronary disease. This study explored differences between ethnic groups that may affect patient recall of physician recommendations of cardiac procedures . • Compared with whites, fewer African American patients recalled physicians recommending some cardiac procedures. If procedure recommendations were recalled, no ethnic differences were found in patient recall of adhering to those recommendations.
Am J Epidemiology 1998;148:741-9

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Disparities in the Receipt of Cardiac Revascularization Procedures between Blacks and Whites: an Analysis of Secular Trends
METHODS: – data from the National Hospital Discharge Survey were used for the analysis. Patients who were Black or White and > or = 40 years of age were included. Independent variables included age at discharge, sex, race, and insurance coverage. Multivariate logistic regression was used to derive odds ratios for the receipt of the three procedures by age group, sex, insurance type, and race. RESULTS: – Significant differences (P < .05) in the odds of receipt of all of cardiac catheterization, percutaneous transluminal coronary angioplasty, and coronary artery bypass graft were found by age group, insurance type, sex, and race. While the disparities persisted from 1979 to 2004, the magnitude of the differences decreased during this time period. CONCLUSION: – Disparities by race, sex, and insurance type existed in the receipt of three cardiac procedures. Although differences are narrowing over time, further in-depth studies are needed to elucidate the patient, physician, and healthcare system factors associated with the disparity in receipt of these beneficial procedures.

Ethn Dis. 2008 Spring;18(2 Suppl 2):S2-112-7.
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The effect of race on coronary bypass operative mortality
OBJECTIVES – The study was done to determine whether race is an independent predictor of operative mortality after coronary artery bypass graft (CABG) surgery. BACKGROUND – Blacks are less frequently referred for cardiac catheterization and CABG than are whites. Few reports have investigated the relative fate of patients who undergo CABG as a function of race. METHODS – The Society of Thoracic Surgeons National Database was used to retrospectively review 25,850 black and 555,939 white patients who underwent CABG-alone from 1994 through 1997. Bridges C, Edwards F, Peterson E, Coombs L. The effect of race on coronary bypass operative mortality. J Am Coll Cardiol. 2000;36(6):1870-1876.

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Health is not just the outcome of genetic or biological processes but is also influenced by the social and economic conditions in which we live. These influences have become known as the ‘social determinants of health’. Inequalities in social conditions give rise to unequal and unjust health outcomes for different social groups
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Key Social Determinants of Health that leads to marginalisation

1. Poverty and Inequality. 2. Social Exclusion and Discrimination. 3. A Life Course Perspective 4. Public Policies and Services 5. The Built Environment 6. Work and Employment 7. Community and Social Participation 8. Health Behaviours 9. Stress.
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1. Poverty and Inequality.
• Both poverty and economic inequality are bad for health. Poverty is an important risk factor for illness and premature death. • It affects health directly and indirectly, in many ways, e.g. financial strain, poor housing, poorer living environments and poorer diet, and limited access to employment, other resources, services and opportunities. Poor health can also cause poverty.
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2. Social Exclusion and Discrimination (a)
Social exclusion is the process by which groups and Individuals are prevented from participating fully in society as a result of a range of factors including poverty, unemployment, caring responsibilities, poor education or lack of skills, women, older people, people with disabilities or homeless people, for example, may experience social exclusion.

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2. Social Exclusion and Discrimination (b)
Social exclusion therefore is about more than poverty . It is about isolation from participation in social life and from power and decision making

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Social exclusion
• Social exclusion is often compounded by discrimination, which can arise on the basis of a person ’ s gender, race or ethnicity, disability, marital, family or caring status, age, religion or • Equality legislation has an important role to play in tackling these forms of discrimination and promoting greater equality, inclusion, and diversity.
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In practice
Health inequalities can be seen as an outcome of Social Inequalities

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References
1. Epidemiology in Medicine – Charles Hennekins. Little, Brown and Company.

2. Health Knowledge website http://www.healthknowledge.org.uk/Epidemiology/Epidemiology%201.htm 3. Szreter SRS. The genesis of the Registrar General’s social classification of occupations. Br J Sociol 1984; 35:522–46. 4. Black. DHSS, Inequalities in Health, report of a research working group, London: DHSS, 1980. 5. Atkinson AB. Measuring inequality and differing social judgments. London: London School of Economics; 1989. 6. Bowling A. Measuring health: a review of quality of life measurement scales, 2nd ed. Buckingham: Open University Press; 1997.

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Q and A Time?

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