The wider determinants of health: Theory into practice

Inequalities in Health: trends, causes and policy

Joop ten Dam PhDNIGZ Support centre for

Community Health (NSCH)www.slag.nu

jtendam@nigz.nl

Contents

► Inequalities in health:

Facts and trends

Causes

Policy

► Inequalities in health

Facts and trends

Causes

Policy

Increase in life expectancy between 1960 and 2000

Source: Eurostat. 2000

Life expectancy trends for men and women in various EU countries in the period from 1970 to 2000

As well as the Netherlands and the EU average (EU-15), the most and leastfavourable countries are shown (Source: WHO-HFA, 2002).

Estimated disability-adjusted life expectancy, 2001

72.8 years

50.1 years

Black Report (1980)

0

20

40

60

80

100

120

140

160

180

I II IIIN IIIM IV V

SMR Mannen

0

20

40

60

80

100

120

140

160

180

I II IIIN IIIM IV V

SMR Vrouwen

Solid Facts (second edition), WHO 2003

Occupational class differences in lifeexpectancy, England and Wales, 1997-1999

Inequalities in health (1)

SES low high Birth weight 3190 3424 (grams) Body length 175 180 (grown men) Chron. diseases 46 29 (number per 100 pers.) Disabilities 19 6 (% persons with > 1) Disablement 18 3 (%) Psych. soc. complaints 8.4 5.2 (mean number)

(Netherlands)

Inequalities in health (2)

SES low high diff women

Lif e expectancy 79,5 82,1 - 3 Without health restrictions 64,7 73,3 - 9 Experienced as healthy 54,2 68,2 - 14

man

Lif e expectancy 73,1 78,0 - 5 Without health restrictions 63,8 73,7 - 10 Experienced as healthy 52,9 68,7 - 16 Source: RI VM 2002

Life expectancy and disability-free life expectancy according to educational level for

Dutch men and women, 1995-1999

elementarytertiary tertiary

elementary

Men Women

Inequalities in health (3)

► Cities less healthier► Concentration of poor health in deprived

neighbourhoods.► Differences in life expectancy between

neighbourhoods more than 10 years► Poor health an extra element in

accumulation of problems

Inequalities in health (4)

► Exist in all Western countries

► Decreasing over the centuries

► Increasing since + 1950 (at the same time as the developing welfare state)

The Widening Mortality Gap Between the Social Classes

Tackling Health Inequalities. A Programme for ActionUK Department of Health 2003

► Inequalities in health

Facts and trends

Causes

Policy

Lalonde Model (1974)

► Biological factors (gender, age, ethnicity)

► Physical environment (living, working)

► Social environment (social position, friends, family)

► Life style (nutrition, exercise, smoking, drinking)

► Health care (access, price, quality)

SES

HealthDeterminants:

environment and behaviour

Health

Selection

Causes

Causes: life styles

low high

smoking man women

47 36

33 21

inactive man women

54 60

31 32

Percentage smokers in men; 1990-2000

25

30

35

40

45

50

55

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

jongeren ouderen lage seshoge ses totaal

rokers (%), mannen

Source: RIVM 2002

Youth is investing in future ‘bad health’

Present levels of unhealthy behaviour:smoking (15-19) 45%alcohol use 50-59% physical inactivity 49%low consumption vegetables and fruit 85-95%overweight 7-16%

Trends in the past decade: smoking unfavourablealcohol use unfavourableconsumption vegetables and fruit unfavourableoverweight unfavourable

Source: RIVM 2002

Overweight more prevalent and in younger age groups

Health on Course? RIVM 2002

Contribution (in per cent) of eight significant determinants to mortality, loss of quality of life and

burden of disease (disability-adjusted life-year (DALY)) in the Netherlands.

Solid Facts (second edition), WHO 2003

Socioeconomic deprivation and risk of dependence on alcohol, nicotine and drugs, Great Britain, 1993

Mortality from coronary heart disease in relation to fruit and vegetable supply in selected European

countries

Solid Facts (second edition), WHO 2003

► Inequalities in health

Facts and trends

Causes

Policy

Starting point

► Structural inequalities in health collide with the democratic principle of equal opportunities

► So decrease avoidable inequalities in health

What it’s all about ...

► By the year 2020, the health gap between socio-economic groups within countries should be reduced by at least one fourth in all member states, by substantially improving the level of health of disadvantaged groups

(Health 21 WHO / EURO)

Conditions for policy

► Effective interventions:►attack crucial factors►are effective

► Effective implementation:►have sufficient support►use long term investments►monitor results

Possibilities for policymaking 1

► Decrease differences in SES:► Income policy►Poverty policy►Policy on education►Labour market policy

► “Seduce” people into a healthy living style;

► Building a healthy physical environment

Possibilities for policymaking 2

► Extra facilities in health care► Keep the health care affordable► School approach (smoking, fruit)► Reduce absence through illness► Medical indication for financial support to

families and children with health problems► Support the chronic patients: remove

thresholds to work and income

Key interventions that will contribute to closing the life expectancy gap

► reducing smoking in manual social groups

► preventing and managing other risks for coronary heart disease and cancer such as poor diet and obesity, physical inactivity and hypertension through effective primary care and public health interventions – especially targeting the over-50s

► improving housing quality by tackling cold and dampness, and reducing accidents at home and on the road

UK Inequalities in health programme for action(UK Department of Health 2003)

Actions likely to have greatest impact over thelong term

► improvements in early years support for children and families

► improved social housing and reduced fuel poverty among vulnerable populations

► improved educational attainment and skills development among disadvantaged populations

► improved access to public services in disadvantaged communities in urban and rural areas, and

► reduced unemployment, and improved income among the poorest

UK Inequalities in health programme for action (UK Department of Health 2003)

Community-approach

Traditional health campaigns and health promotion activities often fail to reach people with a low SES in an adequate way.

If health activities are to reach these people, they should be implemented closer to them, to the places where they live and work. This means that the programmes should be implemented at a local level.

So, a new paradigm is needed.

This change of paradigm is now taking place: from health education to a community-approach

Change of paradigm: from health education to community-approach

health promotion community- approach

method educate, convince support, empower

starting point percieved will to change living conditions of the people

theme narrow: behavior broad: healthy lifestyle, environment, health care

approach closed: a risk factor open

agenda health educator debate with all actors

Change of paradigm: from health education to community-approach

health promotion community- approach

scale national, regional local, setting

production bureau en pretest co-operation with actors

type planning “healthy chaos”

aim healthy lif estyle quality of lif e, health

Improving Health Promotion

• Furthermore health profits from:• Implementation of locally successful initiatives

• Stimulating of prevention within health care

Using the ‘well-known’ insights:

• Prevention fitted to target groups: - youngsters, lower socio-economic groups

• Prevention within existing settings: - school, work, leisure time

• Prevention by combining methods: - health education, laws and regulations, etc.

• Structural prevention:- no project financing, but structural budgets

Bron: VTV 2002

NIGZ - Support centre for Community Health (NSCH)

► NSCH supports organisations that strive to reduce health inequalities in a local context and takes care of the implementation of effective interventions.

NSCH offers several services :

► Developing new methods to address health issues at a local level while sharing existing methods and adapting them to local conditions.

► Direct support to pilot projects and publishing the results for broader use.

► A network of professionals sharing information, analysing projects, and contributing to the development of new methods and policies.

► Access to international information on good practices to local workers.

The wider determinants of health: Theory into practice

Inequalities in Health: trends, causes and policy

Joop ten Dam PhDNIGZ Support centre for

Community Health (NSCH)www.slag.nu

jtendam@nigz.nl