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Health Protection Inequalities:
A European Perspective
Jan C. SemenzaEuropean Centre for Disease Prevention and Control
Social inequalities in health
Source: National strategy to reduce social inequalities in health, Norwegian Ministry of Health and Care Services, 2007
Susceptible
Population
(S)
Infected
Population
(I)
Deaths
Recovered
Population
(R)
The impact of economic crises on communicable disease control
Infection Rate
Removal Rate
Determinants
Suhrcke M, et al., PLoS ONE. 2011; 6(6): e20724
Susceptible
Population
(S)
Infected
Population
(I)
Deaths
Recovered
Population
(R)
The impact of economic crises on communicable disease control
Infection RateDirect•Person to person•Overcrowding (prisons) •Mixing environments (shelters)•High risk pop (homeless)
Indirect•Common Vehicle•Infrastructure breakdown (water treatment)•Vector •Contact rates (TBE)•Vector pop (rodent and mosquitoes)
Removal Rate
•Treatment•Doctors •Access to drugs
•Nutrition•Immunitysystem•Immunization coverage
Determinants
Suhrcke M, et al., PLoS ONE. 2011; 6(6): e20724
Tuberculosis control and economic recession
Reeves A, Bulletin of the World Health Organization. 2015;93(6):369-79
Intervening on health inequalities of infectious diseases
Three intervention approaches:
1) The population-at-risk approach
2) The population-based approach
3) The vulnerable population approach
1) The population-at-risk approach
Public health interventions should focus on that segment of the population with the highest level of risk exposure as indicated by health risk behaviorsor biological markers.
For example, the homeless, a group at very high risk for TB.
Lalonde MA. A new perspective on the health of Canadians, 1974.
1) The population-at-risk approach
Semenza JC. Euro Surveill. 2010;15(27):32-9.
Mean effect Level of (single) risk
Afterintervention
Benefits after intervention
Beforeintervention
Intervening on TB
Inequality gradient of tuberculosis in the EU
20
TB p
reva
lence
/100,0
00 p
opula
tion
140
120
100
80
60
40
2,000 6,000 10,0000 14,000
R2 = 0.69
Public wealth index: GDP/income inequality
≤ 10%
25%
50%
75%
100%
Percentage of national TB cases that were foreign-born is related to the size of the circle
Suk JE et al., Emerg Infect Dis. 2009;15(11):1812-4.
2) The population-based approach
Mass environmental control methods and interventions that attempt to alter some of society’s norms.
For example, public smoking bans; water treatment and distribution systems; safe sex education; or cervical cancer screening.
Rose G. The strategy for preventive medicine. Oxford, 1992
2) The population-based approach
Mean effect Level of risks
Beforeintervention
Afterintervention
Semenza JC. Euro Surveill. 2010;15(27):32-9.
2) Socio-economic indicators and cervical cancer
Human Development Index
SD
R c
erv
ical ca
nce
rw
om
en <
64 y
rs
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
0.800 0.820 0.840 0.860 0.880 0.900 0.920 0.940 0.960 0.980
Franceschi S, et al., Int J Cancer. 2011;128(12):2765-74
2) Socio-economic indicators, cervical cancer and HPV vaccination
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
0.800 0.850 0.900 0.950 1.000
Human Development Index
SD
R c
erv
ical ca
nce
rw
om
en <
64 y
rs
HPV programme not implemented HPV programme implemented
Franceschi S, et al., Int J Cancer. 2011;128(12):2765-74
2) The population-based approach
Mean effect Level of risks
Beforeintervention
Afterintervention
Concentration of risksConcentration of
benefits
Semenza JC. Euro Surveill. 2010;15(27):32-9.
3) The vulnerable population approach
Vulnerable groups share social characteristics that put them at risk for multiple risks. Because of their position in the social strata they are commonly exposed to contextual conditions that distinguish them from the rest of the population.
Low socio economic status is the risk that generates the exposure to other risks, such as smoking, drug use, high risk sexual behavior, etc.
For example, occupational training and educational opportunities for the unemployed
Frohlich KL, Potvin L, AJPH 2008; 98(2):216-221
Afterintervention
3) The vulnerable population approach
Mean effect Level of (multiple) risks
Beforeintervention
BenefitsMinimal benefits
Semenza JC. Euro Surveill. 2010;15(27):32-9.
3) The vulnerable population approach
EmploymentWages,
unemployment
Faith or religion
Guiding, ruling
EconomicsCommunity,
personal
Family structuresFunctional,
dysfunctional
Support networksFriends, family
CultureValues,
traditions
Social factorsCommunity expectations
Social structures
Laws, politics
Social relationships
Relating to others,peer influence
Social view of health
Adapted from: Mosel-Williams L. Health, Life and Living: Book Two. Harcourt Education Australia, 1999.
Summary
• Certain high-risk groups in society, including the poor, migrants, homeless persons, and prison populations suffer disproportionally from infectious diseases in Europe.
• This situation is exacerbated during situations of economic duress.
• Comprehensive interventions should be devised to reduce health inequalities and to avoid unintended consequences.