1. Plenary 1 Chair: Professor Gareth Williams Health Impact Assessment: Making the Difference

2. Professor Sally Macintyre Director of the Medical Research Council and Public Health Sciences Unit, Glasgow Health Impact Assessment: Making the Difference

3. Inequalities in Health: Implications for Health Impact Assessment Sally Macintyre 7 th International Health Impact Assessment Conference 2006

4. Outline l Pervasiveness and magnitude of inequalities in health l Lack of knowledge about how to reduce them l Reasons for lack of knowledge l HIA and evaluation l Closing the feedback loop

5. Inequalities in health l Socio-economic status l Gender l Race/ethnicity l Place of residence l And other axes of stratification e.g. religion, caste In all known societies: Health risks, health behaviours, physical and mental health and life expectancy vary between social groups defined in terms of:

6. Life expectancy, USA, 2003 MalesFemalesDifference White75.480.55.1 Black69.276.16.9 Difference6.24.4 Congressional Research Service, Library of congress Life Expectancy in the USA, March 2005

7. Life expectancy gap Social Class I – V, England 1997 - 2001 Males8.4 years Females4.5 years DH, Tackling Health Inequalities, Status Report 2005

8. Life expectancy in Scotland 2004 I By Local Government Areas MenWomen Aberdeenshire76.380.8 East Dunbartonshire77.080.4 Glasgow City69.376.4 GRO Scotland 2005

9. Life expectancy in Scotland 2004 II By constituency, Glasgow Area MenWomen Eastwood76.381.3 Strathkelvin76.280.3 Springburn66.674.8 Shettleston63.975.2 Health Scotland 2004

10. Life expectancy in New Zealand by ethnic group, 1996 - 1999 MenWomen Maori64.068.7 Pacific67.973.9 Non-Maori, Non-Pacific75.780.8 Difference/Non-Maori, Non-Pacific11.712.1 Blakely et al 2005

11. Average rates do not predict inequalities PeruUzbekistan Mean:49.9Mean:46.8 Poor:78.3Poor:49.5 Rich:19.5Rich:43.5 Robinson et al, in press Infant mortality rates

12. Acheson Report 1998 “We recommend that as part of health impact assessment, all policies likely to have a direct or indirect effect on health should be evaluated in terms of their impact on health inequalities, and should be formulated in such a way that by favouring the less well of they will, wherever possible, reduce such inequalities.” Acheson 1998, p30

13. “A well intended policy which improves average health may have no effect on inequalities. It may even widen them by having a greater impact on the better off. Classic examples include policies aimed at preventing illness, if they resulted in uptake favouring the better off. This has happened in some initiatives concerned with immunisation and cervical screening, as well as in some campaigns to discourage smoking or to promote breastfeeding.” Acheson 1998, p30

14. Acheson ‘Evaluation Group’: Conclusions l lots of data documenting health inequalities l lots of research attempting to explain health inequalities l little information about effectiveness of interventions l even less information about potential harms, costs or priorities l evidence clearer for downstream than upstream interventions Macintyre, Chalmers, Horton, Smith 1998

15. Reducing Inequalities in Health: A European Perspective l work policies - poor design, or health outcomes unevaluated l food policies - ‘little information on the long term effects ….’ l smoking - ‘little direct evidence that permits any definitive judgements’ l children - many interventions: ‘most are not well known and very few have been systematically evaluated’ l access to healthcare - ‘paucity of studies about the best ways to reach poorer people with appropriate and effective services’ Mackenbach & Bakker, 2002

16. Wanless report: Securing good health for the whole population 2004 ‘Although there is often evidence on the scientific justification for action and for some specific interventions, there is generally little evidence about the cost- effectiveness of public health and preventative policies or their practical implementation… little evidence about what works among disadvantaged groups to tackle some of the key determinants of health inequalities’

17. Lack of evaluations of outcomes l Of published or funded public health research in UK, 4% deal with interventions rather than descriptions of the problem l only 10% of them (0.4%) deal with outcomes of interventions l in specific topic areas evidence about inequalities, and tools for capturing social differences, not very robust l very few systematic reviews have focused on effect of interventions on inequalities in health Millward L, Kelly MP & Nutbeam D, 2001 Public Health Intervention Research: The Evidence, London, HDA

18. Reasons for paucity of evidence l Short government time scales; no time to wait for pilots or long term evaluations l Evaluations problematic (window dressing?) l Lack of routine data for monitoring inequalities l Assumption that systematic reviews and RCTs are not suitable for real life community initiatives l Assumption that plausibility is a good basis for policy making l Assumption that public health interventions can’t do harm l Assumption that it is enough to know about aggregate effects

19. Post 1997 Labour Government l Reducing inequalities overarching goal l programmes introduced to do this without knowing whether they’ll work l government focus on inputs and throughputs not effectiveness

20. Reducing health inequalities; an Action Report 1999 l New deal for communities l New deal for employment l Single Regeneration budget l Health Action Zones l Healthy Living Centres l Healthy Schools Programme l Working Families tax credits l Sure Start

21. Demonstration programmes in Scotland l Poor evidence base in first place l Evaluations set up too late l Programmes non evaluable l Decisions on phase 2 taken before evaluations complete Evaluation Task Force Review, Scottish Executive, 2004

22. Lack of good routine data to monitor inequalities l social class or area deprivation indices only available every ten years l health surveys not large enough or long enough series l social class, ethnicity, etc. not collected in NHS records l intervention studies don’t report differential effects by social class, ethnicity, etc.

23. Systematic reviews not suitable for real life community initiatives? But: Systematic reviews have been conducted on: l youth mentoring programmes l impacts of after-school programs on student outcomes l strategies related to the prevention, detection, management and response to terrorism l effects of closed circuit television surveillance on crime l effects of improved street lighting on crime l home based support for socially disadvantaged mothers

24. RCTs not suitable for real life community initiatives? But: RCTs have been conducted on: l re-housing l effectiveness of out-of home day care for disadvantaged families l prison rehabilitation programs l raids on crack houses

25. Systematic review of area based regeneration initiatives in the UK l Little evidence of the impact of national urban regeneration on socio-economic or health outcomes. l Changes often no different from national trends. l However, some harms:  Single Regeneration Budget 1996 - 1999; deterioration in self reported health  Urban programme and City Challenge; worsening of unemployment  Estate Action; increased housing costs  Housing improvement in 1930s Scotland; rents doubled, mortality rates increased (residents couldn’t afford adequate food) Thompson et al, 2006