Denise Kendrick University of Nottingham

 Inequality or inequity?  Differences in injury risk ◦ Child factors ◦ Family factors ◦ Social factors ◦ Environmental factors ◦ Ethnicity factors  How big are the differences?  What can we do to tackle inequities?  The evidence base for tackling inequities  Summary

 The WHO defines health inequality as: ◦ “Differences in health status or in the distribution of health determinants between different population groups”  Whitehead outlined key concepts that distinguish inequalities from inequities: ◦ Differences are “unnecessary, avoidable, unfair and unjust”  Braveman suggests: ◦ “Inequities in health systematically put people who are already socially disadvantaged (e.g. poor, female, and/or members of a disenfranchised racial, ethnic, or religious group) at further disadvantage with respect to their health”

INEQUALITYINEQUITY  Lower birth weight of girls than boys  Men have prostate problems, women do not  Carriers of cystic fibrosis are more likely to have a child with cystic fibrosis than non carriers  Life expectancy for men in Calton in Glasgow is 54 compared to 77 for the UK as a whole  Lower rates of aggressive treatment for MI in women than men

 Child factors ◦ Age ◦ Gender ◦ Behaviour ◦ Disability or co-morbidities  Family factors ◦ Family structure ◦ Psychological factors ◦ Parenting factors ◦ Parental education  Social factors ◦ Socio-economic disadvantage  Environmental factors ◦ Home environment ◦ Neighbourhood environment ◦ Urban/rural  Ethnicity Very limited evidence for some factors, particularly in the UK Complex relationships between many factors Effect modifying and mediating factors often not explored Importance of factors varies by injury mechanism Still considerable proportion of variation in injury rates unexplained

 Most factors listed on previous slide increase risk by of injuries in the order of fold  Socio-economic disadvantage increases risk to a greater extent and varies by injury mechanism

Source:

Source: Pearson et al; Arch. Dis. Child. 2009;94;

Copyright ©2006 BMJ Publishing Group Ltd. Edwards, P. et al. BMJ 2006;333:119 Average annual death rate from injury (with 95% confidence intervals) per children aged 0-15 years by registrar general's social classification

Whitehead defines 4 strategies for tackling inequalities:  Strengthening individuals ◦ Parent/child safety education  Strengthening neighbourhoods ◦ Community wide home fire risk assessments  Improving access to services ◦ Providing injury prevention to “hard to reach” groups  Broad economic and social change ◦ Housing design, housing standards/regulations

 Few systematic reviews & meta-analyses* ◦ Limited evidence ◦ Most studies focus on strengthening individuals, few use other strategies ◦ Most focus on safety equipment provision – families provided with equipment tend to use it ◦ Meta-regression by Kendrick et al showed no consistent evidence that interventions were less effective in higher risk groups *Mackay et al 1999, Dowswell & Towner 2002, Towner et al 2005, Kendrick et al 2007.

 More recent study examined effect of providing and fitting free home safety equipment to families in deprived areas on inequalities in equipment use* ◦ Intervention significantly reduced inequalities in stair gate use by housing tenure and receipt of benefits ◦ Did not reduce inequalities in functioning smoke alarm use Kendrick et al, Health Ed Res 2009; 24(1):32-41

Injury rate 5 x higher in most than least disadvantaged wards Source: Kendrick et al. Soc Sci Med 2005; 61(9):

Sensitivity and specificity for the % of children in benefit dependent households in predicting at least one hospital admission for injury actual ideal Source: Kendrick et al. Health Educ Res. 2005;20(6):709-18

 Child injury risk varies by a wide range of child, family, social, environmental and ethnicity factors  Many, but not all, are inequities as opposed to inequalities  Greatest inequity is in terms of socio-economic disadvantage  Range of strategies to tackle inequities in child injury  Very little evidence about impact of interventions on inequities and limited use of strategies to tackle inequities  Targeted interventions may reduce inequities, but may have little impact on overall burden of injury

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