Patterns of health and health inequalities

Learning outcomes Long-term trends in population health in the UK Comparison to other countries Distribution of health and illness within population: social patterning of health and illness Evidence for health inequality

Definitions Disability free life expectancy = no. of years an individual can expect to live without a limiting chronic illness or disability Gap between life expectancy and disability free life expectancy = years lived with a limiting chronic illness/disability Men and women are living more of their lives disability free Women live longer but more years with a limiting chronic illness/disability than men

Long term trends Public health advances such as better sanitation and clean water, together with changes in social and built environment are associated with changes in pattern of disease. ‘Epidemiological transition’ Disease of ‘affluence’ such as CHD, strokes and obesity become associated with those in lower SES as a country becomes more developed. Acute infections and deficiency related diseases have declined but chronic and non-communicable diseases have increased. Disease patterns changing – Cancer most common cause of mortality (then resp then circulatory). Increased disability free life expectancy.

Infant mortality rate Decreases during the epidemiological transition. Good proxy marker for population health Correlates very well with other proxy measures (e.g. disability adjusted life expectancy) but simpler to measure Highly sensitive to social determinants of health and disease epidemics thus a good measure of what is happening ‘here and now’ A facet of the epidemiological transition is a reduction in the infant mortality rate. Infant mortality is an important proxy marker of the health of a population. Infant mortality rate is sensitive to changes in the health of the whole population and a relative easy measure to collect data on. It is highly sensitive to structural changes as well as disease epidemics so is a good measure of the here and now effects. So rapid changes in the determinants of population health (see Alan’s lecture) are capture quickly by changes in infant mortality rate. And it is highly correlated with more complex and difficult to measure proxy markers such as disability adjust life expectancy. Other measures are slower to capture changes in structural or social determinants of population health.

Uk Comparison to other countries 20 years ago had similar infant mortality rates to other European countries. Now is one of the highest.

Distribution of health Social epidemiology – studies the social distribution and social determinants of health based on things like SES, gender and ethnicity. Problem with this? Not all individuals within a set group will experience the same environment/outcomes. What is health inequality? Systematic differences in health and illness across social groups.

Age/gender/ethnicity/geography inequaltities in health Inequality across all age groups but most marked in childhood. Socio-economic gradients in mortality less steep for women than for men but women live for more years with a disability. People from Black/Minority ethnic groups living in UK are more likely to be diagnosed with mental health problems and report poorer self assessed health. These become more pronounced with age. Northern/Western areas have higher early death rates.

Health and economic position How do you measure socio-economic status? Occupation + income + assets, education and index of multiple deprivation. Link between CHD/lung cancer and SES? Those at bottom most affected. Gap widening. Exceptions? Breast cancer/melanoma highest in higher SES. Prostate cancer most likely in high SES. Why? Better screening/education/enjoy more sunshine/ Live longer?! Socio-economic groups

Social gradient Inequalities in health not only found between rich and poor There is a ‘step-wise’ gradient in health stretching right up the social scale Each step up the social ladder brings an increase, albeit a diminishing one, in better health

explaining social gradient of health and inequalities Behavioural/cultural Materialist: neo-material and lifecourse Psychosocial Not mutually exclusive; factors related to different explanations independently influence the social gradient and are also interrelated to one another Three main type of explanation of the pathways and mechanisms underlying the social gradient

Behavioural Model of health inequalities Result of individual lifestyle choices – smoking, diet, lack of exercise i.e. focus on indiviudal behaviours/choice (social variations) Lower socio-economic groups - Smoking more prevalent Lower social class = increased likelihood of risky behaviours (ill- informed or don’t have discipline to stop) 50% of health inequalities are due to health-related behaviours…so not the whole story If circumstances are good, stopping bad behaviours makes a huge difference. In bad circumstances it makes very little difference.

materialist model of health inequalities Result of material circumstances due to income Largely outside the persons’ control – housing, nutrition, work environment etc Housing – damp can cause asthma or COPD in future Food – healthier diet is more expensive (food deserts – where shops shut down and choice is removed in communities) Further divided into: Neo-materialistic Life-approach

Neo-Materialist model of health inequalities The effect of material circumstances on health reflects a lack of resources at individual and community level Related to public underinvestment in the physical, health and social infrastructure Think of community not just the individual The effect of material circumstances on health reflects a lack of resources at individual and community level; related to public underinvestment in the physical, health and social infrastructure

life course approach to health inequalities Parental health disadvantage transmitted in utero and early life stages  influence later health outcomes Poor childhood circumstances brings later disadvantage - set people on pathways that make it more likely they will be exposed to future disadvantages. Some health problems take years to develop, i.e. explains the gradients Exposure to one form of material deprivation increases the risk of exposure to others Advantage/disadvantage tends to ‘cluster’ across the life-course Poor housing so therefore also more likely to have poor access to food. Problems ‘cluster’

Psychosocial model of health inequalities Result of stressful conditions or low self-esteem Stress affects health: Indirectly – unhealthy behaviours - smoking, drinking etc harmful coping mechanisms Directly – increased susceptibility to mental and physical illness via mind- body pathways e.g. feeling run down and stressed results in a cold Psychological stress affecting health more likely to be chronic then acute Perception of our social position is very important to our health Low self-esteem produces negative emotions (anger and anxiety internally) and anti-social behaviour (less socialising and isolation externally) ‘Relative poverty’ – less than acceptable standard of living e.g. TV, fridge, freezer can have big impacts on self-esteem and therefore health Lower socio-economic groups tend to face negative stress more frequently – low income

Social capital Social networks and norms that facilitate co-ordination and co- operation 2 types: Bonding – strong ties between individuals of a social network that see themselves as homogenous Bridging – links across social groups in society who do not necessarily share similar social identities

Quiz time!!!

Health Inequalities: definition please Systematic differences in health and illness across social groups

Name some factors that may affect health inequalities?(5) Socio-economic group Age Ethnicity Gender Geography

Shift from acute to chronic disease. Reduction in infant mortality rate. Shift from communicable disease (infectious) to non infectious chronic disease. Shift from diseases of affluence (CVD, Stroke etc) being a disease of the poor. Life expectancy increases and deaths from acute infections/deficiency decreases. Answers Shift from acute to chronic disease. Reduction in infant mortality rate. Shift from communicable disease (infectious) to non infectious chronic disease. Shift from diseases of affluence (CVD, Stroke etc) being a disease of the poor. Life expectancy increases and deaths from acute infections/deficiency decreases.

Why is lung cancer more common in men? (2) More likely to smoke Occupational exposure

Give some explanations as to why men tend to not live as long as women Exposure to occupational accidents and deaths Less likely to have a support network and bottle problems Perceive themselves as less vulnerable to illness Less likely to accept emotional pain as valid More likely to normalise symptoms (just part of getting old) More likely to smoke and binge drink Twice as likely to have an alcohol problem Strong alcohol/depression/suicide link in men More likely to be overweight Young men most at risk of accidental death due to risky behaviour culturally perceived as ‘masculine’ – fast driving, heavy drinking 4 times more likely to commit suicide Women more likely to consult GP Well-person checks less well attended by men Men tend to leave symptoms longer before seeking help