Public Health Approach to Health Inequalities

Healthinequalities have been documented in various literatures for decades, but morerecently, the government have introduced specific policies to tackle healthinequalities. Marmot (2010)’s findings showed that people living in poorerareas not only have a lower life expectancy, but experience health inequalitiesfrom housing, income, education, social isolation and disabilities. Althoughlife expectancy in developed countries are now slowly improving, healthinequalities continue to occur (Crombie et al, 2005).

The World HealthOrganisation (WHO | Key Concepts, 2017) believe that social and economicconditions and their effects on people’s lives determine their risk of illness.These also effect the actions taken to prevent them becoming ill or treat anillness when it occurs.  Marmot (2010)supports the notion of social and economic conditions as they strongly suggestthe link between social conditions and health should be a priority, as societywould benefit in many ways if there was an improvement in well-being, bettermental health and disabilities. Thesesocioeconomic factors come under the social determinants of health, which WHO |Key Concepts (2017) state are “the conditions in which people are born, grow,live, work and age”.   These issues occur regionally, nationally andglobally. The Marmot Review that looks into health inequalities in England proposesan evidence based strategy to address the social determinants of health (LGA,2017). Theroot causes of health inequalities are complex and varied, therefore broadpolicies are required to tackle such inequalities in health (Crombie et al,2005). Mackenbach (2002) suggests the most fundamental approach to reducingsuch inequalities in health is to directly tackle the inequalities ineducation, occupation and income.

AimsThis report begins by exploring what constitutes asa health inequality, what are the underlying reasons and how do they manifestthemselves in people. Following this, the reports aims to discuss examples ofhealth inequalities and the reasons behind why they experience them. The reportfurther aims to critically examine the role public health play inreducing health inequalities through findings of current data and theevaluation of policies and strategies implemented to reduce healthinequalities. Thereport will conclude with a summarisation of the findings and where appropriateprovide recommendations for further actions.  What is a health inequality?  Health inequalities are defined in various ways. Abroad and common definition by Graham (2009) states “systematic differences inhealth of people occupying unequal positions in society”. This term emphasisesthe health differences associated to unequal socio-economic positions. WorldHealth Organisation (WHO | Health Impact Assessment, 2017) support thisdefinition by stating “health inequalities can be defined as differences inhealth status or in the distribution of health determinants between differentpopulation groups”.

WHO | Health Impact Assessment (2017) explain that it maynot be possible to change some health determinants, resulting in some healthinequalities being unavoidable. However, uneven distribution is avoidable aswell as unfair, which then shows health inequalities also leading to healthinequity (WHO | Health Impact Assessment, 2017). However, to create health forall additional support may be required to create equality. This may not alwaysbe perceived as equity. Social determinants of health It is widely accepted that social determinants areresponsible for a significant number of health inequities. Whilst some healthinequalities are from natural causes or free choice, many are beyond individualcontrol and can’t be avoided (RCN, 2012). The social determinants of healthspecifically look at; personal characteristics such as age, sex, ethnic group;individual lifestyle factors such as level of physical activity and alcoholuse; social and community networks, living conditions and socioeconomic status,cultural and environmental conditions (PHE, 2017).

The Marmot Review “FairSociety, Healthy Lives” states that to take action on health inequalities,action must be taken across all social determinants of health (PHE, 2017).Underlying reasons for health inequalitiesThe underlying causes of healthinequalities in the UK have been examined for decades, starting from therelease of The Black Report (1980) – a document published by the Department ofHealth and Social Security on inequalities in health. Gray (1982) states TheBlack Report includes details of the unequal distribution rates of ill-healthand death amongst Britain’s population. The Black Report propose four differenttheories that could be the underlying cause of health inequalities: selection,behavioural/cultural, structural and artefact (McCartney, 2013).

The structuraltheory is believed to provide the best explanation as it suggest thatsocioeconomic circumstances such as wealth, power and access at all stages oflife are considered to be causing differences in population health (McCartney,2013).  SHA (1980) explains thesocio-structural factors in distributing health and wellbeing to have manydifferent reasons from the role of economic deprivation, but focus on thedirect influence of poverty or economic deprivation has on mortality. BMA (2017) believe there is a social gradient inhealth, where the lower the social position, the worse their health.

Byexpanding thoughts to address issues further than those requiring medicalattention, a lot of health inequalities were found. NHS Health Scotland (2018)believe the fundamental causes of health inequalities are income, wealth andpower, as these factors the wider environmental issues on health and access toservices, shaping individual and population experiences which result ininequalities. How do health inequalities manifest themselves inpeople?Healthinequalities manifest themselves in people in a variety of ways with a numberof different indicators to measure inequalities within communities, such as lookingat mortality rates, health statuses, environmental factors and risk behaviours.The purpose of health equalitiesare to give everyone the same opportunities to lead a healthy life, no matterwhere they live or who they are (Connolly et al, 2017), however, an differencein health improvement will not always close the gap of health inequalities. Whenlooking at inequalities, factors such as housing, jobs and geographicaldisparity must be considered to explore how they affect health and lifeexpectancies (Newton, 2017).  Life expectancy atbirth in England has generally increased over years, however life expectancy isnot uniform across England and inequalities still exist (PHE | Inequality inhealth, 2017). PHE | Inequality in health (2017) believe there is a socialgradient in life span, with people living in the most deprived areas in Englandhaving on average the lowest life expectancy unlike those living in moreaffluent areas having a higher life expectancy. Children growing up in moredeprived areas often suffer disadvantages throughout their lives (Newton, 2017)which could lead to adverse childhood experiences (ACEs).

A study between Centres for Disease Control andPrevention and Kaiser Permanente found that ACEs are very common and sometimescome in clusters, showing 40% of their sample reporting two or more ACES, thisincreasing the risk factors of disease, disability and early mortality (SAMHSA,2017). Bellis etal (2015) explains how experiences during childhood can affect healththroughout the life course. ACEs can also beharmful for the development of a child’s brain, which could present academicproblems throughout their school years (ACEResponse, 2018).

This canlead to children who have experienced stressful or poor quality childhoodsbecoming likely to adopt health-harming risk behaviours during adolescence suchas binge drinking, smoking and drug use (Bellis, 2015).This emphasises on WHO (2000)’s findings onsensitive developmental stages in childhood and adolescences such as cognitiveskills, coping strategies, attitudes and values being hindered in later life,which follows from ACEs. Reducinghealth inequalities is one of Public Health England (PHE)’s main missions.Connolly (2015) states that PHE understand that the social determinants ofhealth inequalities can be complex and as such, invest heavily intounderstanding what can make a difference.

An approach PHE take to reduce healthinequalities is supporting local authorities and local partners to useresources they have put in place, such as opportunities for using Social ValueAct 2013, promoting good quality jobs, reducing social isolation and improvinghealth literacy (Connolly, 2015). Caldwell (2016) explains the public healthapproach as defining health problems, identifying risks, developingcommunity-level interventions, implement interventions to improve the health ofthe population and continue to monitor its effectiveness.  Anexample of this is Public Health Wales (PHW) who have undertaken new andinnovative approaches to ensure success in reducing health inequalities,resulting in an understanding of resources and commitment required to reduceinequalities (Public Health Wales | Strategic Plan 2017-2020,2017). However, there is a clear view of challenges that PHW aim to preparefor, as they believe that their systems approach of utilising and maximisingcollective assets embraces the sustainability and unique opportunitiespresented by the Well-being of Future Generations Act (Wales) 2015 (PublicHealth Wales | Strategic Plan 2017-2020, 2017).

NHSHealth Scotland (2015) also believe inequalities account for a large element ofthe increasing demands on public health services due to the cycle ofdeprivation. They further believe children and young adults who have beenbrought up in deprived circumstances are more likely to be deprived in laterlife, which will then affect their children. There are various factors that cause recurring poverty,such as irregular work, relationships, children being born into brokenhouseholds and intermittent health issues, which create a poverty cycle andcontinue to experience inequalities (Goulden, 2010). This cycle of poverty iscosting the UK £78bn a year according to Joseph Rowntree Foundation (BBC News,2016).

NHS Health Scotland (2015) found The Christie Commissions Reportsuggests that around 40% of the countries money is being accounted for byinterventions that could have been avoided had preventative approaches beenpriorities.  With interventions in place,Wickware (2017) quotes the chief executive of Public Health England DuncanSelbie who believes that despite a large amount of funding provided to the NHS,it will not improve healthcare inequalities and ‘it will never close the gapbetween the affluent and the poor’. He believes that job creations is one ofthe most important measures for improving health in the next 20 years, as no matterhow much money is put in, it will never change the health profile of thecountry (Wickware, 2017). Strategies andPolicies Actionstowards tackling inequalities are based on evidence of need, understanding ofbarriers to social opportunities and what is most likely to work (NHS HealthScotland, 2015). The UK have had a keen interest in strategies and policies fortackling health inequalities since they were first acknowledged in The BlackReport in 1980.

The Black Report lackedsignificant support due to change in government, as the paper was commissionedby the Labour governments but reported by Conservative party, who dismissed thereport as they refused to address the socio economic and environmental factorsthat health inequalities create (Marmot, 2001). The Black Report stated that they did not believe the persisting problemof health inequalities was because of the NHS, but explained a materialisticexplanation of inequalities by looking at differences in health based issues ondifferent social classes and how they lead their lives (Marmot, 2001).  However, despite various studies and showingthe UK’s efforts to reduce health inequalities, it is questioned if morepractical policies would be more effective (Smith and Eltanani, 2014).  TheHealth of the Nation strategy (HOTN) created in 1992 was the first governmentattempt to develop a strategy based on improving health inequalities in the UK,however its main focuses were coronary heart disease and stroke, cancers,mental health, sexual health and the accidents (Hunter et al, 2000). HOTNemphasises mainly on issues requiring medical based interventions, withoutconsidering socio-economic approaches therefore found that it failed to reduceinequalities. Following the HOTN, the Labour Government in 1997 launched thenew strategy “Our Healthier Nation”, with intentions to also addressinequalities in health (Hunter et al, 2000), which accounts for Acheson(1998)’s report, discussing inequalities in schools, workplaces andneighbourhoods. Acheson made 39 recommendations, recognising that tacklinginequalities required action to address the broader layers (Nutbeam, n.d),whilst evaluating all policies that are likely to have an impact on healthinequalities, to prioritise health of families with children and improve theliving standards of poor households to reduce health inequalities.

FollowingAcheson’s report it was noticed a decrease in child poverty and increasedincome in lower socio-economic groups (Mackenbach and Bakker, 2002).  However, Acheson’s report was criticised forits recommendations being vague and not providing detailed costs, making itdifficult for the government to assess if it would be cost effective (Asthanaand Halliday, 2006). Asemphasized in this report, health inequalities begin from a young age andcontinue to develop. Therefore, strategies have been implemented to reduceinequalities throughout the life course. The life course approach emphasises onsocial perspectives on life experiences across generations to find patterns inhealth and diseases, whilst understanding that past and present experiences areshaped by wider determinants (WHO, 2000). Supporting this, Kawachi (2002)states that the life course approach refers to how health status at any agereflects on contemporary conditions and prior living circumstances.

Socio-economic conditions throughout the life course can cause health damagingor health enhancing opportunities in later life, and individual’s responses maymodify their impact of risk exposures in the futures (Kuh et al, 1997).  A recent strategy implemented to target earlyyears is NICE guidelines strategy of promoting health and wellbeing in under 5sNICE (2016) created their quality standard to improve school readiness, childdevelopment, antisocial behaviour, mental health and educational attainment.They do so by introducing services to support wellbeing, such as home visits,childcare, early intervention and early education. NICE quality standard hasbased their aims and targets based on a Public Health Outcomes Framework (NICE,2016).

NICE (2016) achievement levels are not yetspecified, however they explain they intent to drive quality of care forward to100% success. Though the high aim, NICE understands and take into account thatnot all situations may be appropriate in practise, therefore desired levels ofachievement may vary. The quality standard is in place alongside variouspolicies from the Department for Education, NHS, Ofsted, PHE and the Departmentof Health (NICE, 2016). NICE (2016) believes a relationship between a child andtheir main carer strongly influences the child’s development. Although mostparents in poorer social circumstances still provide nurturing environments fortheir children, it is still strongly believed that children living indisadvantaged homes are more likely to be exposed to risk behaviours.Therefore, the aim of this strategy is to target early years with aims toensure a healthier development to adulthood.

A development for later in life isthe Children and Young People’s Health Strategy 2015-2020 (CYPHS). Thisstrategy is shaped by a numerous factors as children and young people developwith various strengths and vulnerabilities based on how they’ve grown up. CYPS2015 – 2020’s main principles are to identify needs for interventions early,create equal access to services, involve communities in promotion strategies tobetter manage their own health and wellbeing and ensuring safeguarding isstrongly considered in all planning.

Following early interventions fromunder5’s, PHE believe partnership working has a large contribution for takingaction in reducing health inequalities as it can involve a range oforganisations for various sectors such as health services, schools andemployers (PHE | Health Equity Briefing10, 2014). PHE | HealthEquity Breifing3 (2014) have recognised the inequalities in youngpeople not in employment, education or training (NEET). They believe actingearly is the best approach to reduce the prevalence of young people NEET, as itis should prevent it from happening at all. To support their opinions, theThinkForward programmes was created, with the aim to act early to ensure youngpeople are successful in the transition from education to employment by placingcoaches in schools and providing long-term support which includes linking youngpeople to services 


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