Transcript TACKLING SOCIOECONOMIC INEQUALITIES IN HEALTH: AN …

Reducing health
inequalities: What do we
really know about
successful strategies?
Martin McKee
London School of Hygiene and Tropical
Medicine and
European Observatory on Health Systems
and Policies
Our starting point
Commission on Social Determinants of
Health
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Closing the gap in a
generation
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Improve Daily Living
Conditions
Tackle the Inequitable
Distribution of Power, Money,
and Resources
Measure and Understand the
Problem
Assess the Impact of Action
Beyond social inequalities
People are differentiated in many ways that can lead to
inequalities in health
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Gender
Age
Occupation
Income
Wealth
Social class
Rurality
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Education
Ethnicity
Religion
Language
Disability
Liberty
Which inequalities are we trying to reduce?
… and these frequently
coincide
... damp housing leading to increased amounts of
respiratory infection; household overcrowding
facilitating the spread of infection; inadequate diet
associated with low incomes ... failure to perceive the
seriousness of childhood illnesses by poorly educated
and informed parents; stresses leading to child
abuse; a generally poor environment increasing the
risks of child accidents; together with the everyday
strain of coping with a demanding young family in
inadequate circumstances in areas suffering from
multiple deprivation.
(Robinson & Pinch, 1987)
What might work will depend
on what the problem is
Source: Dahlgren & Whitehead
Men die before women, but the gap is
wider in some places than in others
-
Male-female gap in life
expectancy at birth
<= 15
<= 12
<= 10
<= 8
<= 6
<= 4
<= 2
… yet this is not inevitable
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No gender gap found in survival
beyond age 40 in (non-smoking,
non-drinking) Polish Seventh Day
Adventists (Jedrychowski, Scand J Soc Med
1985)
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> 50% of gender gap in life
expectancy at age 15 in Finland
attributable to smoking and alcohol
(Martelin et al, Eur J Publ Health, 2004)
For this inequality, lifestyle related factors play a major role
Unfortunately, women are closing the gap, by behaving more like men
White Americans live longer
than African Americans
Life expectancy at birth
Deaths avoidable by timely and effective
care in the United States
Black
White
300
300
250
250
200
200
150
150
100
100
50
50
0
0
1999-2000
2001-2
2004-5
Nolte & McKee, unpublished
1999-2000
2001-2
2004-5
For this inequality, access to
health care matters
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The obvious solution?
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Universal health care (if we poor
Europeans can do it, why not the
world’s remaining superpower?)
If that is too difficult….
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Interpreter services, outreach workers,
culturally sensitive policies,
recruitment and retention of minority
health workers etc.
(Comonwealth Fund, AHRQ. AAACP and many others)
Although for some inequalities,
we still don’t know (or can’t
agree) what the problem is
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Health outcomes are considerably better among
Swedish than Finnish speakers living in Finland
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“Swedish-speakers possess more structural and cognitive social capital
compared to Finnish-speakers. Social capital explains to some extent
health differences between the language groups.” Nyqvist et al., 2008
“Finnish-speaking men and women reported more frequent
drunkenness, suffered more frequent hangovers, and had alcoholinduced pass-outs significantly more often than men and women in the
Swedish-speaking population. “It seems unlikely that the effect of social
capital on the health differences between the two populations would be
mediated through drinking patterns.”
Paljärvi et al., 2009
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Switzerland
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Deaths from circulatory disease were more common in German
Switzerland, while causes related to alcohol consumption were more
prevalent in French Switzerland.
Faeh et al., 2009
Making a difference
Public health researchers have been
remarkably good at measuring and
understanding inequalities in health
 We have been much less successful
in discovering what to do about them
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“the philosophers have only interpreted the world, the point is to change it”
Karl Marx
… yet we all do know what is the
right thing to do(and we don’t
need research)
Give very poor people money/ food/ clean
water/ shelter/ protection from violence
 Give everyone adequately remunerated,
satisfying and rewarding jobs
 Build them safe, healthy environments
 Stop other people (warlords, tobacco and
alcohol company executives) from killing
them
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… and vote!
Gini coefficient (income after housing costs) in UK
labour
conservative
The end
.... Or is it
Maybe the question is how to improve
the health of the most disadvantaged?
Some good news
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The emphasis of research is gradually
shifting from identification, to diagnosis, to
prescription
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Different ‘entry points’ for intervention and
policy are being identified
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Growing experience in developing,
implementing and evaluating interventions
and policies
The bad news
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Pathways from disadvantage to ill-health
often highly complex
Confounders lurk everywhere
Variable time lags everywhere
Interventions difficult to implement and
beset with unintended consequences
Reluctance by policy makers to subject their
beliefs to evaluation
Yet “natural” experiments can be very
misleading
… all else being equal … except that it rarely is
…and context is all
The Netherlands
England
Czech Republic
First steps
Decide who are the disadvantaged
groups
 Discover how they are disadvantaged
 Discover how this is impacting on
health
 Identify where it may be possible to
intervene
 Find the evidence
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Who are the disadvantaged?
the invisible people
Where is the evidence?
A useful framework?
strengthening individuals
 strengthening communities
 improving access to essential facilities and
services
 encouraging macroeconomic and cultural
change
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(Dahlgren & Whitehead)
Strengthening individuals
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Focus on big issues and help people to make
healthy choices
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Legislation – such as ban on smoking in public
places
Fiscal – such as taxation on unhealthy products
Empowerment
Smoking is a good place to start as studies
consistently show it explains a substantial
proportion of socio-economic inequalities
(although there is the secondary question of why
poor people smoke)
Smoking: evidence on
where
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Workplace
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School
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No convincing evidence of effectiveness of social
influences and social competence interventions
Pregnancy
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Individually targeted interventions (physician
advice, counselling, NRT) work, self-help doesn’t
Smoking cessation programmes work (6 fewer
women per 100 smoke)
Patients in hospital
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Intensive interventions over > 1 month work
Source: various Cochrane reviews
Smoking advice: Evidence on
who does it?
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Nurses
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Physicians
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Increased odds ratio for quitting (1.47)
Less effective when in context of screening
intervention
Increased odds ratio for quitting (1.74)
Intensive intervention marginally more
effective
Partner support
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No convincing evidence of effect
Source: various Cochrane reviews
Individual or collective?
China
California
Strengthening communities
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Economic growth
More jobs
More pleasant
environment
Reduced crime
Better education
More jobs
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Welfare to work programmes widely used in
US but gradually spreading to Europe
All (46) RCTs so far from USA
Small but consistent effect on earnings
($11,021 vs $8,843)
For every 33 participants, an extra one
(compared with controls) will be in long term
employment)
(Smedslund et al, 2006)
In all countries studied so far, those in employment are in better health than those who
are not, even when the unemployed get 100% salary replacement
Health and the environment
Health and the environment
Perceived safety and attractiveness of
environment associated with physical
activity
 Objective measures of walkability
associated with physical activity
 Density of fast food outlets associated
with obesity
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Changing your environment:
The Moving to Opportunity project
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Between 1994-97, 4248 families in Baltimore,
Boston, Chicago, Los Angeles and New York were
randomly assigned to:
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Housing voucher that could be used to move to a low
poverty (<10%) neighborhood along with mobility
counseling;
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Housing voucher with no geographic restrictions;
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Control group (no new assistance, but continued to be
eligible for public housing).
Kling et al, various dates
Moving to Opportunity:
results in 2002
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Girls moving to low poverty area:
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improved educational attainment 83 v 77% graduated or still
in school)
Better mental health (Odds of generalized anxiety disorder
70% less)
Less crime (33% lower lifetime arrests)
Boys moving to low poverty area:
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13% more likely to have been arrested
Tripling of alcohol use, with larger increases in smoking and
marijuana use
Significant increase in non-sports injuries
Reducing crime
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Vast majority of published studies show non-custodial sentences
reduce reoffending, but meta-analysis of 4 RCTs and 1 natural
experiment show no difference (Killias et al., 2006)
Close circuit TV cameras are effective, but mainly against vehicle
crime when in car parks
Improved street lighting is very effective (Farringdon & Welsh,
2008)
Enhanced policing of crime hot-spots is effective (Braga, 2007)
Mentoring of juvenile offenders is moderately effective – more so
for dealing with delinquency and aggression but less so in tackling
drug use and low achievement. Better where emotional support
central.
Swedish people aged 35-64 living in violent neighbourhoods had higher
incidence of coronary heart disease, after adjusting for other factors (Odds
ratios: Female 1.75 (CI 1.37–2.22) / Male 1.39 (CI 1.19–1.63).
Sundquist et al, 2006
Better education
Improving education
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After school programmes show no
demonstrable impact on children’s
educational attainment (Zeif et al., 2006)
Parental involvement interventions achieve
significant improvements in reading and
maths
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Education and Training (for parents)
Rewards and Incentives (for children based
on in-school performance) (Nye et al, 2006)
Head Start
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Pre-school programme for children from poor
families
Launched in 1960s under LBJ
 Evidence of early benefits – numeracy and
literacy
 But also evidence of Head Start Fadeout
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In the long term….
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Whites
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African Americans
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Participation associated with a significantly increased
probability of completing high school, attending college,
elevated earnings in early twenties.
Participation associated with significant reduction in being
charged or convicted of a crime
Greater probability than siblings to complete high school.
Some evidence of positive spillovers from older children
who participate to their younger siblings, particularly
with regard to criminal behaviour.
Improving access to
essential services
More difficult to study than you might
think
 Access involves:
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Relationships over time – not one-off
 Decisions not only made by individuals
but also families and friends
 Proximity does not equal access
 Evidence is contextually bounded
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(Balabanova, McKee et al, 2006)
Increasing uptake of services
(and better services)
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Cervical screening
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Invitation letters work, educational materials
have limited effect
Mass media
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… campaigns can be effective in increasing
uptake of essential services
Source: various Cochrane reviews
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UK Quality and Outcomes Framework in
general practice has reduced inequalities
Source: Roland et al
Encouraging macroeconomic
and cultural change
54%
71%
72%
62%
63%
59%
49%
50%
44%
71%
Source: Fritzell & Ritakallio 2004 using Luxembourg Income Study data, CSDH Nordic Network
24%
Welfare regimes matter:
Odds of poor/fair health in unemployed
compared to employed by welfare regime
Odds ratio poor/ fair health
3.5
(for example, in Anglo-Saxon welfare states, unemployed
almost 3 times more likely to be in poor/fair health than
employed)
Male
Female
3
2.5
2
1.5
1
Scandinavian
Bismarckian
Anglo-Saxon
Southern
Eastern
Bambra et al., 2009
Possible explanations
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Anglo-Saxon systems are simply mean
Low wage replacement levels
 Means testing
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Bismarckian systems emphasise role of
male breadwinner
 Scandinavian systems provide lower
benefits for females who accumulated fewer
entitlements through part-time working
 Eastern systems have more informal
support systems
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Bambra et al., 2009
Some policy innovations
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Policy steering mechanisms
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Labour market and working
conditions
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Health-related behaviour change
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Territorial approaches.
(Source: Mackenbach & Bakker)
Policy steering mechanisms
 Quantitative
targets
Reduction of inequalities in 11
intermediate outcomes (poverty, smoking,
working conditions, ….) – Netherlands
 Health
inequalities impact assessment
Qualitative assessment of impact on health
inequalities of EC agricultural policy –
Sweden
Very little evidence of effectiveness – but equally, no evidence they are ineffective
Labour market and working
conditions
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Universal approaches
 Strong employment protection and active labour
market policies for chronically ill citizens –
Sweden
 Occupational health services offering annual
check-ups and preventive interventions to all
employees – France
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Targeted approaches
 Job rotation among dustmen – Netherlands
Some evidence of effectiveness – active labour market policies may protect in
face of recession
Health-related behaviours
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Universal approaches
 Serve low-fat food products through mass
catering in schools and workplaces –
Finland
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Targeted approaches
 Multi-method intervention to reduce
smoking among low income women –
Britain
Considerable evidence of effectiveness, but
context important
Territorial approaches
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Comprehensive health strategies
for deprived areas
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Health Action Zones – England
Community regeneration
Systematic review of 19 studies
“There is little evidence of the impact of national urban regeneration
investment on socioeconomic or health outcomes. Where impacts have
been assessed, these are often small and positive but adverse impacts
have also occurred.”
Thompson et al, 2006
Tough on ill health, tough on
the causes of ill health…
Are we willing to tackle the immediate
causes of ill-health (tobacco, alcohol,
poor nutrition)?
…or do we think this is just a sticking
plaster ….
 Or instead do we want to change
society fundamentally?
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… and don’t assume we are
all agreed
… on Hurricane Katrina
“Shame on anyone that makes this
tragedy political, socio-economic
or racial. … in the land of
opportunity and personal
responsibility the individual is
ultimately accountable.”
Robert Buckley, Decatur, USA
BBC web site
Medicine is a social science and politics is nothing but medicine writ large ”
Rudolf Virchow
Summary
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There are many inequalities in health, on
many dimensions, and taking many forms
What you do depends on who you are trying
to help, what the problem is, and where you
can intervene
Then you can ask what works
… and when you do something, please
evaluate it and tell the world whether it
really did work…
… so that we can learn from your
experience!