Health Inequalities & CLAHRC (SY)

Sarah SalwayOn behalf of the

Inequalities Implementation Theme

CLAHRC (SY)Inequalities ImplementationTheme

• Lead: Dr Liddy Goyder, ScHARR, UoS• Representatives from Public Health sections of

PCTs - Sheffield, Barnsley, Rotherham, Doncaster

• Academic researchers at UoS and SHU• 3 Research Facilitators one each at Sheffield,

Barnsley, Rotherham PCTs• 2 PhD Students one each at SHU and UoS

Overall aim

To build on existing public health programmes that target deprived communities to promote

evidence-based public health interventions that will improve health outcomes and reduce

inequalities across South Yorkshire

Overview of talk

• What do we mean by 'health inequalities'?• Why are we concerned about health

inequalities?• What does health-related research have to do

with health inequalities?• Attention to inequalities within CLAHRC (SY):

- Inequalities Implementation Theme- Linkages with other Themes

What are 'health inequalities'?

Systematic disparities in health status between groups with different levels of underlying social (dis)advantage including wealth, power or prestige

[Exworthy et al.,2006 after Braveman & Gruskin, 2003]

Defining /describing 'health inequalities'

• Differences between 'groups' • Gaps, disparities, inequities (unfair / avoidable)• Several 'axes' of health disadvantage: gender, class, ethnicity,

age, disability, geography• Axes also demarcate 'difference' and social hierarchy• In UK, predominant focus has been socioeconomic and

geographical• Separate strands of policy activity around race/ethnicity and to

a lesser extent disability and gender• Variety of measures relating to: health outcomes; receipt of

services in relation to need; quality of services (e.g. satisfaction) etc.

• Also sometimes expressed in terms of 'gradients' across whole population

Age standardised death rates per 100,000 population for circulatory diseases under 75 by area of deprivation

0

20

40

60

80

100

120

140

160

180

Mostdeprived

3rd Leastdeprived

1995-97

2002-4

Proportion of people reporting a long-term health condition among four Census 2001 ethnic categories

0.2

.4.6

.81

Pro

port

ion

ill (

men

)

20 30 40 50 60

Age years (grouped)

White British

Pakistani

Bangladeshi

Black African

0.2

.4.6

.81

Pro

port

ion

ill (

wom

en)

20 30 40 50 60

Age years (grouped)

White British

Pakistani

Bangladeshi

Black African

The health gradient

Health state

'Social advantage' (e.g. income, education)

High Low

Low

High

The health gradient

Health state

Social advantage

High Low

Low

High

'Paradox' - while the health of the population as whole may be

improving, the health of the least well off improves more slowly or

in some cases gets worse in absolute terms

(Graham & Kelly, 2004)

1970s

1990s

Shifting the health gradient

Health state

Social advantage

High Low

Low

High

Local illustrations

• Barnsley: People living in poorer areas are twice as likely to die prematurely as those in the more affluent areas.

• Sheffield: 14 year difference in life expectancy between the best and worst off neighbourhoods.

• Compared to White British majority, Black and Ethnic Minority (BME) communities in South Yorkshire have:- much higher rates of diabetes and CHD- greater levels of emergency admissions to hospital - lower uptake of screening and preventive services(though variation between and within groups too)

Why are we concerned with 'health inequalities'?

• Moral imperatives: concern for fairness or justice• Policy imperatives at national and international

level• Legal requirements • Poor health of large sections of the population is

problem for everyone (e.g. worklessness, spiralling NHS costs, exclusion)

• Targets and priorities for whole populations• Alignment of efficiency and equity agendas

DH position

"Health is profoundly unequal. Health inequality … exists between social classes, different areas of the country, between men and women and between people from different ethnic groups. The story of health inequality is clear: the poorer you are, the more likely you are to be ill and to die younger. That is true for almost every health problem"

"Health inequalities are unacceptable. They start early in life and persist not only into old age but subsequent generations. Tackling health inequalities is a top priority for this Government, and it is focused on narrowing the health gap between disadvantaged groups, communities and the rest of the country, and on improving health overall."

What has our research got to do with health inequalities?

• Tend to associate inequalities with public health and social determinants, 'caused by society not health services'

• But, the health system can mitigate or, more often, exacerbate inequalities

• Health services often mirror and (re)create the same hierarchies of exclusion as wider society - persistent inequalities in access and quality of curative and rehabilitative care

• Preventive and health promoting interventions increasingly prioritised - commissioning health rather than healthcare

• Healthy cities, health-promoting environments, healthy choices - health and health inequality is increasingly everybody's business

• Much more has been done to document and describe inequalities than to understand causes or solutions

• Huge need for research evidence that can inform policy and practice to improve health of most disadvantaged sections of society

Research must address difference and disadvantage

Research Governance Framework:'Research, and those pursuing it, should respect the diversity of

human society and conditions and the multi-cultural nature of society, Whenever relevant, it should take account of age, disability, gender, sexual orientation, race, culture and religion in its design, undertaking and reporting. The body of research evidence available to policy makers should reflect the diversity of the population'

World Class Commissioning: 'Commissioning decisions should be based on sound evidence…

In particular, world class commissioning will ensure that the greatest priority is placed on those whose needs are greatest'

Research does not pay attention to

inequalities

Findings overlook processes of

disadvantage / support the status quo → inequalities

remain

Knowledge translation process

considers inequalities issues → may lead to reduced disparities in longer

term

Findings inform new intervention

that benefits better off → inequalities

grow(IGIs)

K

Research does pay attention to

inequalities:- direct focus

- indirect (inclusion)

Findings reinforce processes of

disadvantage / support the status quo → inequalities

remain or even grow

Findings inform new intervention

that benefits worse off → inequalities

decrease

Inequalities Theme aims to encourage and support considered and careful attention to inequalities wherever appropriate

Attention to inequalities within CLAHRC (SY):

Theme-based activity• Evidence-based but also attention to practicality, feasibility

and acceptability in the local context

• Community engagement

• Practitioner engagement - front line staff

• An action research model:identification of issue►review evidence & local context ►design & implement strategy►evaluate & disseminate

• Build on existing public health programmes across South Yorkshire, focus on interventions with direct patient benefits within the 3-5 year timeframe

• Currently identifying potential areas for attention e.g. screening; self-care/self-management for BME groups.

• Aim to develop of a culture of shared learning from the development and evaluation of evidence-based strategies to reduce inequalities

Attention to inequalities within CLAHRC (SY): Linkages to other Themes

• Aiming for wider, more systemic influence within CLAHRC (SY)

• Internal Independent Scientific Review - prompts to alert researchers to inequalities issues

• Briefing Papers: Why? and How?• Support to other Themes at various stages within the

research cycle:- research question formulation- methodology (inclusive approaches)- translation or application of findings (wide and equitable impact)

Contact details:

• Liddy Goyder: e.goyder@sheffield.ac.uk

• Sarah Salway s.salway@shu.ac.uk

Thank you