Plenary 1 Chair: Professor Gareth Williams

Health Impact Assessment: Making the Difference

Professor Sally Macintyre

Director of the Medical Research Council and Public Health Sciences Unit, Glasgow

Health Impact Assessment: Making the Difference

Inequalities in Health:

Implications for Health Impact Assessment

Sally Macintyre

7th International Health Impact Assessment Conference 2006

Outline

Pervasiveness and magnitude of inequalities in health Lack of knowledge about how to reduce them Reasons for lack of knowledge HIA and evaluation Closing the feedback loop

Inequalities in health

Socio-economic status Gender Race/ethnicity Place of residence And other axes of stratification e.g.

religion, caste

In all known societies:

Health risks, health behaviours, physical and mental health and life

expectancy vary between social groups defined in terms of:

Life expectancy, USA, 2003

Males Females Difference

White 75.4 80.5 5.1

Black 69.2 76.1 6.9

Difference 6.2 4.4

Congressional Research Service, Library of congressLife Expectancy in the USA, March 2005

Life expectancy gap Social Class I – V, England 1997 - 2001

Males 8.4 years

Females 4.5 years

DH, Tackling Health Inequalities, Status Report 2005

Life expectancy in Scotland 2004 IBy Local Government Areas

Men Women

Aberdeenshire 76.3 80.8

East Dunbartonshire 77.0 80.4

Glasgow City 69.3 76.4

GRO Scotland 2005

Life expectancy in Scotland 2004 IIBy constituency, Glasgow Area

Men Women

Eastwood 76.3 81.3

Strathkelvin 76.2 80.3

Springburn 66.6 74.8

Shettleston 63.9 75.2

Health Scotland 2004

Life expectancy in New Zealand by ethnic group,1996 - 1999

Men Women

Maori 64.0 68.7

Pacific 67.9 73.9

Non-Maori, Non-Pacific 75.7 80.8

Difference/Non-Maori, Non-Pacific 11.7 12.1

Blakely et al 2005

Average rates do not predict inequalities

Peru Uzbekistan

Mean: 49.9 Mean: 46.8

Poor: 78.3 Poor: 49.5

Rich: 19.5 Rich: 43.5

Robinson et al, in press

Infant mortality rates

Acheson Report 1998

“We recommend that as part of health impact

assessment, all policies likely to have a direct or

indirect effect on health should be evaluated in

terms of their impact on health inequalities, and

should be formulated in such a way that by

favouring the less well of they will, wherever

possible, reduce such inequalities.”

Acheson 1998, p30

“A well intended policy which improves average

health may have no effect on inequalities. It may

even widen them by having a greater impact on the

better off. Classic examples include policies aimed

at preventing illness, if they resulted in uptake

favouring the better off. This has happened in

some initiatives concerned with immunisation and

cervical screening, as well as in some campaigns to

discourage smoking or to promote breastfeeding.”

Acheson 1998, p30

Acheson ‘Evaluation Group’: Conclusions

lots of data documenting health inequalities lots of research attempting to explain health inequalities little information about effectiveness of interventions even less information about potential harms, costs or priorities evidence clearer for downstream than upstream interventions

Macintyre, Chalmers, Horton, Smith 1998

Reducing Inequalities in Health:A European Perspective

work policies - poor design, or health outcomes unevaluated food policies - ‘little information on the long term effects ….’ smoking - ‘little direct evidence that permits any definitive

judgements’ children - many interventions: ‘most are not well known and very

few have been systematically evaluated’ access to healthcare - ‘paucity of studies about the best ways to

reach poorer people with appropriate and effective services’

Mackenbach & Bakker, 2002

Wanless report: Securing good health for the whole population 2004

‘Although there is often evidence on the scientific justification for action and for some specific interventions, there is generally little evidence about the cost-effectiveness of public health and preventative policies or their practical implementation…

little evidence about what works among disadvantaged groups to tackle some of the key determinants of health inequalities’

Lack of evaluations of outcomes

Of published or funded public health research in UK, 4% deal with interventions rather than descriptions of the problem

only 10% of them (0.4%) deal with outcomes of interventions in specific topic areas evidence about inequalities, and tools for

capturing social differences, not very robust very few systematic reviews have focused on effect of

interventions on inequalities in health

Millward L, Kelly MP & Nutbeam D, 2001 Public Health Intervention Research: The Evidence, London, HDA

Reasons for paucity of evidence

Short government time scales; no time to wait for pilots or long term evaluations

Evaluations problematic (window dressing?) Lack of routine data for monitoring inequalities Assumption that systematic reviews and RCTs are not suitable for

real life community initiatives Assumption that plausibility is a good basis for policy making Assumption that public health interventions can’t do harm Assumption that it is enough to know about aggregate effects

Post 1997 Labour Government

Reducing inequalities overarching goal

programmes introduced to do this without knowing whether they’ll work

government focus on inputs and throughputs not effectiveness

Reducing health inequalities; an Action Report 1999

New deal for communities New deal for employment Single Regeneration budget Health Action Zones Healthy Living Centres Healthy Schools Programme Working Families tax credits Sure Start

Demonstration programmes in Scotland

Poor evidence base in first place Evaluations set up too late Programmes non evaluable Decisions on phase 2 taken before evaluations complete

Evaluation Task Force Review, Scottish Executive, 2004

Lack of good routine data to monitor inequalities

social class or area deprivation indices only available every ten years health surveys not large enough or long enough series social class, ethnicity, etc. not collected in NHS records intervention studies don’t report differential effects by social class,

ethnicity, etc.

Systematic reviews not suitable for real life community initiatives?

But:

Systematic reviews have been conducted on:

youth mentoring programmes impacts of after-school programs on student outcomes strategies related to the prevention, detection, management and

response to terrorism effects of closed circuit television surveillance on crime effects of improved street lighting on crime home based support for socially disadvantaged mothers

RCTs not suitable for real life community initiatives?

But:

RCTs have been conducted on:

re-housing effectiveness of out-of home day care for disadvantaged families prison rehabilitation programs raids on crack houses

Systematic review of area based regeneration initiatives in the UK

Little evidence of the impact of national urban regeneration on socio-economic or health outcomes.

Changes often no different from national trends.

However, some harms: Single Regeneration Budget 1996 - 1999;

deterioration in self reported health Urban programme and City Challenge;

worsening of unemployment Estate Action; increased housing costs Housing improvement in 1930s Scotland; rents

doubled, mortality rates increased (residents couldn’t afford adequate food)

Thompson et al, 2006