On the causes of health inequalities • Structural explanations fit best • Behavioural and cultural theories are relevant, but insufficient Blaming poor people for
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Reducing health inequalities: insights from
theory and practiceGerry McCartney
NHS Health Scotland
Reducing health
inequalities: insights from theory and practiceGerry McCartney
NHS Health Scotland
Of all inequalities, injustice in health is the
most shocking and inhumaneMartin Luther King
ͻPremature mortality
ͻMental wellbeing
ͻFirst heart attack <75y
ͻHeart disease mortality
45-75y
ͻCancer incidence <75y
ͻAlcohol first admissions
<75yͻAlcohol deaths 45-75y
ͻMortality 15-44y
ͻLow birthweight
ͻHealthy birthweight
ͻSelf-assessed health
ͻLimited long-term
conditionsMortality rate for those aged under 75 years
Mortality rate for those aged under 75 years, 2015Absolute inequalities -the gap
Slope Index of Inequality (SII)
Mortality rate for those aged under 75 years, 2015 Relative inequality (RII) = Absolute inequality / average= 1.33Ratio, or how many times worseMortality rate for those aged under 75 years
Trends in absolute and relative inequalities
Decline in heart
disease and alcohol- related mortality inequalitiesMortality rate for those aged under 75 years
Blakely T, Disney G, Atkinson J TengA, MackenbachJP. Typology for Charting Socioeconomic Mortality Gradients͗ ͞Go
Southwest". Epidemiology 2017; 28(4)͗ 594-603.
Current situation:
Absolute inequalities
Relative inequalities
Ideal future situation:
Absolute inequalities
Relative inequalities
What causes health inequalities?
4 theories have been proposed:
1.Artefact(i.e. we aren't measuring it well enough)
2.Selection theories (i.e. poor health causes social slide)
3.Behavioursand culture (i.e. poor people behave badly)
4.Structural & political economy (i.e. politics and policy are
the cause)Artefact
ͻUndermined by inequalities demonstrated using different statistical measures of social status ͻVery difficult to sustain a theory that such outcomes are unrelated to social status ͻHowever, improved measures of social status, or, perhaps would still be helpfulSelection
ͻThe zombie hypothesis
ͻSelection -reverse causation argument (i.e. poor health causes social slide) ͻLongitudinal studies which measure social status early in life amongst healthy people and track people over time for health problems show little social slide1 21 Smith G. D., C. Hart, D. G. Watt, D. Hole, V. Hawthorne. 1998. Individual social class, area-based deprivation, cardiovascular
disease risk factors, and mortality: the Renfrew and Paisley study. J EpidemiolCommunity Health 52: 399-402.
2 Power C., S. Matthews. 1997. Origins of health inequalities in a national population sample. Lancet 350(9091): 1584-9.
Behavioural and cultural
ͻImportant, but partial, theory
ͻAdvocates suggest that the prevalence of behaviours (e.g. smoking, alcohol & diet) cultures or skills (e.g. parenting) are the root causes of health inequalities ͻUnhealthy behaviours are more prevalent in lower socio-economic groups, however: ͻThe same behaviours generate higher mortality amongst working class ͻIt ignores why particular social groups adopt unhealthy behaviours1 2 ͻThe patterning of health behaviours is explained by socio-economic circumstances ͻWhere unhealthy behaviours have equalised, mortality inequalities have not3 ͻChanges over time in the causes of death responsible for inequalities suggest that removing one particular exposure (e.g. unclean drinking water) only changes one high cause-specific mortality rate for another4 51 Nettle D. Social class through the evolutionary lens. The Psychologist2009; 22(11): 934-7.
2 Lynch JW, Kaplan GA, SalonenJT. Why do poor people behave poorly? Variation in adult health behavioursand psychosocial characteristics by
stages of the socioeconomic lifecourse. Social Science and Medicine 1997; 44(6): 809-8193 StringhiniS, DugravotA, Shipley M, Goldberg M, Zins M, KivimaM, Marmot M, SabiaS, Singh-ManouxA. Health Behaviours, Socioeconomic Status,
and Mortality: Further Analyses of the British Whitehall II and the French GAZEL Prospective Cohorts. PLoSMed2011; 8(2): e1000419.
doi:10.1371/journal.pmed.1000419.