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Chapter: Medicine Study Notes : Public Health

Social Inequalities in Health

Deprived social and economic conditions strongly associated with poor health.

Social Inequalities in Health


·        Deprived social and economic conditions strongly associated with poor health

·        There is a social gradient in health – it exists in all countries but the slope varies


·        Targets for intervention:

o   Socio-economic status: issues around distribution

o   Intermediary factors: housing, targeted support

o   Health issues: access.  Most countries target their intervention here

o   Link from Health to SES: disability support 

·        Poor health ® deprivation through stigma and ¯earning potential

·        Deprivation ® poor health through the following:

Effect of Deprivation on Health


·        Poor access to health care:

o  Culturally foreign 

o  Financial barriers: GP services, transport, class and language differences between doctor and patient

·        Income:

o  Key SES lever.  Can have a rapid effect on:

§  Effects of a drop in absolute income 

§  Rise in income inequality ® divisive effect on society ® alienation of „work poor households‟: 

·        Measured by the Gini Co-efficient for household equivalent disposable income 

·        Has ­ for NZ since 1988 from 0.26 to 0.33 (biggest change in the OECD)

·        Is followed with a small lag by indicators such as youth suicide, youth unemployment, etc 

§  Formation of social capital. People in „survival‟ mode don‟t have energy to contribute to community 

o  Policy levers: monitoring income inequality, change tax rates and social wage, alter WINZ rules about supplements

o  Single parent families, women, Maori and Pacific Islanders are over-represented in the poor 

·        Education: Increases human capital. Students from poor households are more likely to underachieve, have lower participation rates in tertiary education.

·        Occupation and labour force participation:

o  Translates human capital into income.  Also indicator of social class

o  Higher injury rates in low SES jobs (forestry, construction) 

o  Unemployment: ­stress, social isolation, lack of purpose ® ¯ self esteem

·        Housing: 

o  Impacts of rent, neighbourhood, number of bedrooms, quality of construction and maintenance (eg insulation, ventilation).

o  Issue for the poor, and also for former institutionalised psychiatric patients 

o  Damp housing ® respiratory illness, overcrowding ® infectious diseases, ­mental distress 

·        Feelings of hopelessness and being devalued ® less cohesive society ® violence, exploitation, drug use 

·        Ethnicity:

o  Interacts with SES

o  Sensitive policy area

·        NZDep (NZ Deprivation Index) is a composite measure of deprivation

·        Individual health risks:

o  Adequate food in sufficient quantities („food security‟)

o  Physical exercise: affected by range or sports facilities, clubs, etc

o  Alcohol/tobacco consumption: affected by taxes, restrictions on distribution

o  Early pregnancy

o  Also indicators such as obesity, high blood pressure, high cholesterol, diet, exercise

·        Health behaviours/At-risk behaviour (eg lifestyle factors)

o  Health damaging behaviours more common in low SES

o  Knowledge alone insufficient to change behaviour (eg smoking may be a coping strategy) 

·        Relate these factors to health status using measures of mortality, morbidity (including measurement of self-rated health status, suffer from specific diseases or measure role limitation), health risks, health service utilisation 

·        NZ approach:

o  Monitor social and economic determinants of health

o  No systematic cross country comparisons

o  Slow policy development and implementation

o  Lacks cross party and public support

o  Emphasis on health providers not determinants

·        Conclusions:

o  Socio-economic determinants of health are multi-causal

o  Issues around policy making under conditions of uncertainty

o  Policies should be monitored against goals

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