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 pointCommission on Social Determinants of Health
Closing the gap in a generation 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
Gender Age Occupation Income Wealth Social class Rurality
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
<= 15<= 12<= 10<= 8<= 6<= 4<= 2
-
Male-female gap in life expectancy at birth
… yet this is not inevitable
No gender gap found in survival beyond age 40 in (non-smoking, non-drinking) Polish Seventh Day Adventists (Jedrychowski, Scand J Soc Med 1985)
> 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 roleUnfortunately, 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
Nolte & McKee, unpublished
For this inequality, access to health care matters
The obvious solution?Universal health care (if we poor
Europeans can do it, why not the world’s remaining superpower?)
If that is too difficult….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
Health outcomes are considerably better among Swedish than Finnish speakers living in Finland
“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 alcohol-induced 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
Switzerland 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
“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
… 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
The emphasis of research is gradually shifting from identification, to diagnosis, to prescription
Different ‘entry points’ for intervention and policy are being identified
Growing experience in developing, implementing and evaluating interventions and policies
The bad news
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
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
(Dahlgren & Whitehead)
Strengthening individuals
Focus on big issues and help people to make healthy choices 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
Workplace Individually targeted interventions (physician
advice, counselling, NRT) work, self-help doesn’t School
No convincing evidence of effectiveness of social influences and social competence interventions
Pregnancy Smoking cessation programmes work (6 fewer
women per 100 smoke) Patients in hospital
Intensive interventions over > 1 month work
Source: various Cochrane reviews
Smoking advice: Evidence on who does it?
Nurses Increased odds ratio for quitting (1.47) Less effective when in context of screening
intervention Physicians
Increased odds ratio for quitting (1.74) Intensive intervention marginally more
effective Partner support
No convincing evidence of effect
Source: various Cochrane reviews
Individual or collective?
China California
Strengthening communities
Economic growth More jobs More pleasant
environment Reduced crime Better education
More jobs
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
Changing your environment:
The Moving to Opportunity project Between 1994-97, 4248 families in Baltimore,
Boston, Chicago, Los Angeles and New York were randomly assigned to: Housing voucher that could be used to move to a low
poverty (<10%) neighborhood along with mobility counseling;
Housing voucher with no geographic restrictions;
Control group (no new assistance, but continued to be eligible for public housing).
Kling et al, various dates
Moving to Opportunity: results in 2002
Girls moving to low poverty area: 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: 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 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
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 Education and Training (for parents) Rewards and Incentives (for children based
on in-school performance) (Nye et al, 2006)
Head Start
Pre-school programme for children from poor familiesLaunched in 1960s under LBJEvidence of early benefits – numeracy and
literacy But also evidence of Head Start Fadeout
In the long term….
Whites Participation associated with a significantly increased probability
of completing high school, attending college, elevated earnings in early twenties.
African Americans 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:
Relationships over time – not one-offDecisions not only made by individuals
but also families and friendsProximity does not equal accessEvidence is contextually bounded
(Balabanova, McKee et al, 2006)
Increasing uptake of services (and better services)
Cervical screeningInvitation letters work, educational materials have limited effect
Mass media… campaigns can be effective in increasing uptake of essential
services
UK Quality and Outcomes Framework in general practice has reduced inequalities
Source: various Cochrane reviews
Source: Roland et al
Encouraging macroeconomic and cultural change
71%
71%
72%
Source: Fritzell & Ritakallio 2004 using Luxembourg Income Study data, CSDH Nordic Network
62% 63% 59%
54%49%
44%50%
24%
Welfare regimes matter:Odds of poor/fair health in unemployed compared to employed by welfare regime
Bambra et al., 2009
(for example, in Anglo-Saxon welfare states, unemployed almost 3 times more likely to be in poor/fair health than employed)
Possible explanations
Anglo-Saxon systems are simply meanLow wage replacement levelsMeans testing
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
Bambra et al., 2009
Some policy innovations
Policy steering mechanisms
Labour market and working conditions
Health-related behaviour change
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 assessmentQualitative 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
Universal approachesStrong 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
Targeted approachesJob rotation among dustmen – Netherlands
Some evidence of effectiveness – active labour market policies may protect in face of recession
Health-related behaviours
Universal approachesServe low-fat food products through mass
catering in schools and workplaces – Finland
Targeted approachesMulti-method intervention to reduce
smoking among low income women – Britain
Considerable evidence of effectiveness, but context important
Territorial approaches
Comprehensive health strategies for deprived areasHealth 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?
… 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, USABBC web site
Medicine is a social science and politics is nothing but medicine writ large ”Rudolf Virchow
Summary
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!