Dr Yoga
Senior Lecture in Public Health
GEMS UL
LO = Outline the major forms of inequalities in
health, and the general categories of explanation
put forward to explain them
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Social determinants of health
Social determinants of health inequalities
Discuss health inequalities
Inequalities in Ireland
*
Complexity of social structure:
*
*
Bigger picture of society - culture, power, history
* Opportunities, assumptions, discrimination, social mobility
Social structure that favours higher
social status, individualism and wealth
and disadvantages poorer, dependant
groups
Social
structure
Inequalities
in social
position
Inequalities
in access to
determinants
Inequalities
in health
What comes to mind when I say
“health inequalities”?
Difference or unfairness?

Differences, e.g. between numbers of men
and women who smoke
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Unfairness, e.g. higher cost of fresh fruit in
poorer areas
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Being short as an adult could be due to genetics,
ante-natal difficulties such as blood vessel
malformation, physical illness or condition as a
child, such as polio or cystic fibrosis

Or, poor maternal nutrition, lack of access to
food as an infant, poor nurturing relationship
etc, i.e. as a result of poverty and disadvantage

Being short could disadvantage social progress,
or not
For any factor where there are differences or a social hierarchy, there
could also be unfairness

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Relative poverty
Absolute poverty
Culture and behaviour
Biological responses to stress
Lifecourse effects starting from early years
Social stratification and discrimination
Environment
Poverty
Geography
Individual
differences
Combined social Deprived areas
circumstances
Social inclusion
Lifestyles
Ethnicity
Gender
Disability
Opportunities
Discrimination
Personal choices Age
Health inequalities can be
seen as an outcome of
Social Inequalities
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Healthy early years development is the
foundation for later school achievement,
economic productivity, responsible
citizenship and successful parenting
Very early life is crucial but different
skills mastered at different stages are
equally important
Interventions important at all stages
From what you’ve heard (and
what you know), what do you
think should be the two main
priorities to address in order to
reduce the inequalities gap in
children’s health and wellbeing?
 Reduce
poverty
 Improve
educational
attainment
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Societal problem therefore society has to change
(economic policies, diversity, social welfare etc)
Public sector is part of society – major employers,
service providers, big contribution to health

Planning and practice for health inequalities
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Irish policy emphasis on health inequalities - not
entirely clear about specific action
Taking into account the complexities around
health inequalities, academics suggest three
interlinked approaches which all need to be
addressed but will require different aims and
actions:

Targeting worst off

Closing the gap
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Reducing the gradient
Aim
Examples of actions:
Regeneration,
employability,
targeted health improvement,
services for vulnerable children
Aim
Examples of actions: increase
minimum wage alongside a
millionaire prevention
programme, re-allocation of
resources from affluent to
poor areas
Reducing systematic
inequalities for income,
gender, ethnicity, disability
etc i.e improve access and
opportunities, inequalities
sensitive practice
DVD on The
Great Health
Divide
20
There are many influences on an individual’s
health. These are often categorised into:
Personal
Lifestyle
Biological
Factors
The Physical and
Social
Environment
Health Services
Health Issues in the UK-Inequalities
21
It is now generally recognised that there are many
reasons for health inequalities. People can suffer
health inequalities for many reasons, due in the main
to:
The geographical area they live in.
The racial group they belong to.
Their gender
The common
denominator of
all these factors
is that they all
link to
POVERTY
And, perhaps most importantly,
their social class.
Health Issues in the UK-Inequalities
22
Today, ethnic minorities make up about 6% of the UK population
* There is variation in
health amongst various
racial groups.
* For example,Asians are
more prone to heart
disease and Caribbeans
have a higher incidence of
mental problems
* However, one of the main reasons for ill-health inequalities amongst ethnic
communities seems to arise from RACISM and DISCRIMINATION
* Poor “life chances” often leads to poor educational, employment and housing
opportunities.
* This leads to POVERTY and increased chances of illness and disease.
Health Issues in the UK-Inequalities
23
The GENDER you belong to can also be a contributory
factor to the amount of health you enjoy
Due to 3 main factors:
 Biological - Women’s role
* Women tend to
live longer than
men
* But they suffer
from more illness
during their lives
in reproduction can cause illhealth
 Material - Women still
seen as ‘carers’ commitments often force
them to take low paid /part
time jobs - can lead to
POVERTY and ill-health
 Ageing - Women live
longer more prone to illhealth connected to old age.
Health Issues in the UK-Inequalities
24
In the UK the SOCIAL CLASS you belong to
seems to be influential in determining your health.

BLACK REPORT (1980) concluded that while the
health of the nation as a whole had improved,
inequalities in health had not been eliminated.

In fact, Black stated that the ‘Health Gap’
between higher and lower social classes was
widening.
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He claimed that this was as a result of differences
in social and economic conditions.
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He said that people from lower social classes
tend to drink and smoke more, exercise less and
have poorer diets than those in higher social classes.
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These poor habits can be traced back to
POVERTY.

Health Issues in the UK-Inequalities
25
It is generally recognised that Western lifestyle is bad for your
health……….
Fat seems also to be a
class issue. It seems
the lower the class you
belong to, the greater
the incidence of obesity

 Over 50% of Britons
are overweight and
the number of
overweight children is
a growing phenomenon
in the Western World
 Often opposition
from the food
industry where a
large % of profits can
be made from junk
food profits
Some proposals to
stop children eating junk
food have been
controversial - In 1998
James Report
suggested banning
sweets and fizzy drinks
from schools

Health Issues in the UK-Inequalities
26
Generally that smoking damages
health in the form of cancers and heart
disease

 Smoking seems to link to ill health and
is also a class issue
 By 1990s, professional classes had
listened to advice and had cut down on
smoking.
 The habits of lower classes changed
little during this time.
 Young women are especially
vulnerable, especially teenage girls.
 Girls 20 years behind men in smoking
habits
Health Issues in the UK-Inequalities
27
There are two major approaches to tackling inequalities in health:
THE COLLECTIVIST
APPROACH
THE INDIVIDUALIST
APPROACH
Health Issues in the UK-Inequalities
28
This approach to solving
inequalities is based on
the view that differences
in health are beyond the
ability of the individual
to change
Subscribers to this
view feel that
improvements will only
come by concerted
government action
centering on anti-poverty
strategies

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The view is that
differences in health are due
 Idea first found favour
to major economic and
in the Black Report
social problems in society
(1980) and Acheson
- eg. poor housing stock,
Report (1998)
unemployment, inflation
 These problems impact on
different people in different ways
- but poorer social classes
suffer most.

Health Issues in the UK-Inequalities
29
 This approach is based on
the belief that health
inequalities are the result of
how INDIVIDUALS choose
to lead their lives
There seems to be
differences in health
habits between
different social classes
Government action should
centre on high-profile health
advertising campaigns
etc. Approach favoured by
Tory Government in early
mid 1990s.
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Idea is that people
should be largely
responsible for
monitoring own
health
 People of lower social class
seem to; smoke and drink alcohol
more often, exercise less and have
less healthy diets
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Health Issues in the UK-Inequalities
30
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Gender difference in
favour of females
Males
54% higher for all causes
61% higher for circulatory
45% higher for cancers
48% higher for respiratory
169% higher for
injury/poisoning
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Urban-rural differences
 Urban excess in most
causes of death except
influenza and transport
accidents
Institute of Public Health 2001
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illness levels
 Hospitalisation for
mental illness among
unskilled workers is 6x
higher than for skilled
 The average suicide rate
in economically
deprived areas is 2x that
of non-deprived areas in
N. Ireland
 Children in first year of
life have more ear, chest
and GIT infections
(Dundee study)
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determinants of health
 37% of women with
medical cards smoke
during pregnancy vs
12% of mothers without
 27% of babies born to
unemployed mothers
were breastfed vs 67%
of babies born to higher
professional women
 Cervical screening
uptake > 60% in most
affluent EDs,<40% in
least affluent EDs in
Limerick
50
45
40
35
30
25
20
15
10
5
0
Commenced on discharge at 2 weeks
Tipp NR
Limerick
Clare
MWHB
at 6 weeks
at 4 months at 6 months+
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1838
Poor Law structures
1851
Dispensary service
1972
GMS
1994
Shaping a Healthier Future - health
strategy introduces equity concept
1999
Institute of Public Health (North-South body
with focus on tacking inequalities)
2001
Extension of GMS eligibility to all over
70’s
2008
Removal of above
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Whitehead(2005) suggests a typology of actions to
reduce health inequalities:
 Strengthening individuals
 Strengthening communities
 Improving working and living conditions
 Promoting healthy macro-policies
If your only tool is a hammer, all your
problems will be nails”
Mark twain
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Mr Power has an illness which has both modifiable
and un-modifiable risk factors
? “Social determinants”
What can you as his doctor do to help him?

Prevention
 Primary
 Secondary
 Tertiary