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Throughout history different meanings have been given to the concept of health. One is freedom from clinically ascertainable disease, which has been central to the development of biomedicine. Defining the term health has ranged from purely medical, social or spiritual/mental approaches. The reviewed definition by the World Health Organisation appears to consider each of these three entities and shall be regarded as a sound definition of health:
"A dynamic state of complete physical, mental, spiritual and social wellbeing and not merely the absence of disease or infirmity" (WHO).
Personally, I would alter the definition by the WHO and replace the term 'complete wellbeing' for 'subjective wellbeing'. For the remainder of this essay, the above definition will be utilised as a suitable definition of health. Of course, not everybody will be as equally 'healthy or unhealthy' and differences are present from person to person, race to race, gender to gender, ethnicity to ethnicity and so forth. The purpose of this essay is to explore some the issues concerned with health inequalities and to critically examine some the key debates that have arisen as a result of these health inequalities. The essay will begin by introducing the concept of health inequality, then a detailed look at problems/debates within health inequality and in particular with the notion of social exclusion. The final section of the assignment will focus on the issue of smoking and health inequalities.
What are health inequalities?
At the heart of public health in contemporary Britain is a paradox. Britain is now collectively healthier than it has ever been in its history (Unal et al., 2004). Life expectancy improves and some of the great killer diseases are in retreat as the benefits of both a preventive approach to public health and advances in treatment. At the same time though, the problem of health inequalities remains stubbornly ever present. Collectively, the health of the nation is generally improving whilst the health of the least and less well off either improves more slowly than the rest of the population or in some cases gets worse in absolute terms. This is a challenge to policy makers and practitioners, pointing to the fact that while some of our policy and interventions undoubtedly work they also manifestly fail some sections of the population.
From a health promotion perspective, the issues surrounding health inequality are central to practice. The Lewisham Primary Care Trust (2010), provides a simple, yet succinct definition of what health inequality is:
"Health inequality is the difference in health experiences and health outcomes between different population groups. They can be defined by socio-economic status, geographical area, age disability, gender or ethnic group "(available at www.lewishampct.nhs.uk/index.php, accessed 21/03/10).
Therefore it is reasonable to suggest that health promotion is a pre-requisite to reducing health inequality. To facilitate the process of reducing health inequality and policy making, this assignment will explore some of the conceptual problems and debates associated with discussions of health inequalities.
According to the UK government's Department of Health (DH);
"Tackling health inequalities is a top priority for Government. Why? Because health inequalities are avoidable and are fundamentally unfair. Therefore, the whole of Government is committed to having a clear focus on narrowing the health gap between disadvantaged groups, communities and the rest of the country, as well as improving health overall". (UK DH, 2010)
The government has definitely recognised the issue of health inequality. In recent years, tackling health inequalities has become a key political objective in the UK and other countries. Commissioning the Independent Inquiry into Inequalities in Health (also known as the Acheson Inquiry) was one of the first decisions of the Labour Government in 1997, thus indicating the extent to which tackling health inequalities has become a major policy priority in the UK. The Inquiry's report and its recommendations were instrumental in fostering widespread recognition that health inequalities need to be addressed, and that tackling their wider determinants is crucial to this process. Therefore praise must be directed towards the Acheson Inquiry (1998), and this report will remain a focal reference point throughout this essay. The reports four major impacts can be summarised as follows:
It acted as a prompt to new policies
Engendered a climate of opinion favouring policies to tackle health inequalities
Introduced a health inequalities dimension to current policies
Acted as reference work for future health theory, policy and practice
There is a large literature on health inequalities, although a very much smaller literature on how to reduce health inequalities. Reviews have been undertaken of the evidence dealing with the prevention of low birth weight, social support in pregnancy, the prevention of drug misuse, sexually transmitted infections and HIV, the promotion of physical activity, accidental injury prevention, the management of obesity and overweight, the prevention of alcohol misuse and smoking, the promotion of breastfeeding, and the prevention of teenage pregnancy (Millward et al., 2003). The full results of these reviews are available at: www.hda.nhs.uk/evidence.
Though, the reviews demonstrate an underlying problem of health inequalities in all of these areas, a number of major gaps in the evidence on health inequalities has been uncovered as well and as a consequence debates regarding these issues are ever present. Among these gaps, it is apparent that that the conceptual apparatus to describe inequalities in health is surprisingly limited. For example, the HDA reviews found that dimensions of social position and social difference such as ethnicity, gender, disability, place, age and geography, while never explicitly denied as important, are underdeveloped empirically and theoretically (Graham and hunt, 1998). The question of social position, in other words, requires much more prominence in research and in policy making than it has hitherto received. In addition, the conceptual distinction between the determinants of health and the determinants of inequalities in health is frequently obscured, and therefore has little purchase on the policy making process. Therefore it is vital that we examine the processes that are utilised to measure health inequalities, prior to examining issues of specific inequalities themselves.
Measuring inequalities in Health
When inequalities in health are considered, traditionally, a socioeconomic approach is adopted to understand these inequalities (Influences on Health Model, Dahlgren and Whitehead, 1991). At the centre of this model are individuals, endowed with age, sex and constitutional factors which undoubtedly influence their health potential, but which are fixed. Surrounding the individuals are layers of influence that, in theory, could be modified. The innermost layer represents the personal behaviour and way of life adopted by individuals, containing factors such as smoking habits and physical activity, with the potential to promote or damage health. But individuals do not exist in a vacuum: they interact with friends, relatives and their immediate community, and come under the social and community influences represented in the next layer. Mutual support within a community can sustain the health of its members in otherwise unfavourable conditions (Acheson, 1998).
The model emphasises interactions between these different layers. For example, individual lifestyles are embedded in social and community networks and in living and working conditions, which in turn are related to the wider cultural and socioeconomic environment.
Social gradients and social exclusion
This section will focus in detail on social gradients and social exclusion, their effects upon health and society and the inherent difficulties in attempting to try to reduce or gap the inequalities identified.
Traditionally social gradients and social exclusion were commonly used to categorise the population into socio-economic class categories. A look at the methods employed to achieve this i.e. national consensus reveals a somewhat blurred or inaccurate representation of the true socio-economic constitution of the UK population. With respect to measuring social inequalities In Britain, inequalities between people have been measured primarily through occupation, using measures of occupation originally developed to construct the census in 1911. Occupations were categorised within a five-tier system, running from social class 1 at the top to social class V at the bottom. The occupation of the male head of household was used to determine the social class membership of all the members of the household. This classification meant that women were therefore not accorded their own social class position. It also meant that occupation as a measure was placed at the centre of researchers and policy makers' thinking about social inequality, with little allowance for kinds of social difference other than occupation (Oakley, 1974). It is noteworthy that the bottom social class group in the original census was very large as it included labourers, farm workers and domestic servants. Socialists would argue therefore that the census was a more accurate representation of the employment structure rather than that of social or economic class.
For demographers, the early consensus would have served it purpose, i.e. categorising people, however the consensus does less well in today's Britain. Economic and social changes, including the decline of manual work, the increase in women's employment, patterns of immigration and changes in family composition have fundamentally altered the nature of the population (Oakley, 1974) Nevertheless, the old schema has continued, in modified form, to be used until very recently to describe data about health. This is because, while in many ways outdated and inappropriate, the occupation-based classification continues to capture important features of social inequality in Britain. Not only do living standards (like housing tenure and income) improve at each step up the class ladder, but also so do a range of other important drivers of people's wellbeing, including educational attainment, employment opportunities and health.
Today's researchers however recognise that there are a number of axes of social differentiation in a complex contemporary society like Britain, including ethnicity, gender, sexuality, age, area, community and religion (Anthias,1990). These represent linked but separate dimensions of inequality. For example, research suggests that socioeconomic disadvantage is a major contributor to the poorer health of African-Caribbean, Bangladeshi and Pakistani groups - and exposure to racism is an important part of why they are more disadvantaged than the wider population. In addition, there is evidence that the experience of discrimination takes an additional toll on the health of black and Asian communities (Nazroo, 1997). These inequalities all have something in common, i.e. they result in differences in life chances. These differences are literal: there are marked social variations in the chances of living a healthy life.
Although this appears a relatively straight forward problem to understand and requires immediate problem solving solutions, one needs to consider the obstacles in situ. For instance, the numbers of ethnic minority persons in the UK is rising. This rise may be attributed to an increase in immigration rates, or due to second, third or fourth generations being born into society or due to global issues e.g. war and refugee/asylum intake etc. a significant number of the immigrant population is likely to be unqualified in view of national UK standards of education or qualification. Therefore this will no doubt hinder the chances or opportunity to enter the social ladder at levels where they ought to be. For instance, one will not be surprised to discover many refugee persons with a good standard of education to university or post-graduate levels, however, due to differences in society and value of qualifications, such highly qualified individuals will be forced to struggle from the bottom.
Also, in such circumstances, people of particular communities/ethnic groups prefer to live in communities be it due to fear of racism, ease of settling down or whatever the reason may be, if the community of choice isn't already established in the area of preferred residence such as the Jewish community in North London, then these people will find themselves placed/homed into areas by the council responsible that are less developed, socially deprived and encourage the cycle of 'ill health and inequality' (see section on housing and inequality for greater insight).
It is an important challenge to develop measures of inequality that embrace these differences. The evidence suggests that dimensions of disadvantage interlock and take a cumulative toll on health (Acheson, 1998), these dimensions therefore need to be considered to map and understand the health penalty of social inequality.
Evidence on the scale of socioeconomic inequalities in health has helped to drive forward policies to reduce them. The government White Paper 2004 on health, has placed a great deal of importance in attempting to address the inequalities. The evidence on the links between people's socioeconomic circumstances and their health has generated two kinds of policy responses. The first focuses on those in the poorest circumstances and the poorest health: on the most socially excluded and those with most risk factors and those most difficult to reach. The second approach recognises that while those in the poorest circumstances are in the poorest health, this is part of a broader social gradient in health. This suggests that the poorest groups and communities have poorer health than those in the most advantaged circumstances. Also, there are large numbers of people that may not be described as socially excluded, yet they are relatively disadvantaged in health terms i.e. a primary intervention approach towards health promotion.
There is an assumption that action on the determinants of health automatically tackles the determinants of health inequalities. In fact, positive trends in health determinants can go hand-in-hand with widening inequalities in their distribution among the population - e.g. rising levels of overall educational attainment could mask a growing gap in attainment between the highest and lowest social groups (Graham, 2006). This underlines the importance of understanding the relationship between health inequities and health inequalities. It also explains why local strategies concerned with the underlying determinants of health need to be assessed for their health impact, thus achieving maximum benefit form intervention policy.
The remainder of this article will assess in two aspects of health inequalities and discuss the effects of these inequities. A look at the government policies, which are underway with respect to tackling/reducing, these inequalities will be done also.
Inequality 1: Housing and shelter
There is little doubt that shelter is a pre-requisite for health. However, people who are disadvantaged suffer both from a lack of housing and from poor quality housing. Generally, the fear of crime compounds the social exclusion of people living in disadvantaged areas. There is a strong social stereotype present regarding environments that are believed to be socio-economically deprived and the link between high incidences of crime. This section will look into the inequalities in housing and the environment and health and a summary of the benefits, which might result from such policies will be attempted.
As a result of housing policy in the 1980s and early 1990s, social rented housing - local authority and housing association homes - has increasingly become a housing sector for low-income groups. People moving into social housing have tended to be families with children on the lowest incomes while those moving out have been older, with higher incomes and fewer children (Burrows, 1997). The result is an over-concentration and separation of households with high levels of need in areas with poor amenities, thus compounding social exclusion.
Figures from the Department of the Environment, Transport and the Regions which is now disbanded, (1998), revealed that in the last 20 years a rapid increase in homelessness has been noticed, with the numbers of officially homeless families peaking in the early 1990s (Wilcox, 1997). Over a third of the officially homeless are drawn from minority ethnic groups184. By contrast, minority ethnic groups are not over-represented among the unofficial homeless population, which is older and predominantly male (70 per cent of hostel users and 85 per cent of rough sleepers are men) (Victor, 1997). Rough sleepers are also drawn disproportionately from those who have been in an institution such as prison or mental hospital or have been in local authority care.
Evidence reflecting life statistics for people in such circumstances reveals very high mortality rates for homeless people, particularly for rough sleepers and hostel users (Shaw, 1998). Surveys also point to high levels of health need among the homeless population. Forty five per cent of the bed and breakfast population have been found to experience psychological distress, compared to 20 per cent of the general populationhttp://www.archive.official-documents.co.uk/document/doh/ih/part2m.htm - 184 (Victor, 1997). Rates of self-reported depression and anxiety are three times higher among those in bed and breakfast accommodation and ten times higher in rough sleepers. There is also an elevated prevalence of major mental disorders, most notably schizophrenia (Shaw, 1998), and, among young homeless people, a high rate of attempted suicide. In addition to their higher risk of mental health problems, people who are single and homeless have a higher prevalence of bronchitis, tuberculosis, arthritis, skin diseases, infections, problems related to alcohol and substance misuse, and higher rates of hospital admission (Craig et al., 1996)http://www.archive.official-documents.co.uk/document/doh/ih/part2m.htm - 187. This clearly highlights the fact that beyond purely a housing/socio-economic needs for this sub group concerned, there are also serious health care needs that need to be addressed prior to tackling the inequalities.
Although improvements in quantity and quality of housing are not certain to improve health, it is logical that they should do so. Such benefits would be on a range of health outcomes. Reducing official and unofficial homelessness would meet a basic health need of groups already vulnerable to poverty and ill health, including families and mentally ill young people. If improvements are made through community-led development, this may also enhance social networks, with other potential benefits to health (Gibson, 1993).
To counteract this problem, policies which improve the availability of social housing for the less well off within a framework of environmental improvement, planning and design that takes into account social networks, and access to goods and services. Also, policies that improves housing provision and access to health care for both officially and unofficially homeless people.
Another issue regarding housing inequality is that minority ethnic groups are generally more likely to be living in poor housing than the white majority. Poor quality housing is associated with poor health. Dampness is associated with increased prevalence of allergic and inflammatory lung diseases, such as asthma, independent of smoking and socioeconomic factors (Arblaster, 1993).
Crime, housing and Health Inequality
Mayhew (1994), mentions that crime and fear of crime both affect the quality of people's lives. Not everyone is at equal risk of becoming a victim of crime. Young men, as well as being the most common perpetrators of crime, are also the most likely victims of street crime, especially physical assaults. Older people, especially women, are more likely to be victims of theft from the person. Crime tends to be concentrated in areas of social deprivation. People from minority ethnic groups are at a greater risk of violent crime and of racial harassment. Although the author does not quantify his statements, life experiences would deem such statements as true and valid.
The link between health and crime is that people who suffer from poor health are more likely to be victims of crime than those in good health. However, this may be because of the association of disadvantage with victimisation and poor health, rather than poor health causing victimisation (Mayhew, 1993).
Evidence suggests that society level factors, and poverty and income inequality in particular, may be important underlying causes of crime. One hypothesis is that income inequality is related to crime via depletion in social cohesion, as measured by high levels of mutual distrust and low levels of reciprocity between people living in the same neighbourhood, region, or society (Kennedy, 1998). However the evidence is incomplete, but, the link between income inequality, social cohesion and crime has important policy implications. It suggests that crime prevention strategies which only target the perpetrators and victims of crime and the high crime areas in which both groups live, will not achieve a significant reduction in crime unless they are accompanied by measures to reduce income inequality and promote social cohesion.
It is not for the social or health promotion professional to suggest methods of tackling crime, however it is clear that the most effective approaches to crime prevention are likely to be those which are integrated with wider social and economic policies for reducing health inequalities. The roles of the health and social workers will include educating the public with respect to issues pertaining to health, informing the public of resources at their disposal, engaging community workers to encourage community cooperation in schemes such as environmental projects, littering, sexual health clinics and so forth. The aim here being to promote health at levels of the community and developing greater social cohesion.
Inequality 2: Smoking and health inequalities; a brief overview
Amongst the numerous health inequalities is inequity with respect to smoking and health. Despite a reduction in the overall prevalence of tobacco smoking in the UK over the past 30 years, there has been little change in lower income groups. Smoking in Britain has become increasingly concentrated among those who are most disadvantaged in society (Acheson, 1998). People living on lower incomes are: more likely to take up smoking; less likely to quit; likely to be more nicotine dependent; likely to be more heavily exposed to other people's smoke. Death rates from tobacco are now two to three times higher among disadvantaged social groups than the more affluent, and poorer people can also expect to experience more illness and disability problems
Results from the General Household Survey (2005), reveal that People living on lower incomes are more likely to take up smoking; less likely to quit; likely to be more nicotine dependent; likely to be more heavily exposed to other people's smoke. The disproportionate number of smokers in lower social classes has contributed to the increased health inequalities between rich and poor.
Tackling the issues with respect to smoking and inequalities requires a holistic approach, with every member concerned being vital. The influence of parents upon their children is unquestioned and is paramount, particularly in the pre-school phase of a child's life (Tones, 1992). It has been shown that a significant reduction in the number of children taking up smoking is critically dependent on reducing smoking among adult role models (The Royal College of Physicians, 1992). Studies have shown that children are almost three times as likely to be regular smokers if both their parents smoke than if neither does (Office for National Statistics, 1997).
There is evidence that smoking is a measure of social trajectory, with prevalence being closely related to people's social destination. Poor achievement levels at school and lower levels of self esteem at age 16 indicate an increased risk of being a smoker. Research shows that low income smokers, particularly lone parents, cite smoking as a way of dealing with stress and problems, although there is little to suggest that nicotine has any true sedative action (Jarvis, 2000).
The issue with smokers from lower income groups is that people in low income groups do not appear to be less motivated to give up smoking than other social groups, yet figures reveal that smokers form this category are less likely to quit. It is suggested that people give up smoking for reasons connected to optimism; actual or anticipated improvements in life circumstances, health or feelings about oneself. Higher deprivation and stress levels experienced by those on lower incomes do not motivate smokers to quit. There is strong emerging evidence that the level of nicotine dependence increases systematically with lower income groups. This is evident from questionnaire indicators of dependence from the General Household Survey (e.g. time to first cigarette of the day; and perceived difficulty of going for a whole day without smoking), and from quantitative measures of smoke intake (The Royal College of Physicians, 1992).
In response to the smoking health inequality and its consequences, the government published proposals designed to reduce smoking in the UK, in a White Paper entitled "Smoking Kills" in December 1998. The overall target set for adult smoking was a reduction from 28% to 24% or less by the year 2010; with a fall to 26% by the year 2005. In September 2000 the government launched its NHS Cancer Plan. This Plan set the first ever smoking inequalities target. Its aim is to reduce smoking rates among manual groups from 32% in 1998 to 26% by 2010. From a social context of health, this approach, although is a positive and should be encouraged, the issue here is not a case of reducing stats or figures, rather we need to investigate the reasons of higher uptake and lower cessation rates and from this develop strategies that will tackle the problem at hand. For instance, lower motivation to change/succeed in life goals will need to addressed with methods of developed to improve motivation in life goals i.e. utilising the Model of Behaviour Change with the goal being here to quite smoking yes, but primarily to improve individual health at mental, social and economic levels.
While the health of the population as a whole may be improving, the health of the least and less well off either improves more slowly than the rest of the population or in some cases gets worse in absolute terms. This is a challenge to policy makers and practitioners. It suggests that while some of our policy and interventions undoubtedly work they also manifestly fail some sections of the population.
What can be done to narrow the health gap? Several policy options are available: Reducing economic and social inequalities: Poverty and poor health can turn into a true vicious cycle from birth to death. Children born into disadvantaged families tend to have a lower birth weight due to harmful influences during pregnancy and are more likely to incur accidents. Underprivileged people are also at higher risk of chronic stress and repeatedly disappointed professional and private expectations not only cause long-term disease, but can also push people towards substance abuse. The disadvantaged thus tend to be more frequently subjected to fatal illnesses (cancer, strokes and heart failure) and their chance of surviving these tend to be lower. Therefore it appears that, besides publicly funded health and education services, the reduction of economic and social inequalities is the key to reducing health inequalities. These will include things like redistributive tax policy, social transfer payments e.g. child allowances, pensions etc, reducing homelessness and housing improvements.
Traditional approaches to health promotion, such as providing health information, fail to reduce health inequalities effectively because they tend to benefit the wealthy more than the poor. Measures proposed include developing national health inequality targets, working at the local level, reducing barriers in access to health services, and integrating health determinants into other policy areas. Integrating health determinants into other policy areas. The health sector in itself can only achieve limited results in reducing health inequalities. However, by integrating health determinants into fiscal, education, agriculture and housing policy, a great deal could be done to narrow the health gap.