Overview of health inequality
Health inequality is the comprehensive term used to describe gaps, variations and disparities in the health achievements of individuals, racial, ethnic, sexual orientation and socioeconomic groups in a society (Kawachi et al. 2002). It is generally described in terms of social economic class and its causes are mainly lifestyle factors (smoking, nutrition, alcohol consumption, exercise, weight, stress) and socio economic factors (income, socio economic group,housing,employment and educational status) (House of commons health committee 2004).
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People in the lower social class tend to have lower incomes,poor education,live in poorer housing in deprived areas and are also more likely to suffer worse health (Marmot 2010;The Black report 1980; Acheson report 1998). Life expectancy has increased and illness from disease, infection, hunger and dirty water has decreased over the years in the UK, however the problem now is disease of lifestyle, resulting in increasing levels of respiratory disease, obesity and its complications, heart disease, and cancer due to lack of exercise, smoking, drinking and bad diet (DoH 2010).
The Marmot report (2010) and the National Obesity Observatory (2010) both show the rise in obesity in both males and females over a period of 10 years. As shown in figure 1 below.
Figure1: Prevalence of adult morbid obesity (BMI 40kg/m2 or more), 3 year rolling averages, Health Survey for England.
Source: Information Centre for health and social care, 2009.
Obesity in the lower social class has been identified as a growing health inequality in today’s society by the Marmot report (2010).With 61% of the population obese, 21% still smoking, less than 40% of the nation meeting physical activity needs and 2.4 million people drinking over the recommended weekly amount, the disease of lifestyle remains a major concern and cost burden to the government (DoH 2010) withobesity and the relating health issues costing the NHS £4.2 billion in 2007 (NOO 2010).
This essay is going to look at the increased risk of obesity in lower social class, by exploring the sociological and psychological influences, thus identifying why those in the lower social class are more likely to suffer worse health outcomes (Marmot, 2010). Sociological factors will include type of environment, and income, whereas the psychological aspects will look more at issues influencing behaviours that increase risk of obesity, such as over eating and lack of activity (Foresight 2007). This essay will then go on to look at what is being done to limit the effect of obesity in the lower social class and the role of the nurse and the multi-disciplinary teamin prevention and treatment of obesity.Inequalities in health have been identified throughout the last 30 years, as shown in the Black report (1980), Acheson report (1998) and Marmot report (2010).
Obesity in the lower social class
The Marmot report (2010) identifies obesity in the lower social class as being a prevalent and contemporary inequality in health in today’s society. Obesity is universally measured by Body Mass Index. (Naidoo and Wills 2008). The World Health Organisation (2006) describes obesity as an increase level of fat stored in the body that impairs health.Obesity can result from a number of factors including genetic, metabolic, environmental and psycho-social influence (Aylott et al. 2008).
Disorders closely associated with obesity are heart disease and stroke (main causes of death) where as diabetes, obstructive sleep apnoea, musculoskeletal pain and osteoarthritis, obstetric complications, polycystic ovarian syndrome, infertility, incontinence and mental health problems reduces quality of life as well as life expectancy (NOO 2010). The Marmot review (2010) identifies people living in the poorest areas of England will generally die 7 years earlier than those living in the more affluent areas and also reveals the difference in disability free life as 17 years between the poorest and richest areas.These gradient differences in life expectancy and disability free life are also prevalent in level of education, type of housing, and occupation (Marmot 2010).
The Health Survey for England(2007) revealed the prevalence of obesity was higher in unskilled workers (social class V) than professionals (social class I) with this gap between the two been significant and has widened since 1997 in both sexes.The Black report (1980) showed unskilled workers death rate was twice that of professional workers in 1971.It has been estimated 12% of women in the professional/managerial group (higher social class) were obese, compared to 29% in the routine and manual group (lower class) (HSE 2007).
Figure 2: Obesity and the contributing determinants.
Figure 2 above shows some of the contributingdeterminants of obesity. By understanding the societal influences, such as the influence of the media, peer- pressure and income may help identify and account for the variations in diet between the socio economic groups. However a clear picture of obesity in the lower social class cannot be explored without looking at the influences, such as psychological drives for particular foods, eating patterns and patterns of physical activity on this group (NOO 2010).
Sociological determinants – Structure
The Acheson report (1998) identifies income as a major contributor to social influence on diet and obesity. Daykin and Jones (2008) also identify the link between income and diet related health. However, the Acheson report (1998),and Daykin and Jones (2008), suggests that the types of food eaten by people in each group of social class tends to vary greatly. Those in lower income homes buy foods that are processed, high in salt, sugar and fat, and most importantly cheaper (House of Commons 2004). These energy dense foods are high risk contributors to obesity and the relating health conditions (Daykin and Jones 2008). Although there are many healthy versions of the same products now available, they tend to be more expensive than their counterpart thus deterring those from a lower social class with a lower income from buying theseproducts (House of Commons 2004).
This may also relate to low income areas having a decrease in the number of retail grocers and an increased number of fast food outlets opening in the area (Cummins andMacintyre 2002).In deprived areas most local retailers selling fresh vegetables and fruit have had to change their products because of their inability to cope with large out of town supermarkets selling fresh fruits and vegetables at a cheaper rate, leaving these retailers to stock food that is processed and high in sugar, fat and salts (Caraher and Conveney 2004). This is further exacerbated by those from lower social class being less likely to have their own transport causing further problems for those trying to get to supermarkets with poor transport links (Daykin and Jones, 2008). The Wanless report (1998) also identifies the change in societies eating habits and patterns. There are higher levels of sugar intake due to the carbonated drinks and society tends to snack more with higher levels of eating out, and food being available at all times of day and night (House of Commons 2004). With an increase in fast food venues, opening and selling cheap filling processed food in economically deprived areas, is a contributing factor to the lower social class increased prevalence of obesity and link health problems(Daykin and Jones, 2008).
Psychological determinants – Direct
Research has shown that those in lower social class are affected more by different types of stress (Brinkerhoff et al. 2008). For example those in lower social class are affected more by job insecurities, job loss and physical disabilities, which in turn can be the cause of mental disorders and emotional distress (Stansfeld et al. 1997). This distress over poverty and economic insecurity is extremely important in understanding the causes of major depression (Brinkerhoff et al. 2008). Depression can lead to changes in a person’s activity (hypersomnia or insomnia) and appetite (increased or decreased)(Quitkin 2002). Hypersomnia and increased appetite are important risk factors in development of obesity (Cumella et al. 2008). Obesity can then lead to a person having low self-esteem (Ogden and Flanagan 2008). A person’s self-esteem can then determine whether they have the confidence and motivation to seek a better work or to simply get a job. Without this confidence to find a better paid job the person is more likely to stay in the same lower social class position, with the same stress and depression, thus influencing their psychological behaviours(Stansfeld et al. 1997).Aylott et al. (2008) reveals that those who are obese and have low self-esteem feel stigmatised and therefore are less likely to participate in schemes to lose weight.
Indirect determinants – Action
However, looking at learnt and inherited behaviours explains unhealthy lifestyle choices influencing obesity in the lower social and economic class (Shelton 2005). There has been evidence that suggests that lower levels of physical activity with higher levels of television watching tend to be more prevalent in the lower social class (Aylott et al. 2008). Those in lower social class are less likely to take part in physical activity, men are 38% and women are 68% more likely to be active if from a higher social class (Wandless Report 2003). This disparity in activity is highlighted as a major factor in increased riskof developingobesity (Wandless Report 2003).
The role of the media has more impact on eating habits and behaviours on the lower social class, who spend more time watching TV (House of Commons 2004). Most advertising as identified by the House of Commons Report (2004), were for high fat, sugar or salt foods. With limited advertising for fresh fruit and vegetables, which is drowned out by the sheer number of snack food adverts, this impacts on the choices of foods bought by people (House of Commons 2004). There is evidence also that if one parent is obese then the children are also more likely to be obese, and again reflecting social determinates early on in life and behaviours (Aylott et al. 2008).
There has been increasing research over the past few years that have shown a definite link to obesity and genetics (Boutin and Froquel 2001). Genetic defects have been identified that could pre determine that a person is going to be overweight or obese (Boutin and Froquel 2001). These biological factors have recently been identified not to affect our metabolic rate or nutrition partitioning, but to be a neuro-behavioural disease (O’Rahilly and Farooqi2006). Therefore increased exposure to unhealthy behaviours and a predisposed biological abnormality would increase the chances of a person developing obesity (O’Rahilly and Farooqi 2006).
The Government and the primary care sector recognise obesity as being a problem that needs addressing (NICE clinical guidelines 2006). Obesity results from a complex interaction between various factors such as a societal, individual psychology, physical activity and food consumption and therefore a wholly holistic approach is needed when tackling the obesity epidemic (Aylott et al. 2008). Looking at government policies and strategies as well as professional actions will help identify what is being done to limit the effect of obesity in the lower social class as well as direct approaches in influencing changes in behaviour.
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Health promotion and policies
As identified, to approach obesity collaboration between the government bodies, as well as the media, food industries and communities is needed to achieve the common goal of better public health (Fisher 2005).There have been many policies already targeting healthy behaviours across a variety of intervention schemes (NICE clinical guidelines 2006). The government has identified key areas that need to be addressed in policies, such as start well, policies encouraging healthy habits from birth, prevention and treatment of mental health problems, as well as living and working well policies (DoH 2007). The role of the nurse and other members of the multi-disciplinary team are essential in delivery of these policies and guidelines, to offer advice and support to facilitate behaviour changes (Foresight 2007). The key areas of government strategy have been to:-
To increase levels of walking and cycling in our current environment,
Targeting those at risk with health interventions,
Control demand and supply of obesogenic foods and drinks,
Increasing the responsibility of different organisations to the health and wellbeing of their employees,
Early life interventions, influencing behaviours and attitudes.
(Aylott et al. 2008)
The role of the nurse and multi-disciplinary team in implementation
It has been identified that the prevention and management of obesity in the lower social class should be a priority for all (NICE guidelines 2006). When working with those to prevent or manage obesity a person centred approach should be used (NICE guidelines 2006).Department of Health(2007) strategies indicate primary care workers duty to treat patients as individuals and adjust their care requirements accordingly. However some research has shown that nurses are likely to perceive obese people as lazy and unattractive while caring for them is stressful, hard work, repulsive and disgusting (Poon and Tarrant 2009). This negative view of the patient is likely to be picked up by the patient and cause further problems in the nurse patient relationship (Poon and Tarrant 2009). This will also impact on any advice and support offered by the nurse in health promotion as the patient will not feel the advice it is coming from someone who actually cares about their problems, and will further reinforce the bad body image they have (Poon and Tarrant, 2009). Areas of change and policy governing these have been identified, but without a non-judgmental holistic approach by the primary care sector, much of the advice and information around prevention and treatment of obesity could be ignored (Ogden and Flanagan 2007). However with a holistic assessment of possible causes, individually tailored treatment can be implemented, with appropriate support (NICE clinical guidelines 2006).
Direct behavioural change pathways
The Department of Health (2010), have identified that halting the obesity epidemic, is about individual behaviour and responsibility: how much we eat and what we eat, as well as how much physical activity we take part in. However DoH (2010) also identifies the voluntary and private sector being accountable for behaviours in health and promotion. The DoH (2010) has implemented guidelines, tools and information on changes needed to tackle obesity. One such campaign is the Change4Life. This campaign is aimed at reaching all parts of the community even those from the lower social class (DoH 2010). The aim of the campaign is to make people aware of healthy food choices. The Department of health 2010 have spent£75 million on evidence based marketing programme, which empowers and supports the public to make changes to their lifestyle (DoH
2010). The Government has used extensive advertising campaigns to make people aware of healthy choices, and behaviours (DoH, 2010)the campaign offer advice in several areas of change, such as: portion swap, snack swap, 5 a Day, up and about, drink swap
The Department of Health (2010) cannot emphasize enough the importance of healthcare professionals in the implementation and success of the Change4Life campaign. It recognises that many healthcare professionals are the first point of contact for those at increased risk of developing obesity and are in a position to influence the targeted group in society (Department of Health 2010). Understanding the causes of obesity will allow for the primary care team to take a more active role in prevention, whether through counselling for depression, support groups for self-esteem, weight management consultations, referrals to a dietician, surgery and medication as potential solutions to the behaviours of obesity (Ogden and Flanagan 2007). Ogden and Flanagan (2007) identified in their research that there is focus on the primary care due to many of their clinics now taking weight management as part of their approach to diabetes clinics, COPD clinics and health screening.
Indirect government action
The Government has identified that the food industries need to be dedicated to the delivery and promotion of health choices (DoH 2010). The Foresight report(2007) has identified an effective regulation response to foods and drinks. With local government involved in building partnerships with local food retailers for example the partnership between the Department of Health and the association of convenience stores to increase the availability of fresh fruit and vegetables available in areas that would have limited access to these products (deprived areas) (DoH 2008).
Others areas of effective strategy policy set out by the ‘healthy weight, Healthy lives, 2008 policy show practical ideas around walking, cycling and the surrounding environment. The Department of Health(2008) has encouraged local areas to invest in many cycle paths and schemes encouraging people to walk or ride their bike to school or work. As well as using markers and promotional pedometers, allowing individuals to actively see how much they walk and what that can do for their health (Aylott et al. 2008).
The obesity epidemic has become a huge problem across the whole of the United Kingdom with the lower social class more likely to be affected by obesity and its complication (Marmot 2010). Obesity is a complex disease with many determinants that affect its prevalence in the lower social class (Foresight 2007). One major determinant is income which have a profound effect on the psychological behaviours (depression, self-esteem) as well as the sociological environment (Transport, location, availability of product) (Foresight 2007).A small percentage of people are biologically predisposed to obesity (O’Rahilly and Farooqi 2006). Combination of all of these factors has influenced the prevalence of obesity in the lower social class (Foresight 2007). The prevention of obesity needs a holistic approach in order to reverse the rising tide of obesity (Cross – Government Obesity Unit et al. 2008).
Government policies and campaigns are aimed at promoting healthy eating and lifestyle. They rely mainly on primary care teams to implement this to their local areas and patients, however, the individual’s enthusiasm to change and adhere to policies and advice is vital in closing the gap in this inequality (Foresight 2007). However it is not only the role of the Government to envisage a change, the food marketing and food agency should also take a role in promoting and delivering healthier food to the consumers, whatever class they are from (Wandless 2003).
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