Recent evidence suggests that the health of the population in the United Kingdom continues to improve. However, despite this many people will experience an inequality in terms of their health and the chance of living in good health is unequally distributed within society (House of Common Health Committee 2009). Socio-economic status is one of the most important determinants of health and the link between this and health is widely accepted (NPHS 2004).
Differences in health by social class was examined by the Black Report (1980), which investigated the problem of health inequalities in the UK and found that people of lower economic status were far more likely to experience ill-health and premature death than those of higher socio-economic status. The report concluded that despite the improvement in the overall health of the population, the improvement had not been equal across the social classes and that the health 'gap' between lower and higher social classes was widening. This was supported by the Health Divide (1987) and the Acheson Report (1998), which mirrored the findings of the Black Report. Report findings suggested there was a direct correlation between socio-economic class and health and the likelihood of developing health problems such as coronary heart disease, strokes, lung cancer and respiratory diseases was far higher in the lower social classes.
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The aim of this essay is to discuss the unequal distribution of health within society; this will be achieved through the examination of the incidence of coronary heart disease within a lower socio-economic group. This subject has been chosen because it is of particular relevance within some of the most deprived areas of Wales and accounts for a large proportion of deaths. A further aim of the essay will be to identify and discuss the factors that influence health across a person's lifespan. Psycho-social influences on health will be discussed along with the direct and indirect influence they have on the health of a person. An analysis of pertinent social policy will be provided together with the relevant public health policies that have been developed to tackle the problem of health inequalities. Finally the role of the nurse and the multi-disciplinary team in improving health inequalities will be considered. In order to achieve these aims it is important to fully understand what is meant by health and the term 'health inequality'.
The Biomedical model defines health as the absence of disease and focuses on the eradication of disease and illness through diagnosis and effective treatment. The state of health is determined by assessing whether or not a disease is present and is driven by the belief that cures for diseases need to be found in order for people to be considered healthy (Bury 2005). Despite often being considered to present a negative view of health it is the most prevalent model used in Western society. When people are feeling unwell it is the medical profession's opinion that is sought and the primary concern of the is the treatment of disease and prevention of illness. Symptoms of illness are considered to have an underlying pathology in this model and this pathology can, although not always successfully be treated or restored thus leading to re-instated health (Morrison and Bennet 2009). However this model fails to recognise other factors that influence health.
In contrast the social model of health defines health and illness from an individual's perspective and their functioning in society. Rather than merely considering biological or physiological changes, it regards disease as being a result of the interaction of biological, psychological and social conditions (Brannon and Feist 2007). It emphasises that changes can be made in both the individual's lifestyle and in wider society in order to improve health. In comparison with the World Health Organisation's definition, health should not be viewed merely in terms of the presence or absence of disease but consideration must be given to the overall state of a person's physical, social and mental well-being (WHO 1948). The social model of health considers other important influences that impact on the individual's health and recognises that health does not only result from biological and genetic processes but that it is a state of positive well-being influenced by the wider social and economic conditions in which we live (Farrell et al 2008).
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Consideration of other factors that influence and determine health allows for a better understanding of why some people have better health than others. It also provides a broader understanding of the determinants of health, which in turn allows for identification of the factors which influence health either in individuals or within particular groups in society and goes some way to explaining why inequalities in health persist.
Health inequality was highlighted by the publication of the Black Report in 1980, showing that there was a direct correlation between socioeconomic status and health (Bartley 2004). It refers to the unequal distribution of health between social groups that is distinguished by the unequal structures of which the group is a part (Graham 2007). Health inequalities are random, perceived to be unfair and rather than being a result of biological processes are socially produced (Whithead and Dalgren 2006), generated by the social conditions in which people live (Farrell et al 2008) and refers to the systematic differences in the health of groups that occupy unequal positions in society (Graham 2007) and refer to a particular type of difference in health whereby disadvantaged groups experience worse health and greater risks to their health than less disadvantaged groups (Braveman 2006).
Health inequalities are avoidable but are determined by the political, social and economic influences on the conditions in which people live, grow and work (CSDH 2008). They are a result of a wide range of complex influences and those people who are the most socio-economically deprived are the most likely to suffer ill health in all stages of life and premature death (Townsend & Davidson 1988). An example of this can be seen in the incidence of coronary heart disease and the contributing factors which influence this disease particularly amongst those within the population who are the most socioeconomically deprived.
Coronary heart disease (CHD) is a disease of the blood vessels supplying the heart. Coronary arteries become narrowed or blocked with deposits of fatty materials or cholesterol (atheroma), thus reducing the blood supply to the heart. This deprives the heart of oxygen, causes angina, arrhythmia and can lead to coronary thrombosis, heart failure, myocardial infarction and/or sudden death (National Assembly for Wales 2001). Despite it being a largely preventable illness and leading cause of death in the UK, it still accounts for over 6000 deaths per year in Wales (NPHS 2006). Although the incidence has been falling over the past few decades, figures show that Wales still has a higher incidence of the disease than England and that in areas of high deprivation such as the South Wales valleys the incidence of CHD is at least a third higher than in more affluent areas (Cardiac Disease NSF for Wales 2009).
Mortality rates for CHD show that Wales has a higher rate than the UK average and that areas within Wales with the highest rates are mainly in the South Wales valleys, with Blaenau Gwent and Merthyr Tydfil having rates significantly higher than the national average (NPHS 2006). Some of this may be linked to access to services, in particular angiograph and revascularisation. While the hospital admission rates for coronary heart disease is higher than the national average in areas of low socioeconomic status such as Blaenau Gwent and Merthyr Tydfil, admissions for angiography and revascularisation is lower among these areas (NPHS 2006).
There are many factors that contribute to the incidence of CHD, some of which cannot be changed such as increasing age and genetic disposition. However many social influences such as tobacco use, diet, physical activity, high cholesterol, high blood pressure, use of alcohol and drugs, and stress which contribute to the disease can be modified. Incidence of CHD can also be linked to poverty, low educational status and poor mental health (depression) (WHO 2006b). Exposure to unequal health risks begins before conception and continues through all development stages through to adulthood and leaves the individual vulnerable to a range of disease that includes CHD. (Graham 2004). Environmental conditions such as work environment, income and housing in adulthood contribute to health inequalities and have as much of an impact in determining future health and premature death childhood disadvantage (Kuh et al 2003). Increased behavioural risks in adulthood contribute to CHD and as the incidence increases in the lower socioeconomic groups so do the associated risk factors. Those living in deprived areas are far more likely to smoke, eat a poor diet and take part in less than the recommended amount of physical exercise. These behaviours also increase the risk of high blood pressure, high cholesterol and stress, which are associated with the development of CHD (NPHS 2004)
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Tobacco use is a contributory factor in the development of CHD and the prevalence of smoking among the lowest socioeconomic groups in the UK is approximately 45% of men and 33% of women in the highest social class being smokers compared to 15% and 14% respectively in the lowest social class (Richardson and Crosier). In Wales is estimated that 17% of deaths from heart disease can be attributed to smoking (Cardiac Disease NSF for Wales 2009). Whilst the prevalence of smoking continues to decrease it is still a major problem, the 2008-09 Welsh Health Survey showed that 25% of men and 23% of women were smokers. However in areas with low socio economic status and high deprivation such as Blaenau Gwent and Merthyr Tydfil the number of people who smoked was higher with the percentage of smokers being 30% and 31% respectively (Welsh Health Survey 2007-08).
Another contributory factor in the development of CHD is nutrition; diet plays an important role in the development of heart disease with the consumption of fat being linked to coronary heart disease and high salt intake being linked to high blood pressure which is a contributory factor to CHD. While eating 5 or more portions of fruit and vegetables a day can reduce the risk. Despite this intake of fats and salt is higher in Wales than is recommended (Cardiac Disease National Service Framework) and the number of people who consume the recommended amount of fruit and vegetables is only 36%. As with tobacco use these figures decreases in areas of low economic status; with 30% in Merthyr Tydfil and only 28% in Blaenau Gwent consuming the recommended daily amounts. (Welsh Health Survey 2007-08).
As well as having a high intake of fats and salt people in low socio-economic groups are also far more likely to consume a diet with poor nutritional value which can result in individuals becoming overweight or obese. The highest proportions of people who are overweight or obese are again in areas of low socioeconomic status. As with other risk factors areas such as Blaenau Gwent and Merthyr Tydfil the number of people who are overweight living in these areas is above the national average for Wales (NPHS 2006). While the national average was reported as being 54.1% in 2006 (NPHS2006), the more recent Welsh Health Survey 2007-08 shows that this figure has increased to 57%, with Blaenau Gwent and Merthyr Tydfil being above the average with it being reported that 64% and 59% respectively being overweight or obese in these areas.
Physical activity can contribute to an improvement in physical and psychological quality of life, whereas physical inactivity is a risk factor associated with coronary heart disease and high blood pressure (DoH 1993). The recommended guideline for exercise is 30 minutes of moderate intensity 5 days per week, however only 29% of the Welsh population reported that they achieved this. In areas of low socioeconomic status Blaenau Gwent and Torfaen reported lower than average figures, however Merthyr Tydfil was above the Welsh average. Physical inactivity in the female population is lower than that of males and this trend appears at an early age (NPHS 2006).
Other factors such as high blood pressure, high levels of cholesterol, use of alcohol and drugs and stress all contribute to CHD and can be a result of factors such as poor diet, smoking and reduced levels of physical activity. While some individuals may be genetically predisposed to developing CHD for others personal will have a direct bearing on their future health. Individual personality and how much control they feel they have over their own health influence the choices made. Those people who belief they control outcomes (internal locus of control) are far more likely to be able to modify their behaviour to improve future health. Whereas those who beliefs health outcomes are firmly controlled by powerful others (external locus of control) are more likely to continue risk taking behaviour (Lefcourt 1982).
Nurses can make an invaluable contribution to the reduction of health inequalities through their ability to work with the public to influence behaviour change within the scope of health promotion work. Health promotion allows the nurse opportunity to target vulnerable populations, to promote health in a positive way, to give clients the health information that allows them to make informed decisions about their health and prevention of illness, enhancing the individual's ability to play a key role in their own health (Webster and Finch 2002 in Scriven 2005).and is an area in which the nurse or healthcare professional plays a key role (WHO 1989). Health promotion work although being a key role for nurses does not lie solely within the domain of health and to achieve the ultimate aim of tackling inequalities there needs to be partnership work with a range of healthcare professionals such as health visitors and dieticians as well as other professionals working in related fields such as smoking cessation. In order for it to be completely successful a multi-disciplinary approach is advocated with the need to tackle other health determinants simultaneously being paramount (RCN 2007).
Health inequalities are often a consequence of lifestyle choices and behaviours, with development of illness and disease is the result of many factors. In order to make changes to the most socioeconomically deprived people in society, work needs to be focused on behaviour change and lifestyle choices (Welsh Assembly Government 2002). Publication of reports such as the Black Report, Health Divide and Acheson Report highlighted the severity of the problems facing the health of society and it is from here that government interventions and public health policies are produced.
Publication of the Black Report highlighted the inequalities in health that were present in UK society. The report concluded that health was directly linked to social class and the chance of living a healthy life decreased in lower social classes. It showed that while the health service could play a part in reducing health inequalities measures to reduce socioeconomic differences in income, environment, poor housing, low education standards and unemployment should have a greater importance. It contained 37 recommendations concerned with improving the life of the poorest members of society, particularly children and those with disabilities (Acheson 1998). Recommendations focused on two main areas. It proposed the government should adopt a policy aimed at reducing child poverty in the UK and more money should be spent on health education and the prevention of illness (Townsend & Davidson1988). However government at the time criticised the report, arguing that it did not explain health inequalities and that increased expenditure on the health service would not make a difference to standards of health. Despite this the report was influential in public health debates and research and influenced the decision by the WHO's European region to agree a common health strategy in 1985 (Acheson 1998).
Further reports in 1987 (The Health Divide) and 1998 (Acheson report) drew similar conclusions as the Black Report. The Health Divide argued that socio economic circumstances where a major factor in health inequalities and subsequent health and that the gap between health standards and social class had increased since the publication of the Black Report (Whitehead 1987). The 1997 new Labour government set up an inquiry into health inequalities, signalling that the alleviation of inequalities in health was of primary importance. (Marmot 2004).The result of this inquiry was the publication of the Acheson Report, which found that inequalities in health persisted and mirrored the findings of both the Black report and the Health Divide. It concluded that in order to improve health the gap between rich and poor must be reduced and that health inequalities begin before birth. It recommended that high priority should be given to policies aimed at improving health and reducing inequalities in health particularly in respect of children, women of child bearing age and expectant mothers and health policies that have a direct or indirect effect of health should be evaluated. Additionally the report made 37 further recommendations directed across all governmental departments and called for development of policies that sought to reduce inequalities in health (Acheson 1998).
In the context of Wales, the Welsh Assembly Government has publicised a number of policies and documents seeking to address the issues of health inequalities. In 1998 Better Health; Better Wales highlighted and described health inequalities which exist in Wales and in 2001 it set out its long term plan to improve the nation's health. Improving Health for Wales: a Plan for the NHS with its Partners (2001) set the scene for the NHS over a ten year period. Its main objectives were to make further improvements in health maintenance, provide a significant contribution to health improvements in the population's health and to tackle health inequalities. The Well-being in Wales consultation document in 2002 emphasised that health was the responsibility of everyone not only of the government. This idea of a shared responsibility was reinforced in the 2003 Review of Health and Social Care in Wales, which showed long-term demand for health and social care was unsustainable and there needed to be a greater emphasis on the prevention of ill health and individuals should be held responsible for their own health. This led to the development of Health Challenge Wales, which signposts members of the public to information and activities to improve their own health. In 2005 publication of Designed for Life, a 10 year commitment of creating world class health and social care in Wales built on the work which had been undertaken in 2001. One Wales (2007) upholds the Assembly Government's commitment to improving health and well-being in particular the poorest, most vulnerable members of society.
The status of the health of the population varies considerably and the correlation between socioeconomic status and health has been proven in various reports. Health problems such as CHD that are more prevalent in low socioeconomic groups are further exacerbated by associated risk factors that are more prevalent in these groups. Various reports have highlighted these inequalities and concluded that despite being avoidable, inequalities in health exist and are a result of political, social and economic influences. The Welsh Assembly Government in its strategies has recognised the unsustainability of long term health and social care and that there is a need for individuals to take responsibility for their own health. Health promotion work undertaken by nurses is a key role in promoting health and providing the public with information that allows them to make positive lifestyle choices and change behaviour to improve future health. While this is an important area, health inequalities will not be eradicated within the domain of health; it is vitally important that all government departments develop policies that aim to tackle the risk factors.