Leslie Boydell Institute of Public Health

Leslie Boydell Institute of Public Health

Domains and dimensions of health systems research

31st August 2007www.publichealth.ieHealth inequalities in Ireland: implications for research and policy

Of all forms of inequalities, inequalitiesin health are the most inhumane

Martin Luther King

Three distinguishing features, when combined, turn mere variations or difference in health into a social inequity in health. They are systematic, socially produced (and therefore modifiable) and unfair Dahlgren and Whitehead

Inequalities in health in IrelandThe policy contextResearch into inequalities in health in IrelandInternational inequalities researchGetting research evidence into policyFuture needs for inequalities research in Ireland and contribution of the health system What I will cover

All cause mortality rate in lowest occupational classes is 100-200% higher For circulatory disease, it is 120% higherFor cancers, it is 100% higherFor respiratory disease, it is >200% higherFor injuries and poisoning, it is >150% higherIn Ireland, north and south:

Mortality rate from transport accidents is 354% higher Hospitalisation for mental illness among unskilled workers is 6x higher In Ireland:

37% of women with medical cards smoke during pregnancy vs 12% of mothers without27% of babies born to unemployed mothers were breastfed vs 67% of babies born to higher professional women

Children from disadvantaged backgrounds are 2x as likely to die before their 15th birthday The average suicide rate in economically deprived areas is 2x that of non-deprived areas

In Northern Ireland:

Policy context

National Report for Ireland on Strategies for Social Protection and Social Inclusion 2006-2008 National Action Plan for Social Inclusion 2007-2016 Policy context

Descriptive of inequalities and the social gradientHealth of specific groups Service access and utilisation Evaluations of interventionsMethods of measurementMethods of workingLifecourseResearch into health inequalities in Ireland

User perspective or research into lived experienceIntervention researchAnalysis of mainstream data sources and surveys limited by data collectedMethodsGaps

To achieve policy change bylearning from what we know about the social determinants of health www.who.int/social_determinants/resources/enGlobal Commission on the Social Determinants of HealthPurpose:

Mechanisms by which social determinants generate health inequalitiesRelationships between the determinants of health Policy entry pointsActivities:

Structural determinants of health (eg income and education)Intermediate determinants (eg living and working conditions, population behaviour and food availability)Distinctions

To eradicate inequalities in health, we need to eliminate the social determinants of health inequalities

Studies explaining what can be done to reduce health inequalitiesSystematic studies of policy effects on inequityDifference between the determinants of health and the determinants of health inequalities often confusedHealth of populations and the health of individuals often elidedLinks between proximal, intermediate and distal determinants of health poorly conceptualisedLimitations of evidence base

Further research is needed but enough is presently known for effective action

Dahlgren and Whitehead

Policy-making

Rarely an eventTiming of decisions determined by political considerationsDecisions tend to be driven by underlying beliefsSocial climate will determine what is popular or acceptableCompeting interests will influence what decisions are madePolicy-making

Scientific plausibilityPolitical acceptabilityWhat is practicallyimplementablePolicy-making

Policy entry pointsPlace of evidence in policy makingHow to achieve best fit with dominant political vision and desired outcomesImportance of local infrastructure for implementationPolitical nature of policy making Prepared advocateWhat we need to understand

Research into what worksStrong advocacyTo maximise public involvementIntervene with childrenTo tackle the social determinants of health inequalitiesPolicies which have greater beneficial effects on disadvantaged groupsSo what is needed in Ireland?

To address the gradient

Work on knowledge transfer

Research into the effects of policies on the unequal distribution of the major factors which influence healthSo what is needed in Ireland?

Increase awareness across government and academic disciplines of the centrality of non-health policies and interventions for improving health and tackling health inequalities

As a research community we need to:

Ensure that policy evaluations include measures of health determinants, risk factors and health statusEnsure that evaluation of policies and interventions include effects on subgroupsAs a research community we need to:

Interdisciplinary research and a variety of methodsResearch designs and evaluation strategies that capture the effects of policies on health determinants and outcomesMore research funding on interventions to reduce inequalities

As a research community we need to:

Consider the relationships between the different dimensions of inequalities and how they interactStudy differential responses to similar interventions between different groupsEnsure an inequalities dimension included in topic based researchAs a research community we need to:

Make tackling health inequalities a priorityDevelop strategyGather informationIntegrate action across all health programmesAs a research community we need to:

Pursue community and public involvement work in partnership with other sectorsImprove access for and differentially address the needs of disadvantaged and marginalised groupsWhat can the health services do?

Documents

Leslie Boydell Institute of Public Health