What works in reducing health What works in reducing health inequalitiesinequalities

Sally Macintyresally@sphsu.mrc.ac.uk

What works?

It is important to note a distinction between two questions:

– does it work to improve health?

– does it work to reduce health inequalities?

Because

• no effect on health inequalities if all SES groups benefit equally

• increase health inequalities if the rich benefit more • reduce health inequalities if the poor benefit more

An intervention which, in general, works (e.g. dental health education) might have

More advantaged groups

More advantaged groups find it easier, because of betteraccess to resources :

• time • finance • coping skills• literacy• health

to take up health promotion advice and preventiveservices, and to benefit from these

Disadvantaged groups

Less advantaged groups tend :

• to be harder to reach• find it harder to change behaviour• to receive less benefit from lifestyle change or access to

services

More likely to reduce inequalities

• Structural changes in the environment• Legislative and regulatory controls • Fiscal policies• Income support• Reducing price barriers • Improving accessibility of services • Prioritising disadvantaged groups • Offering intensive support • Starting young

Less likely to reduce inequalities

• Written materials• Campaigns reliant on people taking the initiative to opt in• Campaigns/messages designed for the whole population• Whole school health education approaches • Approaches which involve significant price or other barriers• Housing or regeneration programmes that raise housing

costs • Information based campaigns

The 'toblerone' society

                                                                                                                                                                                                                                 

Inequalities in life chances are increasing

The toblerone society (up to 1980s)

Increasing inequalities in life chances;

The toblerone society 2021

Possibly competing goals

Because the better off tend to gain more from social and public health policies, two public health goals:

– improving population health – reducing health inequalities

may sometimes conflict.

Possibly competing goals

• Targeting the already advantaged may produce more aggregate health gain at relatively less cost.

• Targeting the disadvantaged may produce less aggregate health gain and at greater cost.

Value judgments will have to be made about the relative priority to be given to aggregate health gain or reducing inequalities.

Upstream/downstream: reducing inequalities in health may depend on reducing inequalities in life chances and life circumstances

Intervention ladder

To achieve equality of outcomes:

• Eliminate choice.

• Restrict choice.

• Guide choice through disincentives.

• Guide choices through incentives.

• Guide choices through changing the default policy.

• Enable choice.

• Provide information.

• Do nothing or simply monitor the current situation.

Policy approaches: Universalism v Selectivity

Universal (everyone gets the same)

Selective/targeted/means tested (only the poorest receive the resources)

Progressive Universal Policies

Universalism: all areas, families, individuals eligible for and provided with health promoting resources and opportunities (and protected from health damaging exposures)

tempered by:

Prioritisation: direct more resources to deprived or vulnerable areas, families, or individuals to compensate for greater needs and reverse inverse care/provision law and increase quality.

Key questions

What priority should we give to:

• Different age groups (e.g. early years, teenage transition, elderly etc

• Different sectors (e.g. education, NHS, housing, employment etc)

• Area based v individual/family based• Long term/short term outcomes• Different risk factors (e.g. smoking, alcohol, obesity, drugs

etc.)• Different health burdens (e.g. CHD, cancers, mental health

etc.)