Leslie Boydell Leslie Boydell Institute of Public Health Institute of Public Health

Domains and dimensions of Domains and dimensions of health systems researchhealth systems research

3131stst August 2007 August 2007www.publichealth.iewww.publichealth.ie

Health inequalities in Ireland: Health inequalities in Ireland: implications for research and policyimplications for research and policy

Of all forms of inequalities, inequalities

in 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 Ireland• The policy context• Research into inequalities in

health in Ireland• International inequalities research• Getting research evidence into

policy• Future needs for inequalities

research in Ireland and contribution of the health system

What I will coverWhat I will cover

• Inequalities in health in Ireland

• The policy context

• Research into inequalities in health in Ireland

• International inequalities research

• Getting research evidence into policy

• Future needs for inequalities research in Ireland and contribution of the health system

What I will coverWhat I will cover

• All cause mortality rate in lowest occupational classes is 100-200% higher

For circulatory disease, it is 120% higher

• For cancers, it is 100% higher• For respiratory disease, it is

>200% higher• For injuries and poisoning, it is

>150% higher

In Ireland, north and south:In Ireland, north and south:

• Mortality rate from transport accidents is 354% higher

• Hospitalisation for mental illness among unskilled workers is 6x higher

In Ireland:In Ireland:

• 37% of women with medical cards smoke during pregnancy vs 12% of mothers without

• 27% 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:In Northern Ireland:

• Inequalities in health in Ireland• The policy context• Research into inequalities in health

in Ireland• International inequalities research• Getting research evidence into

policy• Future needs for inequalities

research in Ireland and contribution of the health system

What I will coverWhat I will cover

Policy contextPolicy context

• National Report for Ireland on Strategies for Social Protection and Social Inclusion 2006-2008

• National Action Plan for Social Inclusion 2007-2016

Policy contextPolicy context

• Inequalities in health in Ireland

• The policy context

• Research into inequalities in health in Ireland

• International inequalities research

• Getting research evidence into policy

• Future needs for inequalities research in Ireland and contribution of the health system

What I will coverWhat I will cover

• Descriptive of inequalities and the social gradient

• Health of specific groups

• Service access and utilisation

• Evaluations of interventions

• Methods of measurement

• Methods of working

• Lifecourse

Research into health inequalities in Research into health inequalities in IrelandIreland

• User perspective or research into lived experience

• Intervention research

• Analysis of mainstream data sources and surveys limited by data collected

• Methods

GapsGaps

• Inequalities in health in Ireland• The policy context• Research into inequalities in health

in Ireland• International inequalities research• Getting research evidence into

policy• Future needs for inequalities

research in Ireland and contribution of the health system

What I will coverWhat I will cover

To achieve policy change by

learning from what we know

about the social determinants

of health

www.who.int/social_determinants/resources/en

Global Commission on the Social Global Commission on the Social Determinants of HealthDeterminants of Health

Purpose:

• Mechanisms by which social determinants generate health inequalities

• Relationships between the determinants of health

• Policy entry points

Activities:Activities:

• Structural determinants of health (eg income and education)

• Intermediate determinants (eg living and working conditions, population behaviour and food availability)

DistinctionsDistinctions

“To eradicate

inequalities in health,

we need to eliminate

the social determinants

of health inequalities”

• Studies explaining what can be done to reduce health inequalities

• Systematic studies of policy effects on inequity• Difference between the determinants of health

and the determinants of health inequalities often confused

• Health of populations and the health of individuals often elided

• Links between proximal, intermediate and distal determinants of health poorly conceptualised

Limitations of evidence baseLimitations of evidence base

“Further research is

needed but enough is

presently known for

effective action”

Dahlgren and Whitehead

• Inequalities in health in Ireland• The policy context• Research into inequalities in health

in Ireland• International inequalities research• Getting research evidence into

policy• Future needs for inequalities

research in Ireland and contribution of the health system

What I will coverWhat I will cover

Evidence Experience Judgement

Resources Values

Policy-makingPolicy-making

• Rarely an event

• Timing of decisions determined by political considerations

• Decisions tend to be driven by underlying beliefs

• Social climate will determine what is popular or acceptable

• Competing interests will influence what decisions are made

Policy-makingPolicy-making

Scientific plausibility Political acceptability

What is practicallyimplementable

Policy-makingPolicy-making

• Policy entry points

• Place of evidence in policy making

• How to achieve best fit with dominant political vision and desired outcomes

• Importance of local infrastructure for implementation

• Political nature of policy making

• Prepared advocate

What we needneed to understand

• Inequalities in health in Ireland• The policy context• Research into inequalities in health

in Ireland• International inequalities research• Getting research evidence into

policy• Future needs for inequalities

research in Ireland and contribution of the health system

What I will coverWhat I will cover

• Research into what works• Strong advocacy• To maximise public involvement• Intervene with children• To tackle the social determinants

of health inequalities• Policies which have greater

beneficial effects on disadvantaged groups

So what is needed in Ireland?So 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 health

So what is needed in Ireland?So 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:As a research community we need to:

• Ensure that policy evaluations include measures of health determinants, risk factors and health status

• Ensure that evaluation of policies and interventions include effects on subgroups

As a research community we need to:As a research community we need to:

• Ensure that policy evaluations include measures of health determinants, risk factors and health status

• Ensure that evaluation of policies and interventions include effects on subgroups

As a research community we need to:As a research community we need to:

• Interdisciplinary research and a variety of methods

• Research designs and evaluation strategies that capture the effects of policies on health determinants and outcomes

• More research funding on interventions to reduce inequalities

As a research community we need to:As a research community we need to:

• Consider the relationships between the different dimensions of inequalities and how they interact

• Study differential responses to similar interventions between different groups

• Ensure an inequalities dimension included in topic based research

As a research community we need to:As a research community we need to:

• Make tackling health inequalities a priority

• Develop strategy

• Gather information

• Integrate action across all health programmes

As a research community we need to:As a research community we need to:

• Pursue community and public involvement work in partnership with other sectors

• Improve access for and differentially address the needs of disadvantaged and marginalised groups

What can the health services do?What can the health services do?

• Inequalities in health in Ireland• The policy context• Research into inequalities in health

in Ireland• International inequalities research• Getting research evidence into

policy• Future needs for inequalities

research in Ireland and contribution of the health system

What I will coverWhat I will cover