poverty & people with intellectual disabilities eric emerson institute for health research...
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Poverty & People with Intellectual Disabilities
Eric Emerson Institute for Health Research
Lancaster University
The Plan
What is poverty? Why should we be concerned about poverty
and people with intellectual disabilities? What are the implications for research, policy
& practice?
The Plan
What is poverty? Why should we be concerned about poverty
and people with intellectual disabilities? What are the implications for research, policy
& practice?
Absolute Poverty
‘A condition characterised by severe deprivation of basic human needs, including food, safe drinking water, sanitation facilities, health, shelter, education and information’
UN World Summit for Social Development, Copenhagen 1995
Moderate & Severe Stunting(Under 5s)
0% 10% 20% 30% 40% 50% 60%
AfghanistanYemen
EthiopiaNepal
MadagascarIndia
AngolaCambodia
BangladeshNiger
MaliPakistan
Relative Poverty
‘The inability, due to lack of resources, to participate in society and to enjoy a standard of living consistent with human dignity and social decency’
Child Poverty & Per Capita Gross National Income in Rich Countries
0%
5%
10%
15%
20%
25%
US
A
Ita
ly
Ire
lan
d
UK
Ca
na
da
Au
stra
lia
Jap
an
Sp
ain
Ge
rma
ny
Ne
the
rla
nd
s
Fra
nce
Sw
ed
en
No
rwa
y
Fin
lan
d
De
nm
ark
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000Child Poverty
GNI (PC)
Rise & Fall in Child Poverty: UK 1978-2005
0
5
10
15
20
25
30
35
40
78 80 82 84 86 88 90 92 94 96 98 00 02 04
% c
hild
ren
Poverty Defined: Living in household with less than 60% national median household income (after housing costs)
Poverty …
‘Fundamentally, poverty is a denial of choices and opportunities, a violation of human dignity. It means lack of basic capacity to participate effectively in society.’
- UN Economic & Social Council (1998)
The Plan
What is poverty? Why should we be concerned about poverty
and people with intellectual disabilities? What are the implications for research, policy
& practice?
In General …
Poverty is related to Mortality General health Mental health Educational attainment Life experiences and
opportunities
http://www.who.int/social_determinants/en/
150 Years Ago …..
0
10
20
30
40
50
Liverpool Manchester Leedsaver
age
age
at d
eath
183
8-18
41
LabourersFarmers & TradesmenGentry & Professionals
And Now …….Male Life Expectancy by Occupational Status
55
60
65
70
75
80
85
1972-76 1997-01
V
IV
IIIm
IIInm
II
I
England & Wales 1972-876 & 1997-2001
Social Class
Equivalised Household Income & Child Mental Health in Britain 1999 & 2004
1
2
3
4
5
6
1 2 3 4 5
Equivalised Income Quintile
OR
Conduct DisorderEmotional DisorderAnxiety DisorderDepressionSpecific PhobiaOCDADHDPTSD
What Processes Mediate & Moderate the Link Between SEP and Health?
Health StatusSEP
Accumulated Risk of Exposure
Across the Lifecourse
Physical Hazards(cold/damp housing,
pollution, toxins, poor nutrition)
Psychosocial Hazards
(low status & control, uncertainty,‘life events’)
Poverty and Risk of Exposure to Housing Hazards
1 2 3 4
overcrowding
cold
rising damp
mice/rats
condensation
water getting in
mould
Odds ratios >
Poverty and Risk of Exposure to Potentially Adverse Life Events
1 2 3 4
Parental separation
Parental trouble with police
Bad fire
Saw severe domestic violence
Sexual abuse
Saw relative assaulted
Parent or sibling died
Serious assault
Child’s close friend died
Witnessed sudden death
Serious accident
Odds ratios >
What Processes Mediate & Moderate the Link Between SEP and Health?
Health StatusSEP
Accumulated Risk of Exposure
Across the Lifecourse
Physical Hazards(cold/damp housing,air pollution, toxins, accidents, nutrition
arduous work)
Psychosocial Hazards
(low status & control, uncertainty,‘life events’)
Vulnerability &Resilience
Biological(embedded organ or
systemweaknesses)
Psychosocial (human capital,social affiliations& social capital)
Health Care(including prevention)
The Plan
What is poverty? Why should we be concerned about poverty
and people with intellectual disabilities? What are the implications for research, policy
& practice?
Poverty and Intellectual Disability
In high income economies there is a clear association between poverty and the incidence and prevalence of mild/moderate (but not severe) intellectual disability
Leonard, H., & Wen, X. (2002). The epidemiology of mental retardation: challenges and opportunities in the new millennium. Mental Retardation and Developmental Disabilities Research Reviews, 8, 117-134.
Leonard, H. et al., (2005). Association of sociodemographic characteristics of children with intellectual disability in Western Australia. Social Science & Medicine, 60, 1499-1513.
Area Deprivation & Identification of Developmental Disability
0%
2%
4%
6%
8%
10%
12%
1 2 3 4 5 6+
English Index of Depivation 2004 National Deciles
Pre
vale
nce MID
SID
PMID
ASD
In General …
Poverty is related to Mortality General health Mental health Educational attainment Life experiences and
opportunities
http://www.who.int/social_determinants/en/
Intellectual disability
Equivalised Household Income & Conduct Disorder Among British Children with Intellectual Disabilities 1999 & 2004
10%
20%
30%
40%
1 2 3 4 5
Equivalised Income Quintile
Life Events & Emotional Disorder
0%
5%
10%
15%
20%
25%
30%
ID+ASD ID noASD no ID
No Life Event
1 Type of Life Event
2+ Types of Life Event
Poverty & Neighbourhood Deprivation
Living in unsuitable accommodation
Having less privacy at home Unemployment Not having a voluntary job Not having enjoyed school Being bullied at school Not taking a course Not attending a day centre Not having control over money Less likely to see members of
their family Being an unpaid carer Seeing friends less often Doing a smaller range of
community activities Not having voted
Not knowing about local advocacy groups
Feeling unsafe Being bullied Being a victim of crime Having poor health Having a long-standing illness
or disability Smoking Not being happy Being sad or worried Feeling left out Feeling helpless Not feeling confident Having unmet needs Having wanted to complain
about the support they receive
Area Deprivation & Self-Rated HealthAdults with Intellectual Disability, England 2003/4
0%
5%
10%
15%
20%
25%
1 2 3 4 5
Area Deprivation Quintile
Hea
lth
'No
t G
oo
d'
Attributable Risk
Controlling for increased risks of exposure to potential hazards accounts for 20-35% of the increased risk of
poor child health and mental health
100% of the increased risk of maternal unhappiness
50%+ of the increased risk of maternal low self-esteem and self-efficacy
Emerson, E., & Hatton, C. (in press). American Journal on Mental Retardation. Emerson, E., & Hatton, C. (in press). Journal of Intellectual Disability Research
Emerson, E., Hatton, C., Blacher, J., Llewellyn, G. & Graham, H. (2006). Socio-economic position, household composition, health status and indicators of the well-being of mothers of children with and without intellectual disability. Journal of Intellectual Disability Research 50, 862-873.
Obesity Among Women
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
16-24 25-34 35-44 45-54 55-64 65-74 75+
Women with ID
Women
Poorest 20% of Women
Obesity Among Women (in poverty)
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
16-24 25-34 35-44 45-54 55-64 65-74 75+
Women with ID
Women
Poorest 20% of Women
The Plan
What is poverty? Why should we be concerned about poverty
and people with intellectual disabilities? What are the implications for research, policy
& practice? Delivery Conceptualisation & design of ‘interventions’
Inequity of ‘Need’% of British Children with Intellectual Disabilities & Mental Health Problems by Family Circumstances
0%
25%
50%
75%
100%
British Families British Familes withChild with ID +
Conduct Disorder
Couple, not in poverty
Lone parent, not inpoverty
Couple living in poverty
Lone parent living inpoverty
Delivery Implications
Resource allocation ‘Goodness of fit’ Differential efficacy, effectiveness and
efficiency of interventions Does this intervention reduce (or exacerbate)
inequalities?
‘financial disadvantage was the most salient moderator of outcomes’ of group-based behavioural parent training
Lundahl, B, Risser, H J, Lovejoy, M C (2006). A meta-analysis of parent training: Moderators and follow-up effects. Clinical Psychology Review 26 (2006) 86– 104
Conceptualisation & Design
Health StatusSEP
Accumulated Risk of Exposure
Across the Lifecourse
Physical Hazards(cold/damp housing,air pollution, toxins, accidents, nutrition)
Psychosocial Hazards
(low status & control, uncertainty,‘life events’)
Vulnerability &Resilience
Biological(embedded organ
weaknesses, fitness)
Psychosocial (human capital,social affiliations& social capital)
Health Care(including prevention)
Interventions
Generic risk reduction Poverty reduction
Specific risk reduction (mediating variables) Housing quality Parenting practices Child protection
‘The reforms outlined in the Child Poverty Review must be implemented to end child deprivation and therefore reduce risk factors for mental health problems.’
Conceptualisation & Design
Health StatusSEP
Accumulated Risk of Exposure
Across the Lifecourse
Physical Hazards(cold/damp housing,air pollution, toxins, accidents, nutrition)
Psychosocial Hazards
(low status & control, uncertainty,‘life events’)
Vulnerability &Resilience
Biological(embedded organ
weaknesses, fitness)
Psychosocial (human capital,social affiliations& social capital)
Health Care(including prevention)
Interventions: Building Resilience Individual Family Community
Nurturing, affectionate and secure relationships with parent
Supportive relationship with other adult
Positive, rewarding school environments
Sense of ‘connectedness’ to the school and/or local community
Positive personal achievements Involvement in pro-social peer
groups Positive ‘temperament’ Problem solving Sense of meaning
In Conclusion ….
The health & social inequalities faced by people with intellectual disabilities are, in part, the result of poverty (rather than intellectual disability)
To address these inequalities we need to think beyond social & clinical interventions and directly address the social factors that generate inequality