Reducing health inequalities: What do we really know about successful strategies?

Martin McKee

London School of Hygiene and Tropical Medicine and

European Observatory on Health Systems and Policies

Our starting pointCommission on Social Determinants of Health

Closing the gap in a generation Improve Daily Living

Conditions Tackle the Inequitable

Distribution of Power, Money, and Resources

Measure and Understand the Problem

Assess the Impact of Action

Beyond social inequalities

People are differentiated in many ways that can lead to inequalities in health

Gender Age Occupation Income Wealth Social class Rurality

Education Ethnicity Religion Language Disability Liberty

Which inequalities are we trying to reduce?

… and these frequently coincide

... damp housing leading to increased amounts of respiratory infection; household overcrowding facilitating the spread of infection; inadequate diet associated with low incomes ... failure to perceive the seriousness of childhood illnesses by poorly educated and informed parents; stresses leading to child abuse; a generally poor environment increasing the risks of child accidents; together with the everyday strain of coping with a demanding young family in inadequate circumstances in areas suffering from multiple deprivation.

(Robinson & Pinch, 1987)

What might work will depend on what the problem is

Source: Dahlgren & Whitehead

Men die before women, but the gap is wider in some places than in others

<= 15<= 12<= 10<= 8<= 6<= 4<= 2

-

Male-female gap in life expectancy at birth

… yet this is not inevitable

No gender gap found in survival beyond age 40 in (non-smoking, non-drinking) Polish Seventh Day Adventists (Jedrychowski, Scand J Soc Med 1985)

> 50% of gender gap in life expectancy at age 15 in Finland attributable to smoking and alcohol (Martelin et al, Eur J Publ Health, 2004)

For this inequality, lifestyle related factors play a major roleUnfortunately, women are closing the gap, by behaving more like men

White Americans live longer than African Americans

Life expectancy at birth

Deaths avoidable by timely and effective care in the United States

Nolte & McKee, unpublished

For this inequality, access to health care matters

The obvious solution?Universal health care (if we poor

Europeans can do it, why not the world’s remaining superpower?)

If that is too difficult….Interpreter services, outreach workers,

culturally sensitive policies, recruitment and retention of minority health workers etc.

(Comonwealth Fund, AHRQ. AAACP and many others)

Although for some inequalities, we still don’t know (or can’t agree) what the problem is

Health outcomes are considerably better among Swedish than Finnish speakers living in Finland

“Swedish-speakers possess more structural and cognitive social capital compared to Finnish-speakers. Social capital explains to some extent health differences between the language groups.” Nyqvist et al., 2008

“Finnish-speaking men and women reported more frequent drunkenness, suffered more frequent hangovers, and had alcohol-induced pass-outs significantly more often than men and women in the Swedish-speaking population. “It seems unlikely that the effect of social capital on the health differences between the two populations would be mediated through drinking patterns.” Paljärvi et al., 2009

Switzerland Deaths from circulatory disease were more common in German Switzerland,

while causes related to alcohol consumption were more prevalent in French Switzerland. Faeh et al., 2009

Making a difference

Public health researchers have been remarkably good at measuring and understanding inequalities in health

We have been much less successful in discovering what to do about them

“the philosophers have only interpreted the world, the point is to change it” Karl Marx

… yet we all do know what is the right thing to do(and we don’t need research)

Give very poor people money/ food/ clean water/ shelter/ protection from violence

Give everyone adequately remunerated, satisfying and rewarding jobs

Build them safe, healthy environments Stop other people (warlords, tobacco and

alcohol company executives) from killing them

… and vote!Gini coefficient (income after housing costs) in UK

labour

conservative

The end

.... Or is it

Maybe the question is how to improve the health of the most disadvantaged?

Some good news

The emphasis of research is gradually shifting from identification, to diagnosis, to prescription

Different ‘entry points’ for intervention and policy are being identified

Growing experience in developing, implementing and evaluating interventions and policies

The bad news

Pathways from disadvantage to ill-health often highly complex

Confounders lurk everywhere Variable time lags everywhere Interventions difficult to implement and beset

with unintended consequences Reluctance by policy makers to subject their

beliefs to evaluation Yet “natural” experiments can be very

misleading

… all else being equal … except that it rarely is

…and context is all

The Netherlands England

Czech Republic

First steps

Decide who are the disadvantaged groups

Discover how they are disadvantaged Discover how this is impacting on

health Identify where it may be possible to

intervene Find the evidence

Who are the disadvantaged?the invisible people

Where is the evidence?

A useful framework?

strengthening individuals strengthening communities improving access to essential facilities and

services encouraging macroeconomic and cultural

change

(Dahlgren & Whitehead)

Strengthening individuals

Focus on big issues and help people to make healthy choices Legislation – such as ban on smoking in public

places Fiscal – such as taxation on unhealthy products Empowerment

Smoking is a good place to start as studies consistently show it explains a substantial proportion of socio-economic inequalities (although there is the secondary question of why poor people smoke)

Smoking: evidence on where

Workplace Individually targeted interventions (physician

advice, counselling, NRT) work, self-help doesn’t School

No convincing evidence of effectiveness of social influences and social competence interventions

Pregnancy Smoking cessation programmes work (6 fewer

women per 100 smoke) Patients in hospital

Intensive interventions over > 1 month work

Source: various Cochrane reviews

Smoking advice: Evidence on who does it?

Nurses Increased odds ratio for quitting (1.47) Less effective when in context of screening

intervention Physicians

Increased odds ratio for quitting (1.74) Intensive intervention marginally more

effective Partner support

No convincing evidence of effect

Source: various Cochrane reviews

Individual or collective?

China California

Strengthening communities

Economic growth More jobs More pleasant

environment Reduced crime Better education

More jobs

Welfare to work programmes widely used in US but gradually spreading to Europe

All (46) RCTs so far from USA Small but consistent effect on earnings

($11,021 vs $8,843) For every 33 participants, an extra one

(compared with controls) will be in long term employment)

(Smedslund et al, 2006)

In all countries studied so far, those in employment are in better health than those who are not, even when the unemployed get 100% salary replacement

Health and the environment

Health and the environment

Perceived safety and attractiveness of environment associated with physical activity

Objective measures of walkability associated with physical activity

Density of fast food outlets associated with obesity

Changing your environment:

The Moving to Opportunity project Between 1994-97, 4248 families in Baltimore,

Boston, Chicago, Los Angeles and New York were randomly assigned to: Housing voucher that could be used to move to a low

poverty (<10%) neighborhood along with mobility counseling;

Housing voucher with no geographic restrictions;

Control group (no new assistance, but continued to be eligible for public housing).

Kling et al, various dates

Moving to Opportunity: results in 2002

Girls moving to low poverty area: improved educational attainment 83 v 77% graduated or still

in school) Better mental health (Odds of generalized anxiety disorder

70% less) Less crime (33% lower lifetime arrests)

Boys moving to low poverty area: 13% more likely to have been arrested Tripling of alcohol use, with larger increases in smoking and

marijuana use Significant increase in non-sports injuries

Reducing crime Vast majority of published studies show non-custodial sentences

reduce reoffending, but meta-analysis of 4 RCTs and 1 natural experiment show no difference (Killias et al., 2006)

Close circuit TV cameras are effective, but mainly against vehicle crime when in car parks

Improved street lighting is very effective (Farringdon & Welsh, 2008)

Enhanced policing of crime hot-spots is effective (Braga, 2007) Mentoring of juvenile offenders is moderately effective – more so

for dealing with delinquency and aggression but less so in tackling drug use and low achievement. Better where emotional support central.

Swedish people aged 35-64 living in violent neighbourhoods had higher incidence of coronary heart disease, after adjusting for other factors (Odds ratios: Female 1.75 (CI 1.37–2.22) / Male 1.39 (CI 1.19–1.63).

Sundquist et al, 2006

Better education

Improving education

After school programmes show no demonstrable impact on children’s educational attainment (Zeif et al., 2006)

Parental involvement interventions achieve significant improvements in reading and maths Education and Training (for parents) Rewards and Incentives (for children based

on in-school performance) (Nye et al, 2006)

Head Start

Pre-school programme for children from poor familiesLaunched in 1960s under LBJEvidence of early benefits – numeracy and

literacy But also evidence of Head Start Fadeout

In the long term….

Whites Participation associated with a significantly increased probability

of completing high school, attending college, elevated earnings in early twenties.

African Americans Participation associated with significant reduction in being

charged or convicted of a crime Greater probability than siblings to complete high school.

Some evidence of positive spillovers from older children who participate to their younger siblings, particularly with regard to criminal behaviour.

Improving access to essential services

More difficult to study than you might think Access involves:

Relationships over time – not one-offDecisions not only made by individuals

but also families and friendsProximity does not equal accessEvidence is contextually bounded

(Balabanova, McKee et al, 2006)

Increasing uptake of services (and better services)

Cervical screeningInvitation letters work, educational materials have limited effect

Mass media… campaigns can be effective in increasing uptake of essential

services

UK Quality and Outcomes Framework in general practice has reduced inequalities

Source: various Cochrane reviews

Source: Roland et al

Encouraging macroeconomic and cultural change

71%

71%

72%

Source: Fritzell & Ritakallio 2004 using Luxembourg Income Study data, CSDH Nordic Network

62% 63% 59%

54%49%

44%50%

24%

Welfare regimes matter:Odds of poor/fair health in unemployed compared to employed by welfare regime

Bambra et al., 2009

(for example, in Anglo-Saxon welfare states, unemployed almost 3 times more likely to be in poor/fair health than employed)

Possible explanations

Anglo-Saxon systems are simply meanLow wage replacement levelsMeans testing

Bismarckian systems emphasise role of male breadwinner

Scandinavian systems provide lower benefits for females who accumulated fewer entitlements through part-time working

Eastern systems have more informal support systems

Bambra et al., 2009

Some policy innovations

Policy steering mechanisms

Labour market and working conditions

Health-related behaviour change

Territorial approaches.

(Source: Mackenbach & Bakker)

Policy steering mechanisms

Quantitative targets Reduction of inequalities in 11

intermediate outcomes (poverty, smoking, working conditions, ….) – Netherlands

Health inequalities impact assessmentQualitative assessment of impact on health

inequalities of EC agricultural policy – Sweden

Very little evidence of effectiveness – but equally, no evidence they are ineffective

Labour market and working conditions

Universal approachesStrong employment protection and active labour

market policies for chronically ill citizens – Sweden

Occupational health services offering annual check-ups and preventive interventions to all employees – France

Targeted approachesJob rotation among dustmen – Netherlands

Some evidence of effectiveness – active labour market policies may protect in face of recession

Health-related behaviours

Universal approachesServe low-fat food products through mass

catering in schools and workplaces – Finland

Targeted approachesMulti-method intervention to reduce

smoking among low income women – Britain

Considerable evidence of effectiveness, but context important

Territorial approaches

Comprehensive health strategies for deprived areasHealth Action Zones – England

Community regeneration

Systematic review of 19 studies

“There is little evidence of the impact of national urban regeneration investment on socioeconomic or health outcomes. Where impacts have been assessed, these are often small and positive but adverse impacts have also occurred.”

Thompson et al, 2006

Tough on ill health, tough on the causes of ill health…

Are we willing to tackle the immediate causes of ill-health (tobacco, alcohol, poor nutrition)?

…or do we think this is just a sticking plaster ….

Or instead do we want to change society fundamentally?

… and don’t assume we are all agreed

… on Hurricane Katrina“Shame on anyone that makes this tragedy political, socio-economic or racial. … in the land of opportunity and personal responsibility the individual is ultimately accountable.”

Robert Buckley, Decatur, USABBC web site

Medicine is a social science and politics is nothing but medicine writ large ”Rudolf Virchow

Summary

There are many inequalities in health, on many dimensions, and taking many forms

What you do depends on who you are trying to help, what the problem is, and where you can intervene

Then you can ask what works … and when you do something, please

evaluate it and tell the world whether it really did work…

… so that we can learn from your experience!