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 point
Commission on Social Determinants of

                Closing the gap in a
                    Improve Daily Living
                    Tackle the Inequitable
                     Distribution of Power, Money,
                     and Resources
                    Measure and Understand the
                    Assess the Impact of Action
           Beyond social inequalities
People are differentiated in many ways that can lead to
inequalities in health
      Gender                      Education
      Age                         Ethnicity
      Occupation                  Religion
      Income                      Language
      Wealth                      Disability
      Social class                Liberty
      Rurality

       Which inequalities are we trying to reduce?
      … and these frequently
... 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

                         Male-female gap in life
                         expectancy at birth

                                       <= 15
                                       <= 12
                                       <= 10
                                       <= 8
                                       <= 6
                                       <= 4
                                       <= 2
             … 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
   > 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 role
      Unfortunately, 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
                  Black                                    White
300                                   300

250                                   250

200                                   200

150                                   150

100                                   100

 50                                       50

  0                                       0
      1999-2000     2001-2   2004-5            1999-2000     2001-2   2004-5

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


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
   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
       … 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
 Discover how they are disadvantaged

 Discover how this is impacting on
 Identify where it may be possible to
 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
 encouraging macroeconomic and cultural
                      (Dahlgren & Whitehead)
         Strengthening individuals

   Focus on big issues and help people to make
    healthy choices
       Legislation – such as ban on smoking in public
       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
   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
   Physicians
       Increased odds ratio for quitting (1.74)
       Intensive intervention marginally more
   Partner support
       No convincing evidence of effect
                          Source: various Cochrane reviews
        Individual or collective?

China                           California
     Strengthening communities

   Economic growth
   More jobs
   More pleasant
   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
                                                         (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
 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
       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,
   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
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
       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
     Launched in 1960s under LBJ
     Evidence of early benefits – numeracy and
     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
 Access involves:
     Relationships over time – not one-off
     Decisions not only made by individuals
      but also families and friends
     Proximity does not equal access
     Evidence is contextually bounded

                      (Balabanova, McKee et al, 2006)
          Increasing uptake of services
          (and better services)
   Cervical screening
       Invitation letters work, educational materials
        have limited effect
   Mass media
       … campaigns can be effective in increasing
        uptake of essential services
                                Source: various Cochrane reviews

   UK Quality and Outcomes Framework in
    general practice has reduced inequalities
                                  Source: Roland et al
                 Encouraging macroeconomic
                 and cultural change

                                                                     49%              50%
                                                                              44%            24%
           71%              72%      62%    63%      59%

Source: Fritzell & Ritakallio 2004 using Luxembourg Income Study data, CSDH Nordic Network
                                     Welfare regimes matter:
                                     Odds of poor/fair health in unemployed
                                     compared to employed by welfare regime
                               3.5        (for example, in Anglo-Saxon welfare states, unemployed
                                          almost 3 times more likely to be in poor/fair health than
                                3                                                   Male
Odds ratio poor/ fair health




                                     Scandinavian   Bismarckian   Anglo-Saxon   Southern     Eastern

                                                                                             Bambra et al., 2009
        Possible explanations
   Anglo-Saxon systems are simply mean
     Low wage replacement levels
     Means 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

   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 assessment
         Qualitative assessment of impact on health
          inequalities of EC agricultural policy –
Very little evidence of effectiveness – but equally, no evidence they are ineffective
       Labour market and working
   Universal approaches
         Strong employment protection and active labour
          market policies for chronically ill citizens –
         Occupational health services offering annual
          check-ups and preventive interventions to all
          employees – France
   Targeted approaches
         Job rotation among dustmen – Netherlands
Some evidence of effectiveness – active labour market policies may protect in
face of recession
Health-related behaviours

   Universal approaches
         Serve low-fat food products through mass
          catering in schools and workplaces –

   Targeted approaches
         Multi-method intervention to reduce
          smoking among low income women –
     Considerable evidence of effectiveness, but
     context important
       Territorial approaches

          Comprehensive health strategies
           for deprived areas
               Health 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, USA
                             BBC web site
Medicine is a social science and politics is nothing but medicine writ large ”
Rudolf Virchow
   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

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