Social Inequalities in Health

Social Inequalities in Health
Dr. Ujwal Gautam
Junior Resident
Department of Public Health Dentistry

CONTENT
1. Health Inequality & Health
Inequity
2. Evidences
3. Key issues
4. Measuring Health Inequities
5. Theoretical Explanations for
Health Inequity
6. Principles of Policy action to
ensure Health Equity

Social inequities in health are systematic
differences in health status between different
socioeconomic groups.
These inequities are socially produced (and
therefore modifiable) and unfair.
3

Health Inequality
• Health inequality is the generic term used to designate differences,
variations, and disparities in the health achievements of individuals
and groups.
• Concepts, simply referring to measurable quantities
4

Health Inequity
• Health inequity refers to those inequalities in health that are deemed to
be unfair or stemming from some form of injustice
• “….. the absence of disparities in health (and in its key social
determinants) that are systematically associated with social
advantage/disadvantage.”
5

• Concept of equity is inherently NORMATIVE (that is, value based; while
equality is not necessarily so)
• Can have an accusatory, judgmental, or morally charged tone; has a has a
moral and ethical dimension
• Refers to differences which are unnecessary and avoidable but, in
addition, are also considered unfair and unjust
Health Inequity
6

HEALTH INEQUITY:
Health inequality that is unjust or unfair
Normative judgment is premised upon
(a) one’s theories of justice;
(b) one’s theories of society; and
(c) one’s reasoning underlying the genesis of health inequalities.
7

1. Natural, biological variation.
2. Health-damaging behavior if freely chosen, such as participation in certain sports and
pastimes.
3. The transient health advantage of one group over another when that group is first to adopt a
health-promoting behavior (as long as other groups have the means to catch up fairly soon).
4. Health-damaging behavior where the degree of choice of lifestyles is severely restricted.
5. Exposure to unhealthy, stressful living and working conditions.
6. Inadequate access to essential health and other public services.
7. Natural selection or health-related social mobility involving the tendency for sick people to
move down the social scale.
7 main determinants of health differentials
8

EQUITY: Working Definition
“Equity in health implies that ideally everyone should
have a fair opportunity to attain their full health
potential and, more pragmatically, that no one
should be disadvantaged from achieving this
potential, if it can be avoided.”
9

Equity in Health
The ultimate goal of equity in health
would be the elimination of all
systematic differences in health
status between socioeconomic
groups.
Equity in Healthcare
The ultimate goal would be to
closely match services to the level
of need, which may very well result
in large differences in access and
use of services between different
socioeconomic groups, favoring the
more disadvantaged groups in
greatest need.
10

Life expectancy trends in Sweden 2000−2010 by
education level, men and women
Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P. WHO European review of social determinants of health and the health divide. The
lancet. 2012 Sep 15;380(9846):1011-29. 12

Life expectancy trends in Sweden 2000−2010 by
education level, men and women
lancet. 2012 Sep 15;380(9846):1011-29. 13

Mortality among under-fives and percentage of deprived households
(lacking three or more essential items) in selected European Region
countries
lancet. 2012 Sep 15;380(9846):1011-29.
14

Under five mortality rates per 1,000 live births across wealth quintiles in
South-East Asian countries
Dhillon, P.K., Jeemon, P., Arora, N.K., Mathur, P., Maskey, M., Sukirna, R.D. and Prabhakaran, D., 2012. Status of epidemiology in theWHO South-
East Asia region: burden of disease, determinants of health and epidemiological research, workforce and training capacity. International journal
15

World Health Organization. Health inequities in the South-EastAsia Region: selected
country case studies.
16

Key issues in
understanding and
promoting
health equity
• Address social determinants of
health
• Life-course approach to health
equity
• Acting across social gradient in
health
• Address the processes of
exclusion rather than the groups
• Build on resilience, capabilities
and strength of individuals and
communities
• Ensure gender equity
• Focus on equity within
generationsMarmot M, Allen J, Bell R, Bloomer E, Goldblatt P. WHO
European review of social determinants of health and the health
divide. The lancet. 2012 Sep 15;380(9846):1011-29.
17

Measuring Health Inequities
World Health Organization. Health inequities in the South-East
Asia Region: selected country case studies.
18

MEASURING HEALTH INEQUITIES
Two distinct approaches have been described for evaluating health
inequities;
1. Measure of health
2. Measure of social position or advantage (an “equity stratifier”)
19

MEASURING HEALTH INEQUALITIES
1. Measure of Health
• Health care indicators include access to and utilization of public health
care facilities and preventive and curative services, as well as quality of
services, allocation of financial and human resources, and household
financing and insurance.
• Include mortality, morbidity, nutritional status, functional
status/disability, and suffering/quality of life. 20

MEASURING HEALTH INEQUALITIES
2. Measure of social position or advantage (an “equity
stratifier”)
• Social advantage, mostly, varies by four general equity stratifiers —
socioeconomic status, gender, ethnicity and geographical area.
• Defines strata in a social hierarchy
21

Measures of Inequality
• The range
• Gini coefficient (and associated
Lorenz curve)
• Index of dissimilarity
• Population attributable risk
• Slope and relative index of
inequality
• Concentration index
22

The Range
• Range measures including rate ratios (RR) and rate
differences (RD) and are the most frequently used in the
literature of health inequality.
• These measures compare the range in rates of
illness/mortality between the least healthy and the
healthiest groups or between the lowest and the highest
socioeconomic groups. 23

Gini coefficient (and associated Lorenz
curve)
• Lorenz curve plots the cumulative percentage of a health
variable against the cumulative percentage of the sample,
ranked by their health, starting with the sickest person and
ending with the healthiest.
• If health is equally distributed, the Lorenz curve coincides
with the diagonal. The further the curve is from the
diagonal, the greater the degree of inequality. 24

Gini coefficient (and associated Lorenz
curve)
• Gini coefficient, denoted by G, is defined as twice the area
between the Lorenz curve and the diagonal.
• It ranges from 0 (when there is no inequality) to 1 (when
all the population’s health is concentrated in the hands of
one person)
25

Index of dissimilarity
• It can be interpreted as the percentage of all cases (e.g. ill
individuals or deaths) that has to be redistributed to obtain
the morbidity or mortality rate for all socioeconomic
groups.
• The ID is larger if the groups with the highest and the
lowest rates are larger.
26

Population attributable risk
• Measure can be interpreted as the proportional reduction
in overall morbidity or mortality rates that would occur in
the hypothetical case that everyone experiences the rates
of the highest socioeconomic group, expressed as the
percentage of the overall rate.
• Reflects inequalities across different population sizes.
27

Slope and relative index of inequality
• Reflect the socioeconomic dimension to health
inequalities; approach involves calculating the mean health
status of each socioeconomic group and then ranking
groups by their socioeconomic status (not by their health).
• It can be interpreted as the absolute effect on health of
moving from the lowest socioeconomic group through to
the highest. 28

Concentration index & Concentration
curve
• Concentration curve plots the cumulative percentage of
the health variable against the cumulative percentage of
the sample, ranked by their socioeconomic status,
beginning with the most disadvantaged, and ending with
the least disadvantaged.
• Health concentration index, denoted by C, is defined as
twice the area between the concentration curve and the
line of equality.
29

Theoretical explanations of social
inequality in oral health
Macintyre S.The black report and beyond what are the issues?. Social science
& medicine. 1997 Mar 1;44(6):723-45.
30

THE BLACK REPORT
• Artefact explanation
• Theories of natural or Social Selection
• Materialistic or structuralist explanation
• Cultural/behavioural explanation
31

The Black Report
• Report (1980) by the working group on Health Inequalities
set up in 1977 by the Secretary of State for Health in the
Labour Government.
• Remit was to review information about differences in
health status between the different classes, to consider
possible causes and their implications for policy, and to
suggest further research
32

The Black Report
Working group had four members, two medical doctors and
two social scientists:
1. The Chairman, Sir Douglas Black, then the Chief Scientist at
the Department of Health and Social Security;
2. Professor Jerry Morris, Professor of Community Health;
3. Dr Cyril Smith, Secretary of the Social Science Research
Council; and
4. Professor Peter Townsend, Professor of Sociology
33

The Black Report
Components:
I. Description of differences between occupational classes in
mortality, morbidity and use of health services, trends in these
over time, and comparisons with other industrial countries;
II. Analysis of likely explanations for these inequalities; and
III. Recommendations for further research and for a broadly
based strategy to reduce health inequalities or to reduce their
consequences. 34

Artefact Explanation
“suggests that both health and class are artificial variables
thrown up by attempts to measure social phenomena and
that the relationship between them may itself be an
artefact of little causal significance.”
The Black Report 35

• Argues that inequalities in health are NOT REAL but
artifact.
• Effect is produced in the attempt to measure something
(health, social class) which is more complicated than the
tools of measurement can appreciate.
36

• Artifactual mechanisms include errors of measurement,
such as undercounts in the census, numerator–
denominator problems, such as inconsistencies in reports
between registration and census data, or inappropriate
measures of mortality or SES
38

“HARD” VERSION
No relation between class and
mortality; purely an artefact of
measurement
Magnitude of observed class
gradients will depend on the
measurement of both class and
health
“SOFT” VERSION
39

• It should be stressed that, compared with general
epidemiology, valid measures of the dental diseases may
be obtained, i.e. number of teeth affected by dental decay
or number of edentulous persons.
EVIDENCE
40

Natural & Social Selection
“Occupational class is here relegated to the status of a
dependent variable and health acquires the greater degree
of causal significance. The occupational class structure is
seen as a filter or sorter of human beings and one of the
major bases of selection is health, that is, physical strength,
vigour or ability”
The Black Report 41

• Social inequalities are caused by a health selection
process
• People in poor health would tend to move down the
occupational scale and concentrate in the lower social
classes, while people in good health would tend to move
up into higher classes.
42

• Observed differences in health reflect a process of social
mobility.
• Class structure is seen as a filter or sorter of human
beings, and one of the major bases of selection is health,
i.e. physical and mental strength.
43

• Gap between the health of higher and lower social classes
would therefore be kept open indefinitely and would be
inevitable whatever improvements in health occur over
the entire population.
44

“HARD” VERSION
Health determines class
position, therefore class
gradients are morally neutral
and explained "away“.
Health can contribute to
achieved class position and help
to explain observed gradients.
“SOFT” VERSION
45

• It seems rather unlikely that dental health, even in terms
of dental appearance, can determine subsequent social
position and thereby be of relevance to social mobility
EVIDENCE
46

Materialist or Structuralist Explanation
“Occupational class is multifaceted... . …socio-economic
position--income, savings, property and housing--there are
many other dimensions which can be expected to exert an
active causal influence on health…. These other dimensions
of material inequality are also closely associated with
another determinant of health-education”
The Black Report 47

• Emphasizes the role of external environment; the
conditions under which people live and work and the
pressures on them to consume unhealthy products.
• Health inequality occurs as a result of material
deprivation, i.e. a shortage of the material resources on
which healthy human existence depends
48

• Emphasize factors which are linked to an individual’s
position in the social structure, arguing that factors such as
income and education are not directly responsible for
inequalities in health
49

“HARD” VERSION
Material, physical conditions of
life associated with the class
structure are the complete
explanation for class gradients in
health
Physical and psychosocial
features associated with the
class structure influence health
and contribute to observed
gradients
“SOFT” VERSION
50

• Access to dental services can be limited by materialist
factors in two ways:
i. Cost of treatment,
ii. Costs incurred in accessing treatment
EVIDENCE
51

• In many non-industrialized countries there is an acute
shortage of trained dental personnel, and the small
number of dental services tend to be concentrated in
hospitals in urban centres.
• Access for poor families who live in rural areas is restricted
by the cost of transport to and from hospital and means
that even the most basic care cannot be received
EVIDENCE
52

• In many industrialized countries access to dental services is
limited by the high costs of treatment. More people are
being forced to attend private practices to receive dental
care. In areas where the availability of dental practitioners
is low, access for poor families is prevented by the high
costs of treatment. Regular attendance at the dentist is
therefore associated with individuals of higher SES.
EVIDENCE
53

• “Better oral health in the higher social classes may be the
result of ‘differences in lifestyle, attitudes, behavior and
access to health providing products, foods and services
rather than being due to the effectiveness of preventive
dentistry”
EVIDENCE
o Kay E. How often should we go to the dentist? Br Med J 1999;319:204–5.
54

• Dental health is clearly influenced by environmental
working conditions.
• Furthermore, it has been demonstrated that the reduction
of inequalities in dental health among children and
younger adults in Denmark are likely to have occurred as a
result of social and health policy initiatives
EVIDENCE
55

Cultural / Behavioural Explanation
“… These are recognisable by the independent and autonomous
causal role which they assign to ideas and behaviour in the
onset of disease and event of death. Such explanations … often
focus on the individual as a unit of analysis emphasizing
unthinking, reckless or irresponsible behaviour or incautious life
style as the moving determinant of poor health status”
The Black Report 56

• Stresses differences in the way individuals in different
groups; choose to lead their lives: the behavior and
voluntary lifestyles they adopt
• Inequalities in health evolve because lower social groups
have adopted more dangerous and health-damaging
behavior than the higher groups, and than have less
interest in protecting their health for the future
57

• Focus on the individual as a unit of analysis emphasizing
unthinking, reckless or irresponsible behavior or incautious
lifestyle as the moving determinant of poor health status
58

“HARD” VERSION
Health damaging behaviours
freely chosen by individuals in
different social classes explain
away social class gradients
Health damaging behaviours are
differentially distributed across
social classes and contribute to
observed gradients
“SOFT” VERSION
59

• Criticized for failing to achieve sustainable improvements
in oral health and failing to address the underlying social,
political and economic determinants of health
• Evidence suggests that behavioural factors are perhaps not
as influential in explaining inequalities in oral health as
once thought, behaviours may in fact be an expression of
underlying material and social influences
EVIDENCE
60

• Dental health status and treatment needs are so clearly
related to individual behavior (e.g. sugar consumption, oral
hygiene, and dental visit habits).
• However, empirical data suggest that inequalities in dental
health are not completely explained by social differences
in dental behavior
EVIDENCE
61

Fig. Conflict model for the explanation of actual dental visit habits. Model stresses primary effect of material and
structural factors and secondary importance of normative factors.
Petersen PE. Social inequalities in dental health: towards a theoretical explanation. Community dentistry and oral epidemiology.
1990 Jun;18(3):153-8.
62

Psychosocial Perspective
• Health inequalities result from differences in the
experience of psychological stress between
socioeconomic groups
Sisson KL. Theoretical explanations for social inequalities in oral health. Community
dentistry and oral epidemiology. 2007 Apr;35(2):81-8.
63

• Individuals from lower socioeconomic backgrounds are
hypothesized to experience higher levels of psychosocial
stress resulting from a higher number of negative life
events, having lower levels of social support less control at
work, less job security and living in communities with
lower levels of trust and higher levels of crime and
antisocial behaviour, than individuals from higher
socioeconomic groups. 64

Stress could influence health through the direct and indirect
models;
• Direct model postulates that stress leads to the
development of ill health by triggering a specific chain of
events that leads to the development of specific diseases,
or by having a general negative effect on the body,
reducing resilience and increasing vulnerability to disease.
65

Stress could influence health through the direct and indirect
models;
• Indirect model proposes that people experiencing higher
levels of psychosocial stress are more likely to make
behavioural or lifestyle choices that are damaging to
health.
66

• Evidence suggests that those in lower socioeconomic
groups experience a greater level of psychosocial stress
and anxiety and that this increased level of psychosocial
stress can lead to an increase in smoking and/or an
increase in the consumption of ‘comfort foods.
• Evidence also suggests that stress is a significant risk factor
in the development of periodontal disease in adults.
EVIDENCE
67

Life Course Perspective
• Health status at any given age, for any given birth cohort is
a result not only of current conditions but also of the
embodiment of prior living conditions from conception
onwards.
• Health inequalities result from the interaction of
materialist, behavioural and psychosocial factors over
time.
Sisson KL. Theoretical explanations for social inequalities in oral health. Community
dentistry and oral epidemiology. 2007 Apr;35(2):81-8.
68

• Popular models within this perspective include:
othe accumulation model and
othe critical periods or latent effects model.
69

• Accumulation model suggests that exposure to advantage
or disadvantage at different stages of life course has a
cumulative effect and this increases or decreases the risk
of developing chronic disease
• Social circumstances during childhood such as poverty,
health status and educational achievement set the
individual off on a life trajectory that in turn influences
health status.
70

• Critical periods model suggests that a limited time
window is responsible in which an exposure can have
adverse effects on development and subsequent disease
outcome.
• Outside this window, this developmental mechanism for
mediating exposure and disease risk is no longer available
71

Principles for Policy Action
for tackling social inequities in health
Whitehead M, Dahlgren G. Concepts and principles for tackling social
inequities in health: Levelling up Part 1. World Health Organization: Studies on
social and economic determinants of population health. 2006;2.
72

EQUITY: Aim of Policy
“…. is not to eliminate all health differences so that
everyone has the same level and quality of health,
but rather to reduce or eliminate those which result
from factors which are considered to be both
avoidable and unfair.”
73

Polices should strive to level up, not level down
Only way to narrow the health gap in an equitable way is to
bring up the level of health of the groups of people who are
worse off to that of the groups who are better off.
Levelling-down is not an option.
1
74

i. Focusing on people in poverty
only
ii. Narrowing the health divide
iii. Reducing social inequities
throughout the whole population
Three main approaches to reducing social inequities
in
health are interdependent and should build on one
another
2
75

in
another
Measures progress in terms of an improvement in health for the
targeted group only: targeting approach.
Any improvement in the health status of disadvantaged groups
can be considered a success, even if the health divide between
rich and poor is increasing.
2
Focusing on people in poverty only
76

in
another
Considers health of disadvantaged groups relative to the rest of
the population.
Focus is to reduce the gap between the worst off in society and
the best off – the disparity in health status between the
extremes of the social scale.
2
Narrowing the health divide
77

in
another
Recognizes that morbidity and premature mortality tend to
increase with declining socioeconomic status and that they are
not just an issue of a gap in health between rich and poor.
Takes in the whole population to reduce the differences in
health by equalizing health opportunities across the
socioeconomic spectrum
2
Reducing social inequities throughout the whole population
78

Population health policies should have the dual
purpose
of promoting health gains in the population as a
whole and reducing health inequities
Portrayal of trade-off between gains in population health and
reducing social inequities in health is FALSE.
The objective of reducing health inequities constitutes an
integral part of a comprehensive strategy for heath
development, not an alternative option.
Two goals of whole population strategy and reducing social
inequities in health should go hand in hand.
3
79

Actions should be concerned with tackling the
social
determinants of health inequities
Should focus not only on the social determinants of health in
general (the social conditions that can affect people’s health),
but also focuses on the main determinants of the systematic
differences in opportunities, living standards and lifestyles
associated with different positions in society.
This requires a greater understanding of the processes that
generate and maintain social inequities and then intervening in
these processes at the most effective points
4
80

Stated policy intentions are not enough: the
possibility of actions doing harm must be monitored
Requires an assessment of differential impacts, not just average
effects.
The welfare systems, which originally intended to support the
sick have turned medical poverty trap, where the increasing
necessity to pay for care when sick pushes more people into
poverty.
5
81

Select appropriate tools to measure the extent of
inequities and the progress towards goals
Measures that only monitor comparison between the extremes
of the social scale will not be able to assess the impact across
the whole of society. This may require indicators of the so-called
shortfall – that is, the cumulative difference between the most
advantaged group and each successive social group for each
specific factor.
It is important to monitor both relative and absolute changes in
social inequities in health, because they give different
information about the magnitude and direction of change
6
82

Make concerted efforts to give a voice to the
voiceless
The more articulate members of the population and those with
the most powerful representation tend to have more influence
than those in a weaker position.
To address this, administrators and professionals need to make
a determined effort to provide administrative systems and
information to make it easier for lay people to participate in
decisions that affect their health.
7
83

Wherever possible, social inequities in health should
be described and analysed separately for men and
women
Separate description and analysis is needed because both the
magnitude and the causes of observed social inequities in
health are sometimes different for the two sexes.
It is therefore of critical importance that these differences are
known and taken into consideration when developing strategies
to combat inequities in health.
8
84

Relate differences in health by ethnic background or
geography to socioeconomic background
Analyses of systematic differences in health by ethnic
background should, whenever possible, be related to
socioeconomic background, as the magnitude and causes of
the ethnic differences observed tend to differ by social
position.
Age-adjusted health status in areas with a fairly homogenous
population from a socioeconomic perspective can then be used
as a proxy for assessing socioeconomic inequities in health,
when measures of individual socioeconomic status.
9
85

Health systems should be built on equity principles
• Public health services should not be driven by profit, and
patients should never be exploited for profit.
• Services should be provided according to need, not ability to
pay. This requires a system of health care financing that pools
risks across the population, so that those at high risk are
subsidized by those at low risk at any given time
1
0
86

Health systems should be built on equity principles
• The same high standard of care should be offered to
everyone, without discrimination with respect to social,
ethnic, gender or age profile.
• The underlying values and equity objectives of a health
system should be explicitly identified, and the monitoring
carried out to ensure these objectives are approached in the
most efficient way possible.
1
0
87

CONCLUSION
Increasing numbers of counties have been striving to face
the challenge of social inequities in health and are working
out what practical action can be taken in their own country
to improve the situation.
The aim should be to help promote a common
understanding of the concepts and principles on which
actions for tackling health inequities can be based.
88

REFERENCES
• Pine CM, Harris R, editors. Community oral health. Oxford; Boston: Wright;
1997.
• Braveman P, Gruskin S. Defining equity in health. Journal of Epidemiology &
Community Health. 2003 Apr 1;57(4):254-8.
• Whitehead M. The concepts and principles of equity and health. Health
promotion international. 1991 Jan 1;6(3):217-28.
• Whitehead M, Dahlgren G. Concepts and principles for tackling social
inequities in health: Levelling up Part 1. World Health Organization: Studies
on social and economic determinants of population health. 2006;2.
• Mackenbach JP, Stirbu I, Roskam AJ, Schaap MM, Menvielle G, Leinsalu M,
Kunst AE. Socioeconomic inequalities in health in 22 European countries. New
England journal of medicine. 2008 Jun 5;358(23):2468-81.
• Kawachi I, Subramanian SV, Almeida-Filho N. A glossary for health
inequalities. Journal of Epidemiology & Community Health. 2002 Sep
89

REFERENCES
• Singh-Manoux A, Marmot M. Role of socialization in explaining social
inequalities in health. Social science & medicine. 2005 May 1;60(9):2129-33.
• Braveman P, Tarimo E. Social inequalities in health within countries: not only
an issue for affluent nations. Social science & medicine. 2002 Jun
1;54(11):1621-35.
• Marmot M. Social determinants of health inequalities. The lancet. 2005 Mar
19;365(9464):1099-104.
• Goldman N. Social inequalities in health. Annals of the New York Academy of
Sciences. 2001 Dec 1;954(1):118-39.
• Petersen PE. Social inequalities in dental health: towards a theoretical
explanation. Community dentistry and oral epidemiology. 1990 Jun;18(3):153-
8.
• Macintyre S. The black report and beyond what are the issues?. Social science
& medicine. 1997 Mar 1;44(6):723-45.
90

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