There are many and varied definitions of what health is, the Cambridge English Dictionary for example defines it as “A sound state of body or mind; freedom from disease” (Cambridge English Dictionary, p183) – but this rather simplistic definition does not wholly encompass the vast range of human experience which informs each individual’s definition of health. Definitions of health vary widely from person to person; as noted by Blaxter (1997), people have a desire to claim a healthy status, and may offer alternative explanations of their, or other peoples health experience rather than accept a state of ill health. Perhaps it is a western unease with the idea of ill health which leads to the disbelief many feel at the idea of the existence of inequalities in health (Blaxter, 1997).
Despite perhaps a conceptual discomfort with the idea of inequalities in health, there is information which suggests that there are inequalities in health, and that the inequality between rich and poor, termed the ‘health gap’, is continuing to grow (Smith et al., cited in Davidson, Hunt ; Kitzinger 2003). The evidence for health inequalities is a matter of some contention however, with some suggesting that inequalities are simply an artifact of the interpretation of vast amounts of indifferent data (Gillespie ; Prior, 1995). Certainly there is a high level of agreement within the lay public that health is dependent on individual behaviours rather than housing, environment or personal prosperity (Blaxter, 1997); furthermore there is the question of whether health inequalities are unjust or simply inequities caused by, for example, the prevalence of specific genes in certain socio-economic groups (which although leading to inequalities are not inherently unfair) (Whitehead, cited in Mackenbach ; Kunst, 1997).
This essay will discuss what evidence exists for health inequalities, and the origins suggested for these inequalities. The impact of biological, social, environmental and psychological factors on health and how these factors interact to produce inequalities will be briefly considered. Finally, the question whether health promotion may act to reduce these inequalities will be discussed.
The evidence for inequalities ; health affecting factors
In a study by Blaxter (1997), those who are traditionally considered to be disadvantaged in health terms, i.e. those in the social classes IV/V, were the only people to completely deny the existence of health inequalities, and would only attribute ill health to external factors (for example damp housing or pollution) as a last resort (Blaxter, 1997; Popay et al. 2003). An opinion which is perhaps reinforced by the popular media, in which the more right-wing papers emphasize the importance of individual health behaviour over and above the importance of social environment (Davidson, Hunt ; Kitzinger, 2003).
But this attitude is not supported by the evidence. In 1842, the then Home Department published a report entitled ‘Report to Her Majesty’s Secretary of State for the Home Department from the Poor Law Commissioners on an Inquiry into the Sanitary Condition of the Labouring Population of Great Britain’ (Chadwick, 1842) – this report brought into the awareness of the then government the relationship between the living conditions of the poor and high rates of illness and mortality. Since then there have been several seminal works which continued to highlight inequalities in health, most famously the ‘Black Report’ (Black et al., 1980) and more recently the Independent Inquiry into Inequalities in Health Report (Acheson, 1998) (also known as the Acheson Report).
The Black report (Black et al., 1980) argued that social and economic factors such as work, income, education, housing, environment and transport all affect health, and furthermore that the better off classes benefited from all of these factors being biased in their favour (Townsend & Davidson (eds), 1982). Not only that, but that manual classes make less use of the healthcare system despite needing it more. Although there is a lack of recent quantitative research in many areas, the research that does exist indicates some link between socio-economic status and use of healthcare facilities. A quantitative study correlating the attendance at antinatal clinics with social class and ethnicity found a link between social inequality and attendance – women from lower social classes were found to be more likely to initiate antinatal care late, and have fewer visits (Rowe & Garcia, 2003).
Residential area deprivation (poor quality housing, poor access to health services and lack of social organisation) has also been found to affect the health of individuals; many studies have found a strong correlation between smoking (with it’s concomitant health risks) and lower socio-economic status (Shohaimi et al. 2003). Educational status can also be used as an accurate predictor of smoking habit (Shohaimi et al. 2003). A study in Tower Hamlets, a highly deprived area of London, comparing hospital admissions due to asthma and chronic obstructive airways disease and the proximity to main roads, found no link – leaving open the disturbing prospect that the 80% above average admissions to hospital for respiratory illness is again related to the high levels of deprivation found in the area (Morris et al., 2000).
Another example of evidence for socio-economic deprivation linking with poor health outcomes is seen in recent study of colorectal cancer. A significant difference in five year survival rate was demonstrated between the highest socio-economic group and the lowest (Coleman, Babb ; Damiecki 1999). That the results of this study covering 1971 to 1995 remain accurate was confirmed in a study by Wrigley et al. (2003) with survival rates collected from 1991 on, again being adversely affected by socio-economic deprivation.
But there are yet more social and cultural effects on individual health; religion can have an adverse effect on health – a study of Middle Eastern Asian Islamic women living in a major city in the United States found that they did not participate in the breast cancer screening program or examine their breasts regularly for lumps despite being aware of the health benefits (Rashidi ; Rajaram, 2000). This contrasts with the results of a descriptive study of Islamic women in Iran (Montazeri, Haji-Mahmoodi ; Jarvandi, 2003) – the difference being explained by the altered practice of Islam outside Islamic countries. It is likely that a similar effect may be seen in Middle Eastern Asian Islamic women living in the United Kingdom.
Psychosocial factors and social relations at work can also exert independent effects on health. Absence from work due to sickness is a valid indicator of health status, although short absences are normally affected most by social factors; long term absences are strong indicators of an individuals health (Chevalier, cited in Melchoir, et al., 2003). A six year study of the GAZEL cohort in France found that the quality of the work environment affected health independently of social relations. This study suggests, therefore, that a poor work environment, poor social support, and low satisfaction with social relations can all independently lead to an increase in ill health.
Research has comprehensively shown the existence of inequalities in health. Health can be adversely affected not just by availability of healthcare, individual behaviour patterns and ‘lifestyle choices’, but also by education, presence or absence of work, type of work, religion, residential deprivation, and the entire range of socio-economic factors. Many of these factors independently affect health; however, those in the lower socio-economic groups are disadvantaged by nearly all of them, and although they may not interact, the combination of factors leads to a significantly higher health burden for those in lower socio-economic groups.
Health education and health promotion
The Black report (Black et al., 1980) stated that factors affecting health were not just a question of individual initiative and responsibility, improvements in multiple areas of life – improving standards of living at work, at home and in the community – what is now called health promotion would be vital in improving the nations health. However, during the period of Conservative government (from 1979 to 1997) the issue of health inequalities remained low on the political agenda, with attempts to improve public health by the Conservatives limited by a desire not to acknowledge socio-economic and environmental aspects of health and a ‘victim blaming’ approach utilising well intentioned but ultimately misdirected health advice (Davidson, Hunt ; Kitzinger, 2003).
Because the factors which affect health are so strongly interlinked with all parts of society, improvements in public health require government, local and individual action. The two white papers, Towards a Healthier Scotland, A White Paper on Health (1999), and Saving Lives: Our Healthier Nation (1999) both stress the importance of this combined approach to improving public health. This, however, is a major challenge for health policy – but improving the health of the worst off members of society offers the potential to vastly improve the overall health of the nation. It is not just the United Kingdom which suffers from such inequalities. The World Health Organisation set a target that “By the year 2000, the differences in health status between countries and between groups within countries should be reduced by at least 25%, by improving the level of health of disadvantaged nations and groups” (‘Health for All’ strategy, cited in Mackenback ; Kunst, 1997).
In a speech to the Faculty of Public Health Medicine, the Secretary of State for Health stated that “the health debate in our country has for far too long been focussed on the state of the nation’s health service and not enough on the state of the nation’s health [it is now time] to put renewed emphasis on prevention as well as treatment […] to improve the health of all and to improve the heath of the poorest fastest” (Milburn, 2002). The speech goes on to recognise that improving public health is not merely a matter of health education. It requires health promotion – as suggested originally in the Black report (Black et al., 1980). It is clear then that inequalities in health are firmly back on the political agenda, and that an important component of government attempts to improve public health is health promotion.
As previously noted however, public health is influenced by the interaction of psychological, social, economic and environmental factors and so health promotion must mean not only health education; but public policy, the creation of appropriate environments in which healthy choices can be made, the tackling of local health problems, and improving the prevention and protection functions of health services are all required policy features if inequalities in health are to be reduced.
The first of these, health education, can lead to changes in the behaviour of the public (Landman, Ling ; Glantz, 2002). But the correct presentation of health education messages is an important factor. Messages relating to health produced by the government can easily lead to accusations of social engineering – or that the government is nannying the population (Davidson, Hunt ; Kitzinger, 2003). Messages produced by industries (for example the tobacco industry’s ‘youth smoking prevention’ programs particularly prevalent in the United States) can be deliberately exploitative of known weaknesses in health education. The tobacco industry’s ‘Think. Don’t smoke’ campaign in the United States was found to be less effective than the ‘Truth’ smoking prevention program initiated by public health groups (Landman, Ling & Glantz, 2002) .
Changes in public policy, originally suggested again in the Black report (Black et al., 1980) are reappearing, with improved cooperation between public and private housing sectors (particularly seen in rural areas), increased funding of preventative health measures, legislation preventing the advertising of tobacco products, stated national health goals and minimum working conditions all having appeared since the publication of the report.
Another change is the use of Health Impact Assessment; this process is used to find and improve both positive and negative health effects of non-healthcare programmes or policies (Mindell & Joffe, 2003). Although there is no legal requirement for their use, beyond an EU requirement for policies to consider health, the Health Impact Assessment has become widely used throughout the United Kingdom. By using Health Impact Assessment, unintentional negative health effects can be reduced and thus public health can benefit from it’s integration into the creation of general public policy (Mindell ; Joffe, 2003).
That socio-economic health inequalities exist is now almost an indisputable fact, it is no longer the case that their alledged existence can easily be ascribed to mere interpretation of statistics. The large body of work on inequalities in health has highlighted many factors which contribute to the inequity of health experience – all of which need to be tackled if an end to health inequalities is to be achieved. Currently a wide variety of public policy measures are being implemented which, if they work as their proponents claim, will significantly reduce the levels of health inequality. Whether these measures work as intended and whether the national health service can integrate the prevention and protection roles remains to be seen. Whether they work or not however, as long as inequalities remain in the public consciousness, the government will have to continue to attempt to eradicate health inequality from our society.