Understanding

Health
Inequalities
PHPS30020 - 05 Dec 2023

Lecturer: Carolyn Ingram

PhD Candidate | Education Technologist
School of Public Health, Physiotherapy, and Sports Science
Learning Objectives

• Understand the definitions and distinctions between health

equity, health inequalities, and health inequities.

• Explore and discuss the social and structural determinants of

health and understand their role in affecting health
outcomes using the WHO Conceptual Framework for Action
on the Social Determinants of Health.

• Understand which populations are experiencing health

inequities in Ireland.
Optimal Health
 IN
NOT
Optimal Health
Important Terms
Health equity

Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires
r e m o v i n g o b s t a c l e s t o h e a l t h s u c h a s p o v e r t y, d i s c r i m i n a t i o n , a n d t h e i r c o n s e q u e n c e s .

( R o b e r t Wo o d J o h n s o n F o u n d a t i o n 2 0 1 7 )

Health inequality

An obser ved difference in health status between population groups.

Health inequity

A difference in health status or access to the resources needed to achieve optimal health status which are:
AV O I D A B L E , U N FA I R , U N J U S T.

(Health Equity Institute 2019)

Important Terms
Health equity

Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires
r e m o v i n g o b s t a c l e s t o h e a l t h s u c h a s p o v e r t y, d i s c r i m i n a t i o n , a n d t h e i r c o n s e q u e n c e s .

( R o b e r t Wo o d J o h n s o n F o u n d a t i o n 2 0 1 7 )

Higher rates of breast

Health inequality cancer in women than in men

An obser ved difference in health status between population groups. Higher rates of breast
cancer in disadvantaged
areas than in affluent areas
Health inequity

A difference in health status or access to the resources needed to achieve optimal health status which are:
AV O I D A B L E , U N FA I R , U N J U S T.

(Health Equity Institute 2019)

Important Terms
Health equity

Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires
r e m o v i n g o b s t a c l e s t o h e a l t h s u c h a s p o v e r t y, d i s c r i m i n a t i o n , a n d t h e i r c o n s e q u e n c e s .

( R o b e r t Wo o d J o h n s o n F o u n d a t i o n 2 0 1 7 )

Higher rates of breast

Health inequality cancer in women than in men

An obser ved difference in health status between population groups. Higher rates of breast
cancer in disadvantaged
areas than in affluent areas
Health inequity

A difference in health status or access to the resources needed to achieve optimal health status which are:
AV O I D A B L E , U N FA I R , U N J U S T.

(Health Equity Institute 2019)

What does this look like in practice?

Education
Employment
Crowding

Comparison of Pobal HP Deprivation Index 2016 rankings and Covid-19 Vaccination Rates by national decile as of March 2022 in Dublin, Ireland.
Source: https://www.sciencedirect.com/science/article/pii/S0264410X22014967?via%3Dihub
 What does this look like in practice?

Environmental
Exposures
Socioeconomic
factors Comparison of Washington Environmental Health Disparities Map cumulative impact rankings (a) and cumulative positive
Persons of colour COVID-19 case rates per 1000 residents (b) in 397 census tracts: Seattle, King County, WA, July 12, 2020
Underlying
conditions Source: https://link.springer.com/article/10.1007/s40615-021-01063-y
What does this look like in practice?

A growing body of research shows that centuries of racism in the [United States] has had
a profound and negative impact on communities of color. The impact is per vasive and
deeply embedded in society—affecting where one lives, learns, works, worships and
plays and creating inequities in access to a range of social and economic benefits—such
as housing , education, wealth, and employment.

The data show that racial and ethnic minority groups, throughout the United States,
experience higher rates of illness and death across a wide range of health conditions,
including diabetes, hypertension, obesity, asthma, and heart disease, when compared to
their White counterparts. Additionally, the life expectancy of non-Hispanic/Black
Americans is four years lower than that of White Americans. The COVID -19 pandemic,
and its disproportionate impact among racial and ethnic minority populations is another
stark example of these enduring health disparities.

Source: Centers for Disease Control and Prevention: Racism and Health
Pathways to
health equity?
To act on health inequalities, we must first understand what’s driving them…

Needing to leave Occupation that is Low wage/lack of Health is impacted by

school earlier to earn potentially hard on insurance prevent job and limited income
money or because the mind and body access to quality to ensure a healthy
higher education is healthcare lifestyle
too expensive
+

Exacerbated by access
barriers to care
WHO CONCEPTUAL FRAMEWORK FOR ACTION ON THE
SOCIAL DETERMINANTS OF HEALTH

Created by the WHO Commission

on Social Determinants of Health
to answer:

1. Where do health differences

among social groups originate, if
we trace them back to their
deepest roots?

2. What pathways lead from root

causes to the stark differences in
health status observed at the
population level?
Socio-economic & Political Context
How do the policies that guide how societies (re) distribute material resources shape
the quality of social determinants of health?

Definition of needs, discrimination, civil society participation, accountability/transparency

Fiscal policies, trade, labour market structures…

Social welfare, housing opportunities (20% of the differences in infant mortality between
countries is determined by the type of welfare state)

Quality of education, medical care, water and sanitation

What value is placed on health? Is it seen as a collective social concern?

Socioeconomic position
What is a person’s power, prestige, and access to resources?

Includes resource-based and prestige-based capital (money and status!)

More prestige-based… how much control does one have over available resources?

Three most important proxy indicators of socioeconomic position

Structural Determinants of Health

Structural determinants (or social determinants of health

inequities) are made up of:

• SOCIOECONOMIC AND POLITICAL CONTEXT

• STRUCTURAL MECHANISMS that generate and reinforce

social stratification and socioeconomic divisions

• Resultant INDIVIDUAL SOCIOECONOMIC POSITION

For your exam, make sure you are familiar with the
different components of the structural determinants of
health
Structural Determinants of Health

In other words, does the context of where you live -

the government, social and public policies, culture-
encourage or prevent inequality according to status
and wealth?

And – within this context – how much power do you

have to shape your own health and access to
resources?

Of course, privilege, lack of discrimination, higher

education, higher income, prestigious occupation… all
these things give us more power. If we live in an
‘unequal’ context but still have power, we can achieve
better health.
These structural determinants of health Shape the social determinants of health
Social Determinants of Health
Based a person’s socioeconomic position, to what extent are they then exposed and
vulnerable to conditions that impact health?

Housing (e.g., secure tenancy, running water, central heating, toilet, crowding)

Healthy food

Warm clothing

Physical working environment

Neighborhood environment (proximity to pollution, greenspace, safety)

Social Determinants of Health
Based a person’s socioeconomic position, to what extent are they then exposed and
vulnerable to conditions that impact health?

Smoking

Diet Response to material

deprivation and
Alcohol consumption stress

Physical exercise

Genetic factors

Age and sex

Social Determinants of Health
Based a person’s socioeconomic position, to what extent are they then exposed and
vulnerable to conditions that impact health?

Psychosocial stressors (negative life events, job insecurity, discrimination and

social exclusion, violence)

Lack of social support

Social Determinants of Health
Based a person’s socioeconomic position, to what extent are they then exposed and
vulnerable to conditions that impact health?
“When a person in homelessness is for discharge, they'll hand them a prescription with
a long list of medications and just hand it to them. They're not going to check, ‘have
they money to get it?’ ‘Have they a medical card?’ Unfortunately, due to the business of
the hospital, they treat them like everyone else, hand it to them and say, ‘Oh, you'll get
an appointment in the post for four weeks or you'll get a virtual follow up appointment.’
A lot of the clinics since COVID have gone virtual. Respiratory do virtual. The fracture
clinic do virtual. So, they're sending out these crazy appointments, ‘You'll receive a
phone call between 9:00 and 5:00 on the 5th, please be available to take this’, but this
guy doesn’t have a phone and needs surgery… you know?” (Social Inclusion Nurse
speaking about service users in homelessness in 2023)

Access

Affordability

Geographic barriers

Stigma and discrimination in care

Social Determinants of Health
Based a person’s socioeconomic position, to what extent are they then exposed and
vulnerable to conditions that impact health?
“You're often an advocate for,...because busy teams like surgeons, they'll come around if
someone's not doing what they tell them. They're like, ‘Well, I don't care. I have lots of
other patients’, and they'll just leave them. You know, so you try and be the advocate for
the person and try and explain that, ‘Look, he doesn't really mean to behave like this, his
only way of knowing how to deal with the situation was always to fight their corner.’
You know, a lot of people in homelessness, they've had to fight for everything in their
lives since they were kids, be it food, clothes. So then when they come into a hospital
and they're being told what to do, their only way of dealing with it is fighting back. So,
you're just there to advocate as well. To just be the person to give them a voice.” (Social
Inclusion Nurse speaking about service users in homelessness in 2023)

Access

Affordability

Geographic barriers

Stigma and discrimination in care

Social Determinants of Health
Based a person’s socioeconomic position, to what extent are they then exposed and
vulnerable to conditions that impact health?
“You know, it is not uncommon for a doctor... Say somebody comes in and they've had a loss
of consciousness. It is not uncommon to meet a doctor who will say, ‘Well, that was just the
drugs, why are we treating that?’ Now, maybe it was the drugs. If they've hit their head,
they still deserve care. Maybe it was epilepsy. You need to do the checks. You can't just
assume that just because somebody's also on drugs they haven't also had a seizure. Both of
those things could be happening. There's a rhetoric of blame ‘Well, we know what
happened, that was probably just a drug, and by the way, they made a choice.’ And that is
completely ignorant of actually what happens. I mean, I work with women. So, if you're
talking about drug use, you're also talking about sexual violence, you're talking about
domestic abuse, and this sort of contextual view.” Health Equity Researcher 2023

Access

Affordability

Geographic barriers

Stigma and discrimination in care

Health
Programme
Strategies
 Vertical Horizontal
Focused on a specific demographic Focused on providing integrated
population, disease, or health issue healthcare for entire population

Specific, measurable outcome Preventive and primar y health care

objectives within a defined time-
frame
Generally financed by an external
donor (e. g. , NGO)
within national health system
Reporting to/financed by national
health system

Occurs in parallel to normal primar y

care activities

Promoted in areas of poverty,

increased need
Vertical Horizontal
Example Example
The Irish
Context
Despite nationwide improvements in deprivation measures, the gap between Ireland’s most
disadvantaged areas and the national average has increased.

195,992 people now live in areas classed as very or extremely disadvantaged.

Source: https://www.pobal.ie/pobal-hp-deprivation-index/
One response:

The Social Inclusion and

Community Activation Programme
(SICAP) 2018 – 2023 provides
funding to tackle poverty and social
exclusion.

Administered by Pobal, SICAP is co-

funded by the Irish Government,
through the Department of Rural
and Community Development, and
the European Social Fund Plus
under the Employment, Inclusion,
Skills and Training (EIST) Programme
2021 -2027.
 Disadvantaged Children and Families, Young Referring to socioeconomic
People, Women disadvantage: limited
potential for education,
People living in Disadvantaged Communities training, or employment

A t r i s k o f p o v e r t y. M a y
Low Income Workers/Households include carers, someone on
Economically Inactive disability payments, retired
person who is receiving a
low income…

Emerging Needs Group Substance misusers, the

homeless

Migrants, refugees and

Remember these New Communities a syl um s e e ke rs expe r i e nc i ng
groups! disadvantage

An individual may hold less ‘prestige’ in the system (e.g., women, an elderly individual, someone not from Ireland), however
target groups in Ireland are those who are also financially unable to access equal resources.
Social Determinants of Health

Now imagine for an Irish

Traveller, how might SICAP
change their pathway to health?
 Reduced opportunities for
Racism and social work, poor housing
stratification conditions, stress

But what about…

Cultural context that continues

to favour ethnic majority groups

High rates of Discrimination in

smoking and the health system
drinking
 Reduced opportunities for
Racism and social work, poor housing
stratification conditions, stress

For an asylum
seeker?

Limited rights within the system

Excluded from public policies

Culture that can favour an ‘Irish

first’ mentality

Discrimination in
the health system
No right to work
 Reduced opportunities for work,
poor housing conditions, stress,
loneliness
Mental health challenges

For someone in
homelessness and
addiction?

Limited available/affordable
housing

Culture that continues to blame

drug users

Harmful behaviours Access barriers to Discrimination in

healthcare the health system
As clinicians…
 REMEMBER
• Empathy
• Referrals to community support services.
• Facilitating access to available services and
advocating for your patients throughout the
process.
• Recognising barriers & working towards lifting
those barriers.
• Shifting from “focusing/blaming individual
behaviour” to creating enabling environments
• Recognising potential for your own bias
• Recognising your own limitations as well! You work
within a system
 Helpful Resources

Kings Fund - What are health inequalities?

https://www.kingsfund.org.uk/publications/what-are-health-
inequalities

WHO Conceptual Framework for Action on the Social

Determinants of Health
https://www.who.int/publications/i/item/9789241500852