Addressing Health Inequalities in Health Promotion Practice

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Addressing Health Inequalities in Health
Promotion Practice

• Louise Potvin,
• Centre de recherche Léa-Roback sur les inégalités
  sociales de santé de Montréal, Montréal, Canada
• 5th Nordic Health Promotion research Conference
• Edsjberg, Denmark, June 2006

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Principles and successes of a population approach
to disease prevention and health promotion
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Principles of a population approach

• The distribution of risk in a population is
  shaped by contextual conditions Causes of cases
  differ from causes of incidence

• The aim is to improve the condition of the
  overall population by modifying the conditions
  that shape the distribution of risks most of
  health gains are from people at medium risk

• Changing the conditions that affect the overall
  distribution in the population also improves the
  risk of those at greater risk

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Context and distribution of risks
From Evans, R. (2002). Interpreting and
addressing inequalities in health From Black to
Acheson to Blair to? London Office of Health
Economics
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Principles of a population approach

• The aim is to improve the condition of the
  overall population by modifying the conditions
  that shape the distribution of risks

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Small effects throughout distribution lowering
of risk for those at high risk
Serdula, M. K. et al. Trends in alcohol use and
binge drinking, 1985-1999. Am J Prev Med 2004
26(4)294-298.
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Revisiting population health approach in light
of lifecourse
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Principles of lifecourse perspective

• Peoples life is integrated events in one sphere
  of their life impact other spheres (biological,
  economical, cultural and social)
• People live interconnected lives they are
  affected by life events affecting their loved
  ones
• Vulnerabilities and advantages are cumulative at
  any point in time ones position in a
  distribution is function of all previous
  affecting events

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5-month health indicators by income, birth status
(ELDEQ 1998)

Perceived Health lt excellent
Chronic Problems


39 weeks
lt 39 weeks
39 weeks
lt 39 weeks
10
Effectiveness hypothesis non differential
reduction of risk throughout the distribution
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Concentration of vulnerabilities following
population interventions
Concentration of vulnerabilities
Concentration of advantages
Mean effect
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Effective interventions that increased
inequalities in Canada

• Smoking cessation
• Number of smokers decreased by more than half in
  40 years
• Smokers are 4 times more numerous among people
  with incomplete secondary education
• Infection disease
• Decrease in infectious disease mortality past 50
  years
• Infectious disease mortality 3 times higher in
  lowest quintile income compared to highest
  quintile
• Health care
• Decrease in lethality of most morbid conditions
• Higher survival among highest socio-economic
  strata for most chronic conditions even with
  universal care coverage

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Differential effects of interventions
Less vulnerable
Corrective approach
Health Outcome
Most vulnerable
Time
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Limits of a population approach

• Health system traditional model of action based
  on the dissemination and use of expert knowledge
  through institutional population programs has
  been very successful at achieving the aim of
  improving the health of the overall population.
• In the case of health, as in the case of
  wealth, however, benefits and costs associated to
  this progress are not evenly distributed in the
  population.
• Those who are better off, who have better
  access to services and a sufficient education to
  transform public and private resources into well
  being and health gain more benefits from health
  system.
• Those who are already vulnerable have a
  tendency to cumulate risks and increase their
  vulnerability throughout the course of their
  life.
• Vulnerable populations call for other,
  complementary, approaches

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Two potentially conflicting health objectives

• Improve the health of the general population
  effectiveness of the interventions
• Reduce the unjust health inequalities between
  various social strata equity of the
  interventions

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Four sources of inequalities in health promotion
interventions

• Inequalities due to planning are intervention
  priorities determined with a view to the
  disparities between various social strata?
• Inequalities due to implementation are certain
  classes of people more easily reached?
• Inequalities due to effects do our interventions
  have different effects depending on various
  social factors?
• Inequalities due to impacts for equivalent
  effects, are the health impacts the same across
  the entire population?

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Inequalities due to planning

• Requires that health indicators can be linked to
  social indicators of inequalities unavailable in
  most countries
• Requires that corrective approaches are planned
  taking into account the sources of health
  inequalities (Acheson report in UK) backlash on
  affirmative action and social programs
• Very few studies highlighting those issues
  Montreal study shows that core budget items reach
  higher values for more affluent areas while less
  areas have more renewable program monies

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Inequalities due to implementation

• Requires monitoring social status of program
  participants or beneficiaries
• Very few studies for programs other than those
  involving the health care system
• For most preventive examinations disparities
  between the rich and poor in prescriptions / use
• In population prevention programs harder to
  obtain the consent of more disadvantaged parents
  for school programs in health education

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Inequalities due to effects

• Requires testing programs interaction effects
• A little more knowledge
• Fluoridation programs tend to reduce inequalities
  ( low income family children)
• Promotional campaigns
• increase the disparities in awareness of CVD
  risk factors (income)
• do not affect the disparities among risk factors
  (income)

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Inequalities due to impacts

• Requires testing the interactions between social
  determinants and risk factors
• Some results of etiological studies, which have
  not been reproduced, lead to conclude that
  certain effects do not translate in the same way
  into impact on the health of different segments
  of the population
• Not aware of any recent study undertaken to
  examine that question

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Actions to promote equity as a value for health
interventions

• Always couple reducing inequalities to improving
  health in health intervention objectives
• Collect data that allow to estimate trends and
  identify major sources of health inequalities
• Develop methods for assessing each of the four
  sources of inequalities in programs