Causes of inequalities in health
Social determinants of health inequality and inequity
Inequalities in health arise because of differences in people’s daily living conditions. Those with more power, money and resources live and work in better conditions, have better health and a longer life (Marmot, 2010; WHO, 2010). People achieve more power, money and resources if they have a high socio-economic position, which is strongly determined by their ethnicity, gender, education, income and occupation (Figure 3.18).
Socio-economic position reflects and determines people’s
- • material circumstances, which include their physical environment such as housing, working conditions and neighbourhood, and economic circumstances such as income and access to goods and services
- • psychosocial factors, which include stressors caused by negative life events such as bereavement, lack of social support or isolation
- • health-related behaviours and biological factors, such as smoking, alcohol consumption and sedentary behaviour, and their biological impact such as high blood pressure. It also includes the influence of genes
- (WHO, 2010)
The health system, that is both public health and healthcare, has a role to play. It can
- • encourage equal access to care
- • promote collaboration to improve the health of citizens such as improving transport so that people can access care
- • invest in the early detection of illness, rehabilitation and support with social reintegration
- • encourage people to participate in and influence their health system
- • use its influence to improve the social determinants of illness and health inequity
- (WHO, 2010)
Figure 3.18 Social determinants lead to health inequalities
Figure 3.19 Commission on the Social Determinants of Health Conceptual Framework Source: World Health Organization, 2010 p.6. Reproduced with permission from the World Health Organization.
These social determinants of health are influenced by the ways in which a society organises itself and makes decisions. The wider social, political and cultural context shapes whether power, money and resources are equally or unequally distributed. For example,
governance and its processes, e.g. how a society defines a population’s needs, patterns of discrimination, how much people are encouraged to participate in the governance of a society, whether the administration of public affairs is transparent and whether those who run them are accountable and to whom
- • macroeconomic policies, e.g. trade, finance and monetary policies
- • social policies, e.g. the distribution of land, housing, employment/the labour market and systems of welfare for the poor or vulnerable
- • public policies, e.g. how a society manages water, sanitation, education, housing, health services and social care
- • culture and societal values, e.g. value placed on religion(s), equality, health, collective responsibility and the distribution of resources
- (WHO, 2010)
The World Health Organization’s Conceptual Framework (Figure 3.19) indicates how all the social determinants work with one another to produce a society that promotes health inequalities (WHO, 2010). They argue that health equity is a matter of social justice and is linked to human rights. Reducing the health gap, so that groups of people are not destined to more ill health and a shorter life than others, is related to the sort of society in which people want to live.
Life course approach to understanding inequalities in health
The World Health Organization (2010) acknowledged the importance of considering the life course approach alongside their Conceptual Framework. The two are complementary. The life course approach considers the health journey of an individual from their conception to death. It seeks to understand the risk of disease and/or the long-term health effects from
... physical or social exposures during gestation, childhood, adolescence, young adulthood and later adult life. The aim is to elucidate biological, behavioural and psychosocial processes that operate across an individual’s life course, or across generations, to influence the development of disease risk.
(Kuh etal, 2003 p.778)
The life course approach aims to bring together the social risks and biological risks to health. It contributes to understanding the factors that culminate in a person’s socioeconomic position and their health, recognising each influences the other. From this, researchers can understand some of the mechanisms that lead to some people having worse heath and shorter lives than others (Table 3.7). Researchers examine
- • the causes of ill health that accumulate over time. These can include chains of risks, that is, one disadvantage may lead to another
- • the timing of certain exposures or actions. These are either critical periods, limited windows of time in which an exposure could be protective or adverse, or sensitive periods when we are particularly sensitive to being affected (e.g. infancy)
- • people’s resilience, susceptibility or vulnerability to exposures or the factors that can help to modify or mitigate an exposure
- (Kuh et al, 2003)
Marmot (2017) summarises how the social gradient of health runs across the life course. The lower the socio-economic position of young children, the worse they do on tests that measure linguistic, cognitive, social, emotional and behavioural development.
84 Sally Robinson et al. Table 3.7 Life course models
Accumulation of risk model
The accumulation of facts, events, decisions (direct and indirect) that influences health over time.
Chain of risk model
Events are linked together in a chain, e.g. being born into disadvantage puts an individual on a path from which it is difficult to leave.
Critical period model
Analyses when an event happened to a person because some moments of life are particularly ‘sensitive’ and events will have a greater impact.
Source: Kuh et al. (2003).
This gradient in young children can be greatly explained by parenting activities, and it can be reduced by support for parents and families and by reducing child poverty. A child’s readiness for school affects their later school performance, and their educational achievement is strongly associated with adult health. Adults’ health is directly influenced by their own education, which also influences their income, working and living conditions and psychological processes. Children born into lower socioeconomic circumstances are more likely to experience adverse childhood experiences, which can include abuse, neglect and exposure to violence. These adverse experiences are associated with a range of health-damaging behaviours in adulthood such as substance misuse, smoking, under-age sex, domestic violence, and subsequently higher rates of illness which lead to earlier deaths than the general population.
Fair Society Healthy Lives
In November 2008, Professor Sir Michael Marmot undertook a review of evidence to reduce inequalities in health in England. The review was published in 2010 under the title Fair Society Healthy Lives. His two main reference points were
- • the Commission on the Social Determinants of Health Conceptual Framework
- • the life course approach
The aims of the review were to
• improve health and wellbeing for all
reduce health inequalities
The two overarching goals were to
- • create an enabling society that maximises individual and community potential
- • ensure social justice, health and sustainability are at the heart of all policies
Marmot’s key messages were
- • reducing health inequalities is about fairness and social justice
- • action should focus on reducing the social gradient in health
Figure 3.20 Action across the life course
Source: Marmot, M. (2010) Fair society, healthy lives. The Marmot review. H.M. Government: London. Reproduced with permission from UCL Institute of Health Equity.
- • health inequalities are the result of social inequalities, and the solutions need action from across all social determinants of health
- • the need for proportionate universalism. This means recognising that focusing on the most vulnerable alone will not reduce health inequalities very much. To reduce the steepness of the social gradient in health,
Actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. We call this proportionate universalism.
- (Marmot, 2010 p. 15)
- • reducing health inequalities will benefit the whole of society in many ways, including economic benefits due to less sickness
- • tackling social inequalities in health must go together with tackling climate change. Both are more important measures of a country’s success than economic growth
- • six objectives for English policy:
A give every child the best start in life
В enable all children, young people and adults to maximise their capabilities and have control over their lives C create fair employment and good work for all D ensure a healthy standard of living for all
E create and develop healthy and sustainable places and communities F strengthen the role and impact of ill health prevention
- • national and local government, the National Health Service and private and third-sector organisations, and groups, will need to participate in delivering these national policy objectives. Local policies and delivery systems need to be effective and focused on equity
- • Effective participatory decision-making needs to be part of the local delivery, and this depends on empowering local communities and individuals
Marmot illustrates his approach in his diagram of Action across the life course
(Figure 3.20). Marmot makes clear:
Action to reduce health inequalities must start before birth and be followed through the life of the child. Only then can the close links between early disadvantage and poor outcomes throughout life be broken ... For this reason, giving every child the best start in life (Policy Objective A) is our highest priority recommendation.
(Marmot, 2010 p.20)
Health Equity in England
In 2020, Marmot and colleagues reported on the state of health inequalities in England 10 years after Fair Society Healthy Lives (Marmot, 2010). Health Equity in England (Marmot et al., 2020) reinforced the same core recommendations. They commented on the era of austerity that followed the international financial crisis of 2007 to 2008, and cite declines in education, the rise of zero-hours contracts, the rise in unaffordable housing and the rise in the use of food banks as examples of how the social determinants of health had deteriorated in England:
... health is getting worse for people living in more deprived districts and regions, health inequalities are increasing and, for the population as a whole, health is declining.
(Marmot et al., 2020 p. 149)
The social causes of inequalities in health can be traced back to the social, political and cultural contexts in which we live. These affect people’s health before they are born, throughout their whole lives and the next generation’s. The solutions need to come from all sectors of society and be directed at all stages of people’s lives.