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Professor Clare Bambra

Newcastle University & Fuse

1: Health Inequalities

2: Insights from Theory

3: Evidence from Practice4: Future Prospects

OverviewOverviewOverviewOverview

Part 1: Health InequalitiesPart 1: Health InequalitiesPart 1: Health InequalitiesPart 1: Health Inequalities

“systematic differences in health

between different socio-economic

groups within a society … Because

they are socially produced they are

potentially avoidable and widely

considered unacceptable in a

civilised society”

Prof Dame Margaret Whitehead

Bambra, C. (2016) Health Divides: where you live can kill you, Bristol: Policy Press

Bambra, C. (2016) Health Divides: where you live can kill you, Bristol: Policy Press

Then and Now

National Survey for Wales 2016-17:Percentage of adults who were overweight or obese, by area deprivation

0

10

20

30

40

50

60

70

Quintile 1 - Most

deprived

Quintile 2 Quintile 3 Quintile 4 Quintile 5 - Least

deprived

Pe

rce

nt

Overweight or obese Obese

13.6 13.5 13.2 13.5

7.89.4

8.6 8.8

2012/13 2013/14 2014/15 2015/16

Most deprived Least deprivedDifference between

most and least deprived

Percentage of children aged 4 to 5 years who are obese, most and

least deprived fifth in Wales, Child Measurement Programme for

Wales, 2012/13-2015/16

Produced by Public Health Wales Observatory, using CMP data (NWIS) and WIMD 2014 (WG)

5.74.1 4.6

4.7

Loring & Robertson (2014) Obesity and inequities - Guidance for addressing inequities in overweight and obesity.

WHO Regional Office for Europe

Country Total Prevalence Highest Lowest Absolute RII 95% CI

Italy 5.0 1.5 9.7 8.2 6.03 4.71–7.71

Norway 6.8 5.9 6.4 0.5 1.75 0.76–4.01

Spain 7.0 3.0 12.3 9.3 5.09 3.08–8.44

France 11.1 5.0 19.9 14.9 4.21 2.46–7.21

Netherlands 11.4 6.4 17.0 10.6 2.87 1.89–4.34

Sweden 13.5 4.7 28.2 23.5 3.87 2.12–7.04

Germany 15.2 4.9 24.6 19.7 5.07 2.95–8.71

England 23.3 15.6 29.4 13.8 2.19 1.66–2.87

Thomson et al. (2017) Regional inequalities in self-reported conditions and non-communicable diseases in European countries: Findings

from the European Social Survey (2014) special module on the social determinants of health European Journal of Public Health 27 (S1)

14-21

Part 2: Insights from Theory Part 2: Insights from Theory Part 2: Insights from Theory Part 2: Insights from Theory

A. Causes of health inequalities

B. Levels of intervention

C. Approaches to reduction

Socially Produced?

A: Causes of Health Inequalities

• Behavioural/Cultural model

• Materialist

• Psychosocial

• Life course

• Political Economy

Behavioural/Cultural model

Lakshman, R., et al., Association between area-level socioeconomic deprivation and a cluster of

behavioural risk factors: cross-sectional, population-based study. Journal of Public Health, 2011.

33(2): p. 234-245.

Materialist

• Study of Leeds, Yorkshire found that for every additional fast food outlet, child obesity increased by 1%

• Every 1 point Increase in neighbourhood deprivation led to 0.3% increased risk of obesity

Psychosocial• Whitehall 2 study found a dose-

response relationship between work stress and risk of obesity.

• Odds ratio of obesity for one, two, and three or more periods of work stress were 1.17, 1.24, and 1.73 (trend p < 0.01)

• Work stress higher amongst lower SES

Life course

• Intergenerational transmission -HSE study

• Two overweight parents associated with an increased risk of child obesity OR = 2.2

• Having two obese parents = even higher risk of child obesity OR = 12.0;

• Two severely obese parents OR = 22.3

Political Economy

Rise of neoliberalism by welfare regime

Women Overweight and/or Obese by welfare state regime

A neoliberal epidemic?

B: Levels of Intervention

• Strengthening individuals

• Strengthening communities

• Improving living and working conditions

• Promoting healthy macro policy

C: Policy Approaches

1. Improving the position of the most disadvantaged groups

2. Reducing the gap between the best and worst off

3. Shifting the entire social gradient in health

4. Proportionate universalism

Framework for Reducing Inequalities in Obesity

APPROACH

LEVEL

Individual Community Societal

Strengthening Individuals Strengthening Communities Improving Living and

Working Conditions

Promoting Healthy

Macro Policies

Disadvantage Targeted

Individual health

promotion and lifestyle programmes

Community based health

promotion and lifestyle programmes

Gap

Gradient

Proportionate

Universal Tackling obesogenic environment

Restrictions,regulations and

fiscal measures

Behavioural

Psychosocial

Material

Political EconomyLife course

Part 3: Evidence from PracticePart 3: Evidence from PracticePart 3: Evidence from PracticePart 3: Evidence from Practice

Child Review: Individual

• Screen time reduction can have beneficial effects in low SES but not high SES children (short & long term)

• Mentor-based health promotion can have beneficial long-term effects among low SES who are most at risk (overweight and obese)

Hillier-Brown FC, et al. A systematic review of the effectiveness of individual, community and

societal level interventions at reducing socioeconomic inequalities in obesity amongst children.

BMC Public Health 2014;14:834

Community

• School-based nutrition and physical activity education combined (not education only) with exercise sessions can be effective in low SES school-aged children

• Family-based education can be beneficial for weight loss and weight maintenance for whole social gradient

• Group-based exercise only (but not education only) may result in short-term weight loss among low SES school-aged children

Hillier-Brown FC, et al. A systematic review of the effectiveness of individual, community and

societal level interventions at reducing socioeconomic inequalities in obesity amongst children.

BMC Public Health 2014;14:834

Societal

• No societal level studies found –evidence gap

Hillier-Brown FC, et al. A systematic review of the effectiveness of individual, community and

societal level interventions at reducing socioeconomic inequalities in obesity amongst children.

BMC Public Health 2014;14:834

Example Interventions

Example 1:

• A two-year School Nutrition Policy Initiative based on multifaceted education and environment interventions in some low-income schools in the USA increased nutritional knowledge, the availability of healthy food, and reduced the amount of overweight children by 35%.

Example 2:

• An Australian ‘Be Active Eat Well’ intervention designed to build a community’s capacity to create its own solutions to promoting healthy eating, physical activity and healthy weight found that after three years children in the intervention schools had significantly lower increases in waist circumference and BMI.

Child Review Summary

• Evidence suggests that individual, community and societal interventions do not increase inequalities in obesity

• School-based educational and environmental interventions were found to be the most effective in reducing inequalities

• Community empowerment may also play an important role in effective public health obesity interventions.

• No evidence of societal interventions – evidence gap

• Evidence of effectiveness limited to primary school children

• Evidence is largely based on international studies

• High quality studies need to be undertaken in the UK and among adolescents.

Hillier-Brown FC, et al. A systematic review of the effectiveness of individual, community and

societal level interventions at reducing socioeconomic inequalities in obesity amongst children.

BMC Public Health 2014;14:834

For more …

• Dr Frances Hillier-Brown

• 3pm Friday

• ASO Symposium 4 "Public health & workplace interventions to tackle social inequalities and obesity"

• Main Auditorium

Part 4: Future ProspectsPart 4: Future ProspectsPart 4: Future ProspectsPart 4: Future Prospects

Women

Men

Trend in adult obesity prevalence by social classHealth Survey for England 1994 to 2013 (five year moving average*)

Adult (aged 16+) obesity: BMI ≥ 30kg/m2

I - Professional II - Managerial technical IIIM - Skilled manual

IIIN - Skilled non-manual IV - Semi-skilled manual V - Unskilled manual

I - Professional II - Managerial technical IIIM - Skilled manual

IIIN - Skilled non-manual IV - Semi-skilled manual V - Unskilled manual

Men Women

Acknowledgements