Plenary 1 Chair: Professor Gareth Williams Health Impact Assessment: Making the Difference
Plenary 1 Chair: Professor Gareth Williams
Health Impact Assessment: Making the Difference
Professor Sally Macintyre
Director of the Medical Research Council and Public Health Sciences Unit, Glasgow
Health Impact Assessment: Making the Difference
Inequalities in Health:
Implications for Health Impact Assessment
Sally Macintyre
7th International Health Impact Assessment Conference 2006
Outline
Pervasiveness and magnitude of inequalities in health Lack of knowledge about how to reduce them Reasons for lack of knowledge HIA and evaluation Closing the feedback loop
Inequalities in health
Socio-economic status Gender Race/ethnicity Place of residence And other axes of stratification e.g.
religion, caste
In all known societies:
Health risks, health behaviours, physical and mental health and life
expectancy vary between social groups defined in terms of:
Life expectancy, USA, 2003
Males Females Difference
White 75.4 80.5 5.1
Black 69.2 76.1 6.9
Difference 6.2 4.4
Congressional Research Service, Library of congressLife Expectancy in the USA, March 2005
Life expectancy gap Social Class I – V, England 1997 - 2001
Males 8.4 years
Females 4.5 years
DH, Tackling Health Inequalities, Status Report 2005
Life expectancy in Scotland 2004 IBy Local Government Areas
Men Women
Aberdeenshire 76.3 80.8
East Dunbartonshire 77.0 80.4
Glasgow City 69.3 76.4
GRO Scotland 2005
Life expectancy in Scotland 2004 IIBy constituency, Glasgow Area
Men Women
Eastwood 76.3 81.3
Strathkelvin 76.2 80.3
Springburn 66.6 74.8
Shettleston 63.9 75.2
Health Scotland 2004
Life expectancy in New Zealand by ethnic group,1996 - 1999
Men Women
Maori 64.0 68.7
Pacific 67.9 73.9
Non-Maori, Non-Pacific 75.7 80.8
Difference/Non-Maori, Non-Pacific 11.7 12.1
Blakely et al 2005
Average rates do not predict inequalities
Peru Uzbekistan
Mean: 49.9 Mean: 46.8
Poor: 78.3 Poor: 49.5
Rich: 19.5 Rich: 43.5
Robinson et al, in press
Infant mortality rates
Acheson Report 1998
“We recommend that as part of health impact
assessment, all policies likely to have a direct or
indirect effect on health should be evaluated in
terms of their impact on health inequalities, and
should be formulated in such a way that by
favouring the less well of they will, wherever
possible, reduce such inequalities.”
Acheson 1998, p30
“A well intended policy which improves average
health may have no effect on inequalities. It may
even widen them by having a greater impact on the
better off. Classic examples include policies aimed
at preventing illness, if they resulted in uptake
favouring the better off. This has happened in
some initiatives concerned with immunisation and
cervical screening, as well as in some campaigns to
discourage smoking or to promote breastfeeding.”
Acheson 1998, p30
Acheson ‘Evaluation Group’: Conclusions
lots of data documenting health inequalities lots of research attempting to explain health inequalities little information about effectiveness of interventions even less information about potential harms, costs or priorities evidence clearer for downstream than upstream interventions
Macintyre, Chalmers, Horton, Smith 1998
Reducing Inequalities in Health:A European Perspective
work policies - poor design, or health outcomes unevaluated food policies - ‘little information on the long term effects ….’ smoking - ‘little direct evidence that permits any definitive
judgements’ children - many interventions: ‘most are not well known and very
few have been systematically evaluated’ access to healthcare - ‘paucity of studies about the best ways to
reach poorer people with appropriate and effective services’
Mackenbach & Bakker, 2002
Wanless report: Securing good health for the whole population 2004
‘Although there is often evidence on the scientific justification for action and for some specific interventions, there is generally little evidence about the cost-effectiveness of public health and preventative policies or their practical implementation…
little evidence about what works among disadvantaged groups to tackle some of the key determinants of health inequalities’
Lack of evaluations of outcomes
Of published or funded public health research in UK, 4% deal with interventions rather than descriptions of the problem
only 10% of them (0.4%) deal with outcomes of interventions in specific topic areas evidence about inequalities, and tools for
capturing social differences, not very robust very few systematic reviews have focused on effect of
interventions on inequalities in health
Millward L, Kelly MP & Nutbeam D, 2001 Public Health Intervention Research: The Evidence, London, HDA
Reasons for paucity of evidence
Short government time scales; no time to wait for pilots or long term evaluations
Evaluations problematic (window dressing?) Lack of routine data for monitoring inequalities Assumption that systematic reviews and RCTs are not suitable for
real life community initiatives Assumption that plausibility is a good basis for policy making Assumption that public health interventions can’t do harm Assumption that it is enough to know about aggregate effects
Post 1997 Labour Government
Reducing inequalities overarching goal
programmes introduced to do this without knowing whether they’ll work
government focus on inputs and throughputs not effectiveness
Reducing health inequalities; an Action Report 1999
New deal for communities New deal for employment Single Regeneration budget Health Action Zones Healthy Living Centres Healthy Schools Programme Working Families tax credits Sure Start
Demonstration programmes in Scotland
Poor evidence base in first place Evaluations set up too late Programmes non evaluable Decisions on phase 2 taken before evaluations complete
Evaluation Task Force Review, Scottish Executive, 2004
Lack of good routine data to monitor inequalities
social class or area deprivation indices only available every ten years health surveys not large enough or long enough series social class, ethnicity, etc. not collected in NHS records intervention studies don’t report differential effects by social class,
ethnicity, etc.
Systematic reviews not suitable for real life community initiatives?
But:
Systematic reviews have been conducted on:
youth mentoring programmes impacts of after-school programs on student outcomes strategies related to the prevention, detection, management and
response to terrorism effects of closed circuit television surveillance on crime effects of improved street lighting on crime home based support for socially disadvantaged mothers
RCTs not suitable for real life community initiatives?
But:
RCTs have been conducted on:
re-housing effectiveness of out-of home day care for disadvantaged families prison rehabilitation programs raids on crack houses
Systematic review of area based regeneration initiatives in the UK
Little evidence of the impact of national urban regeneration on socio-economic or health outcomes.
Changes often no different from national trends.
However, some harms: Single Regeneration Budget 1996 - 1999;
deterioration in self reported health Urban programme and City Challenge;
worsening of unemployment Estate Action; increased housing costs Housing improvement in 1930s Scotland; rents
doubled, mortality rates increased (residents couldn’t afford adequate food)
Thompson et al, 2006