Alistair Woodward

Why reduce health inequalities

It is well known that social, cultural and economic factors cause substantial inequalities in health. Should we strive to achieve a more even share of good health, beyond improving the average health status of the population? We examine four arguments for the reduction of health inequalities. 1 Inequalities are unfair. Inequalities in health are undesirable to the extent that they are unfair, or unjust. Distinguishing between health inequalities and health inequities can be contentious. Our view is that inequalities become “unfair” when poor health is itself the consequence of an unjust distribution of the underlying social determinants of health (for example, unequal opportunities in education or employment). 2 Inequalities affect everyone. Conditions that lead to marked health disparities are detrimental to all members of society. Some types of health inequalities have obvious spillover effects on the rest of society, for example, the spread of infectious diseases, the consequences of alcohol and drug misuse, or the occurrence of violence and crime. 3 Inequalities are avoidable. Disparities in health are avoidable to the extent that they stem from identifiable policy options exercised by governments, such as tax policy, regulation of business and labour, welfare benefits and health care funding. It follows that health inequalities are, in principle, amenable to policy interventions. A government that cares about improving the health of the population ought therefore to incorporate considerations of the health impact of alternative options in its policy setting process. 3 Interventions to reduce health inequalities are cost effective. Public health programmes that reduce health inequalities can also be cost effective. The case can be made to give priority to such programmes (for example, improving access to cervical cancer screening in low income women) on efficiency grounds. On the other hand, few programmes designed to reduce health inequalities have been formally evaluated using cost effectiveness analysis. We conclude that fairness is likely to be the most influential argument in favour of acting to reduce disparities in health, but the concept of equity is contested and susceptible to different interpretations. There is persuasive evidence for some outcomes that reducing inequalities will diminish “spill over” effects on the health of society at large. In principle, you would expect that differences in health status that are not biologically determined are avoidable. However, the mechanisms giving rise to inequalities are still imperfectly understood, and evidence remains to be gathered on the effectiveness of interventions to reduce such inequalities.

Daily mortality in relation to weather and air pollution in Christchurch, New Zealand

Objective : To investigate the relationship between the daily number of deaths, weather and ambient air pollution.

National infant mortality rates in relation to gross national product and distribution of income.

We examined the relation between infant mortality rates, gross national product, and income distribution. Our findings support the hypothesis that average measures of population health are influenced by the distribution of income within societies.

Anonymous linkage of New Zealand mortality and Census data

Background : The New Zealand Census‐Mortality Study (NZCMS) aims to investigate socio‐economic mortality gradients in New Zealand, by anonymously linking Census and mortality records.

Does the frame affect the picture? A study into how attitudes to screening for cancer are affected by the way benefits are expressed

Objective To find out how presenting information about the benefits of screening for cancer in different ways affects an individuals decision to accept or reject screening. Methods A telephone survey of the Wellington region, New Zealand was carried out. Results A response rate of 75.6% was obtained. Respondents were most likely to accept screening when the benefits of screening were presented as a relative risk reduction. They were most likely to reject screening when the benefits were presented as numbers needed to screen to save one life. Conclusions An individuals decision about screening for cancer is affected by the way the benefits are framed. Health professionals must choose between framing the benefits of screening in the most positive light, to enhance participation rates, and presenting information in such a way as to reduce framing effects—for example, by expressing the benefits in a variety of forms. Clearly there may be a tension between these approaches; the former is arguably manipulation, and the latter may enhance informed choice, but may also reduce participation rates in screening programmes.

Socioeconomic deprivation and fatal unintentional domestic fire incidents in New Zealand 1993-1998

A cross-sectional study was undertaken in Aotearoa New Zealand to investigate the relationship between socioeconomic deprivation and risk of an unintentional fatal domestic fire incident. Addresses of unintentional fatal domestic fire incidents were geocoded to small area (census meshblock) level and analysed with the New Zealand index of socioeconomic deprivation. Fatal unintentional domestic fire incidents occurred disproportionately in dwellings in the most socioeconomically deprived meshblocks. Annual rates of fatal unintentional fire incidents per 100,000 households in the most deprived decile were significantly higher than rates in the least deprived decile (RR 5.6, 95%CI 1.9-16). Strategies to prevent fire related deaths must overcome barriers to household fire safety in population groups experiencing increased risk, including the socioeconomically deprived, seniors, and ethnic minorities. Specific intervention strategies relevant to risks associated with socioeconomic deprivation include improving quality and affordability of housing; increasing prevalence of installed and functioning smoke detectors; and regulation of specific characteristics of cigarettes to reduce risk of ignition from abandoned heat sources. Substantial progress awaits reduction of the underlying socioeconomic determinants of disadvantage.

Questionnaire and hair measurement of exposure to tobacco smoke

To assess the relation between nicotine and cotinine levels in hair and reported exposure to environmental tobacco smoke (ETS), hair samples from 112 children (aged 3 months to 10 years) and 76 of their mothers were analyzed and information on the smoking habits of household adults in the preceding 6 months recorded. It was found that the levels of nicotine in childrens hair were related to the number of smokers in the house, and increased with the total number of cigarettes smoked by all household adults (P<0.0001). In a multiple regression analysis, mothers smoking was much more a contributor to childrens nicotine levels than smoking by the father or other household adults. Cotinine levels were less strongly associated with reported ETS exposure than nicotine. There was a strong correlation between nicotine hair levels in children and mothers (rs=0.7, P<0.0001). However, nicotine levels in the hair of active smokers were not correlated with the reported number of cigarettes they smoked per day. In this population, there was a consistent relation between exposure to ETS (assessed by questionnaire) and dose (as measured by nicotine in hair). We conclude that hair nicotine levels rather than hair cotinine levels provide an informative and objective measure of ETS exposure. The number of cigarettes smoked by active smokers may not be an accurate measure of the total nicotine levels in their bodies.

Protecting human health in a changing world: the role of social and economic development

The biological and physical environment of the planet is changing at an unprecedented rate as a result of human activity, and these changes may have an enormous impact on human health. One of the goals of human development is to protect health in the face of rapid environmental change, but we often fail to do this. The aim in this paper is to distinguish between socioeconomic aspects of development that are likely to be protective and those that are likely to increase vulnerability (the capacity for loss resulting from environmental change). Examples include climate change in the Pacific. We conclude that protecting human health in a changing world requires us to take steps to minimize harmful change wherever possible, and at the same time to be prepared for surprises. The goals of mitigation (reducing or preventing change) and adaptation (response to change) are not mutually exclusive. In fact, steps to make populations more resilient in the face of change are often similar to those that are needed to lighten the load on the environment. We need social policies that convert economic growth into human development. Wider application of sustainable development concepts is part of the solution. In particular, there is a need to promote health as an essential asset of poor and vulnerable populations. It is their key to productivity and to surviving shocks; it is also the key to achieving broader development goals such as universal education. For these reasons it is in the interests of all sectors--economic, social and environmental--to play their particular roles in protecting and improving health.

Socioeconomic Deprivation and Ethnicity are both Important for Anti-tobacco Health Promotion

The aim of the study was to explore the relative importance of socioeconomic deprivation and ethnicity for smoking in New Zealand in order to assist with the design and evaluation of health promotion programs. Smoking data were derived from the 1996 census. Socioeconomic deprivation was measured using the NZDep96 index of socioeconomic deprivation for small areas, which combines nine variables from the 1996 census. There was a strong and consistent relationship between area-level socioeconomic deprivation and the proportion of regular smokers. In all age-groups, at each level of deprivation, Mäori smoked more than the “European and Other” ethnic group. The findings of this study support the view that effective tobacco control activities should address ethnic differences in smoking behavior as well as socioeconomic deprivation, and must operate at the levels of populations, places and environments, as well as individuals.

Measures of exposure to environmental tobacco smoke. Validity, precision, and relevance.

Abstract: It is often not clear what the best measures of exposure are for a risk assessment, or even how one should answer this question. Environmental tobacco smoke (ETS) provides a good example for an exploration of uncertainty. There are a variety of methods for estimating exposure and each has shortcomings. In this paper we summarize the physical characteristics of ETS and the principal methods for assessing exposure. We review the accuracy and applicability of these methods, and explore major sources of uncertainty in the assessment of ETS.