INEQUALITIES

IN
HEALTH
STATUS
Prepared by:
Mary Ann B. Valencia,
RPh
Inequalities in Health Status
Health inequalities versus health inequities
Health inequality  Generically refers to differences in the
health of individuals or groups.
 Any measurable aspect of health that
varies across individuals or according to socially relevant
groupings.
Health inequity  or health disparity
 is a specific type of health inequality that
denotes an unjust difference in health
 are systematic differences in health that
could be avoided by reasonable means
Inequalities in Health Status
Health inequalities versus health inequities

The key distinction between the

terms inequality and inequity is that the former is simply a
dimensional description employed whenever quantities are
unequal, while the latter requires passing a moral judgment that
the inequality is wrong.
Inequalities in Health Status
Health inequalities versus health inequities
The term health inequality can describe racial/ethnic disparities in US infant
mortality rates, which are nearly three times higher for non-Hispanic blacks versus
whites, as well as the fact that people in their 20s enjoy better health than those in
their 60s. Of these two examples, only the difference in infant mortality would also be
considered a health inequity. Health differences between those in their 20s versus 60s
can be considered health inequalities but not health inequities. Health differences
based on age are largely unavoidable, and it is difficult to argue that the health
differences between younger and older people are unjust, since older people were
once younger people and younger people, with some luck, will someday become old.
On the other hand, differences in infant mortality rates among racial/ethnic
groups in the United States are partially attributable to preventable differences in
education and access to health and prenatal care. Unlike the example of age-related
health differences, disparities in health outcomes across racial/ethnic groups could be
aggressively prevented. Policies and programs that improve access to health and
prenatal care for underserved US racial/ethnic groups, for example, could reduce
unjust differences in infant health outcomes.
Inequalities in Health Status
CONCEPTS FOR OPERATIONAIZING THE STUDY OF
HEALTH INEQUALITY
A. Group-level differences versus overall health distribution
There are two main approaches to studying inequalities within and
between populations. Most commonly, we examine differences in health
outcomes at the group level to understand social inequalities in health. For
example, we might ask how mean body mass index (BMI) of the poor
compares to that of the rich. Because recognizing social group differences in
health is necessary for targeting investments to the worst off groups, a group-
level approach can support the creation of laws and programs that seek to
eliminate social group differences. Because social inequities in health are
shaped by unfair distributions of the social determinants of health, tracking
social group differences in health is important for monitoring the state of
equity in a society.
Inequalities in Health Status
CONCEPTS FOR OPERATIONAIZING THE STUDY OF
HEALTH INEQUALITY
A. Group-level differences versus overall health distribution
Alternatively, it is possible to focus on health differences across
individuals, for example, describing the range or variance of a given measure
across an entire population. This method is agnostic to social groupings,
effectively collapsing all people into one distribution. Researchers studying
global income inequality have used this approach to highlight the relative
wealth of poor individuals in rich countries compared to well-off individuals
in poor countries. For example, In contrast to focusing on how people from
similar backgrounds compare to one another, exploring the income
distribution across one global population has yielded important insights into
just how unequally resources are currently distributed, as well as what
factors drive these differences.
Inequalities in Health Status
CONCEPTS FOR OPERATIONAIZING THE STUDY OF
HEALTH INEQUALITY
B. Social group health inequalities: defining groups
Health disparities along racial, ethnic, and socioeconomic lines are
observed in both low- and high-income countries, and may be widening,
underscoring the importance of studying of group-level health differences.
Understanding socially patterned health disparities requires constructing
meaningful groups of individuals. Each society has its own unique ways of
stratifying and dividing people into social groups. In Australia, the distinction
between white Australians and aboriginal people is meaningful, while in India,
caste is important. Race/ethnicity is a particularly meaningful distinction in the
United States, while the level of schooling achieved contributes to social
divisions in the United Kingdom.
Inequalities in Health Status
A ‘social gradient’ in health exists where increasing quantities of social
resources such as education, social class, or income correspond with increasing
levels of health in a dose–response relationship.
Inequalities in Health Status
Inequalities in Health Status
C. Absolute versus relative social position
Notions of absolute versus relative poverty highlight that measures of
income can be both objective and subjective. The amount of money in one's
bank account is an objective measure of wealth. Whether someone feels
wealthy or poor in relation to his neighbors is a subjective measure of wealth.
Absolute poverty, which is an objective measure of wealth, is a useful
measure for testing the absolute income hypothesis, which posits that an
individual's health depends only on his own income and not on what others
in a population earn.
Inequalities in Health Status
D. Geographic health inequalities: place versus space
Geographic setting, not just social group, plays an important role in
shaping health. Differentiating the concepts of space and place helps us to
better understand the different ways in which geography can affect health.
Space deals with measures of distance and proximity such that exposure to
spatially distributed health risks and protective factors will change according to
an individual's precise location. For example, air pollution that exacerbates
asthma symptoms would be an example of a health risk that is distributed
across space. Proximity to landfills, crime clusters, and health clinics are other
examples of spatially patterned health risks and protective factors. In
contrast, place refers to membership in political or administrative units, such as
school districts, cities, or states. Many government run programs and policies
that affect health, such as food assistance programs or tax policies, are specific
to administrative units and operate uniformly within their boundaries. As a
result, the health impacts of a wide range of programs and policies do not
depend on residents’ precise physical location, but rather on membership in a
given political or administrative unit.
Inequalities in Health Status
E. Tracking health inequalities over time
Inequalities between groups can be expressed as absolute differences or
as relative differences. Computing absolute differences involves subtracting
one quantity from another, while expressing relative difference requires
dividing one quantity by another to produce a ratio. As health differences are
tracked over time, absolute differences between groups can increase while
relative differences increase, or vice versa. For instance, if 10 people per
100,000 are hospitalized for asthma each year in State A while 20 per 100,000
are hospitalized for asthma in State B, the absolute difference in asthma
hospitalizations is 10 per 100,000. There are a few points to note in this
example. First, both villages enjoy very low asthma hospitalization rates,
though this fact is lost when only reporting on the magnitude of the inequality.
Secondly, while a difference of 10 hospitalizations per 100,000 is relatively
small, the villages appear to have vastly asthma hospitalization rates when the
difference is expressed as a ratio.
Inequalities in Health Status
FRAMEWORK FOR UNDERSTANDING HEALTH INEQUALITIES
A. Causal pathways and conditional health effects
When studying the relationship between an exposure, such as
occupation, and an outcome, such as blood pressure, it often becomes clear
that a third variable matters as well. Variables that lie on the causal pathway
between exposure and outcome, called mediators, are those that explain how
a given exposure leads to an outcome of interest. For instance, in a study of
occupation and its effects on blood pressure, we might learn that income is
the link that explains how a person's job influences their blood pressure. In
this example, occupation could determine income, which then might affect
blood pressure by influencing whether a person can buy healthy food, receive
adequate medical care, or experiences stress over financial matters.
Inequalities in Health Status
B. Selection
Selection is another fundamental concept for understanding health
inequalities. Selection refers to the fact that people have a tendency to sort
themselves into neighborhoods, social groups, and other clusters.
Selection is also sometimes proposed as an explanation for educational,
occupational, and even racial/ethnic differences in health.
C. Context versus Composition
When selection may be a source of geographic health inequalities,
researchers generally want to
distinguish contextual from compositional effects. Contextual effects refer to
the influence a neighborhood or other type of higher level unit has on
people, while compositional effects are simply reflective of the characteristics
of individuals comprised by the neighborhood or other setting.
Inequalities in Health Status
C. Context versus Composition

Classrooms, schools, neighborhoods, states, hospitals, and other units of

organization can all exert contextual effects. Contextual factors that affect
health include policies, infrastructural resources, and public support programs
and are, therefore, potential targets of intervention for reducing health
inequalities.
Compositional effects refer to variations in health attributable to the
health status of the individuals who are members in a given context. If the
construction of a specialized healthcare facility suddenly attracted large
numbers of chronically ill residents to a given neighborhood, the poor health
status of residents in that neighborhood compared to surrounding areas
would be compositional.
Inequalities in Health Status
D. Life course perspective
The impact of geography and social group membership on health is not
only powerful but also persistent. Differences in early life and in
utero circumstances can impact later health regardless of subsequent life
events, generating health inequalities between social groups. There are critical
or sensitive developmental periods during which health is affected in ways
that cannot be completely reversed. For example, poor nutrition in
adolescence, when bones develop, could put individuals at risk for bone
fracture in later life, regardless of attempts to slow bone loss in adulthood.
Habits that develop early in life may influence the trajectory of one's health
choices.
Inequalities in Health Status
When social mobility is low and socially marginalized groups have historically
limited options about where to live, early life conditions may be especially powerful in
explaining current health inequalities. For example, in societies that struggle with the
intergenerational transfer of poverty, or have a long history of ghettoizing marginalized
groups, it is likely that individuals currently exposed to socially patterned health risks
were previously exposed to socially patterned health risks as well.

The impact of socioeconomic status on health across the life course.

Inequalities in Health Status
EXPLAINING HEALTH INEQUALITIES
Social epidemiologists apply the concepts presented above to help
measure and understand health inequalities.
• One type of explanation points to material factors in the creation of health
disparities. Material factors include food, shelter, pollution, and other
physical risks and resources that influence health outcomes. Measures of
absolute resources, such as absolute income, are useful in testing the role
of material deprivation in creating health differences, as are objective
measures of physical health risk factors such as air quality. An unequal
distribution of physical health risks and resources across geographies and
social groups contributes to social inequalities in health via material
pathways.
Inequalities in Health Status
EXPLAINING HEALTH INEQUALITIES
• A second class of explanation points to psychosocial factors as driving
health inequalities and social group differences in health in particular.
Psychosocial health impacts stem from feelings of social exclusion,
discrimination, stress, low social support, and other psychological reactions
to social experiences. Negative psychological states affect physical health by
activating the biological stress response, which can lead to increased
inflammation, elevated heart rates, and blood pressure, among other
outcomes. Measures of relative position, perceived versus objectively
measured variables, and instruments that capture different experiences of
stress are all useful in studies of psychosocial risk factors. To the extent that
certain social groups are systematically more likely to have stressful,
demoralizing, and otherwise emotionally negative experiences,
psychosocial factors can help explain health inequities.
Inequalities in Health Status
EXPLAINING HEALTH INEQUALITIES
• Behavioral differences are also commonly cited as contributing to health
inequalities. For example, a behavioral explanation might attribute health
inequalities to differences in eating habits, smoking prevalence, or cancer
screening rates across social groups or across individuals in a population.
While health behaviors often do vary across groups, Eco social and social–
ecological frameworks prompt us to ask what upstream factors might be
responsible for these variations. For example, if differences in smoking
rates are caused by unequal educational opportunities, an inequitable
distribution of psychosocial risk factors, and targeted marketing, attributing
health disparities to behaviors may be of limited usefulness.
Inequalities in Health Status
EXPLAINING HEALTH INEQUALITIES
• A fourth type of explanation points to differences in biological health risk
factors that are patterned across social groups or contexts, or vary across
individuals in a population. Biomedical explanations can suffer the same
weaknesses as behavioral explanations for social inequalities in health
when they focus on the downstream effects of social context without
acknowledging why levels of biological risk factors vary across populations.
Genetic and gene-by-environment interactions explanations are also, in
part, biomedical in their nature. This class of explanation may be more
useful for understanding variations in health observed across individuals in
a population where social group differences are not the focus of
investigation.
Inequalities in Health Status
NEW SCENARIOS REGARDING SOCIAL INEQUALITIES IN HEALTH
A. Urbanization and the importance of cities
In 2014, 54% of the world population lived in urban areas. In 1950, this
percentage was only 30% and it is estimated that in 2050 this percentage will
exceed 70%. The highest rates of urbanization are in North America (82% of
the population) and the lowest are in Africa (40% of the population). Latin
America and the Caribbean have high urbanization rates, with 80% of their
population concentrated in urban areas, rates that are close to that of North
America.
This intense growth in urbanization was due to the massive transfer of
the rural population to urban areas. The definition of urban can range from
agglomerations with a few thousand inhabitants to megacities with several
million inhabitants. In relatively restricted areas these centers group together
a large number of people. These agglomerations create a series of problems
and challenges which have repercussions in the health sphere; there tends to
be an unequal and unfair distribution of space between social groups.
Inequalities in Health Status
B. Migrations and the limits of human movements
Since time immemorial, sectors of populations or even whole populations
have moved to new destinations for various reasons. In 2013, it was estimated
that 232 million people - 3.2% of the world’s population - lived outside their
country of birth, and another 700 million were internal migrants in their own
country of birth. The patterns and motives for these migratory movements
have changed greatly over time; however, it is clear that the majority of
migrants who cross national borders do so in search of better economic and
social opportunities. In recent decades, exacerbated disparities between
nations, global economic expansion, geopolitical transformations, wars,
ecological disasters and many other occurrences have had, and will continue to
have, a profound impact on people’s decisions to move to other nations. The
recent phenomenon of the massive migration from some Arab countries to
Europe is an example of the explosive and uncontrolled possibilities that the
migratory issue can generate.
Inequalities in Health Status
GLOBAL HEALTH CONDITIONS: THE EXPANSION OF INEQUALITIES
A. A BRIEF SUMMARY OF INEQUALITIES BETWEEN NATIONS
An estimated 800 million people worldwide are chronically hungry. One in six
children in developing countries is underweight, and more than one-third of
deaths among children under five are attributable to malnutrition. Insufficient
access to safe and nutritious food exists despite the fact that global food
production is sufficient to cover 120% of global dietary needs.
Life expectancy at birth is an important marker of health conditions and the
chances of survival for a population. On the global average, the life
expectancy at birth of an individual in 1990 was 64 years; in 2013 that number
had increased by seven years to 71 years. However, as averages these values
conceal a series of inequalities. For example, in 2013 the average life
expectancy at birth in countries ranged from a minimum of 46 years (38 in
1990) in Sierra Leone, to 84 (79 in 1990) in Japan. By 2013, life expectancy
had increased in both countries and although the gap has narrowed slightly
(from 41 to 38 years) they are still at unacceptable levels.
Inequalities in Health Status
10 facts on health inequities and their causes

There is ample evidence that social factors, including

education, employment status, income level, gender and
ethnicity have a marked influence on how healthy a person is. In
all countries – whether low-, middle- or high-income – there are
wide disparities in the health status of different social groups.
The lower an individual’s socio-economic position, the higher
their risk of poor health.
Inequalities in Health Status
10 facts on health inequities and their causes
A. Fact 1: Health inequities are systematic differences in health outcomes
Health inequities are differences in health status or in the distribution of health
resources between different population groups, arising from the social conditions in
which people are born, grow, live, work and age. Health inequities are unfair and could
be reduced by the right mix of government policies.
Inequalities in Health Status
B. Fact 2: Every day 16 000 children die before their fifth birthday
They die of pneumonia, malaria, diarrhoea and other diseases. They are 14 times more
likely to die before the age of five in sub-Saharan Africa than the rest of the world.
Furthermore, children from rural and poorer households remain disproportionately
affected. Children from the poorest 20% of households are nearly twice as likely to die
before their fifth birthday as children in the richest 20%.
Inequalities in Health Status
C. Fact 3: Maternal mortality is a key indicator of health inequity
Maternal mortality is a health indicator that shows the wide gaps between rich and
poor, both between and within countries. Developing countries account for 99% of
annual maternal deaths in the world. Women in Chad have a lifetime risk of maternal
death of 1 in 16, while a woman in Sweden has a risk of less than 1 in 10 000.
Inequalities in Health Status
D. Fact 4: Tuberculosis is a disease of poverty
Around 95% of TB deaths are in the developing world. These deaths affect mainly young
adults in their most productive years. Contracting the disease makes it even harder for
these adults to improve their personal economic condition and that of their families.
Inequalities in Health Status
E. Fact 5: 87% of premature deaths due to noncommunicable diseases occur in low-
and middle-income countries
In low-resource settings, health-care costs for noncommunicable diseases (NCDs) can
quickly drain household resources, driving families into poverty. The exorbitant costs of
NCDs are forcing millions of people into poverty annually, stifling development.
Inequalities in Health Status
F. Fact 6: Life expectancy varies by 34 years between countries
In low-income countries, the average life expectancy is 62 years, while in high-income
countries, it is 81 years. A child born in Sierra Leone can expect to live for 50 years while a
child born in Japan can expect to live 84 years.
Inequalities in Health Status
G. Fact 7: There are alarming health inequities within countries, too
For example, in the United States of America, African Americans represent only about
13% of the population but account for almost half of all new HIV infections. There is no
biological or genetic reason for these alarming differences in health.
Inequalities in Health Status
H. Fact 8: Health disparities are huge in cities
In Glasgow, male life expectancy ranges from 66.2 years in Ruchill and Possilpark to 81.7
years in Cathcart and Simshill – a difference of 15.5 years. In London, when travelling
east from Westminster, each tube stop represents nearly one year of life expectancy lost
according to the findings of the London Health Observatory.
Inequalities in Health Status
I. Fact 9: Health inequities have a significant financial cost to societies
The European Parliament has estimated that losses linked to health inequities cost around
1.4% of gross domestic product (GDP) within the European Union – a figure almost as high
as the EU's defense spending (1.6% of GDP). This arises from loses in productivity and tax
payments, and from higher welfare payments and health care costs.
Inequalities in Health Status
J. Fact 10: Persistent inequities slow development
Close to 1 billion people in the world live in slum conditions, representing about one
quarter of the world's urban population. The likelihood of meeting the Sustainable
Development Goal 3 on good health and well-being is closely linked to the targets of
goal 11 on sustainable cities and communities.
Inequalities in Health Status
THE GROWTH IN HEALTH INEQUALITIES: POSSIBLE SOLUTIONS
There are clear academic and political arguments that favor the
implementation of actions to redress the determinants of health inequalities,
policies to mitigate these inequalities have been scarcely implemented as part
of the public policies of national governments, and still less to alleviate
inequalities between nations. There are several reasons for this lack of
political motivation; however, some aspects have been recurrent in the
literature regarding health inequalities.
One of the first aspects to consider is the consolidation of a health system
based on biomedical knowledge and the resulting technologies, together with
strong industrial and service sectors. These forces tend to generate and
consolidate health systems that are only slightly affected in conceptual and
structural terms, or favor actions directed at the social determinants of health.
Inequalities in Health Status
THE GROWTH IN HEALTH INEQUALITIES: POSSIBLE SOLUTIONS
Another aspect is that interventions regarding the social determinants of
health require coordinated action in relation to various aspects of the life of
societies, which in governmental terms implies multisectoral actions. The latter,
even when they are desired, are always difficult to coordinate and implement
from the political and technical points of view.
In poor and developing countries, where health inequalities are of the
highest magnitude, there are few examples of the latter being among the
priorities of public policy. For example, following the establishment by the WHO
of its Commission on Social Determinants of Health, Brazil, which is a country
with immense social and health inequalities, created its own national
commission. However, after two years of work this commission produced a
report which, in the main, was not assimilated into government actions.
Nevertheless, over the last two decades the implementation in many developing
countries of redistributive policies such as income-transfer and micro-credits,
which are non-health policies, have had positive effects on health inequalities.
Inequalities in Health Status
THE GROWTH IN HEALTH INEQUALITIES: POSSIBLE SOLUTIONS
With regard to inequalities between countries, the proposals and actions
have been even more timid. For example, the final report of the WHO
Commission on Social Determinants of Health places great emphasis on
inequalities within a particular society and less on inequalities between
nations. It has a chapter dedicated to the issue of health inequalities in the
global sense, which focuses on the need to strengthen so-called “global
governance” and explains the need for coordination among various
intergovernmental agencies. Some of these ideas were subsequently deployed
in actions, such as the Millennium Development Goals (MDGs), which focused
on the eradication of extreme poverty from 2000-2015 and their successor, the
Sustainable Development Goals (SDGs), which include the additional aspiration
of sustainable development in its three forms (economic, social and
environmental) during the period 2016-2030.
Inequalities in Health Status
THE GROWTH IN HEALTH INEQUALITIES: POSSIBLE SOLUTIONS

Interest in the issue of health inequalities has increased from the

academic point of view, this interest has only had a limited impact on public
policies aimed at improving the health of populations. Social inequalities in
health are a global problem that, to a greater or lesser extent, affects all
human societies. They are mainly due to the inequalities that exist between
the different social groups in each society. Although the inequalities that exist
between different societies and nations are relevant, and are often of a
greater magnitude, they are not always considered to be unjust, and as such
they are subject to political actions. The most plausible theory that has been
put forward to solve the latter type of inequalities has been to improve the
mechanisms of global governance, insofar as this includes an understanding of
how nations were historically founded and the effect of the position of each
country in the global productive system.
Inequalities in Health Status
UPDATES ON INEQUALITIES IN HEALTH STATUS
A. A LOOK AT URBAN HEALTH INEQUALITIES IN THE PHILIPPINES
Inequalities in Health Status