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![Considerations…….
The social conditions in which people live and work can help create or destroy their
health. Lack of income, inappropriate housing, unsafe workplaces and lack of access
to health care systems are some of the social determinants of health leading to
inequalities. (World Health Organization [WHO], 2004)
Prior to entry, a migrant’s health reflects the disease profile of his or her country of
origin….. In a new country, living and/or working conditions can also affect a
migrant’s health (ECDC, 2009)
Crowded, unventilated living conditions facilitate the spread of TB infection. Poor
housing conditions have been documented among migrants and ethnic minority
groups in the EU (Bates et al., 2004; Wanyeki et al.,2006; ECDC & WHO Regional Office for Europe,
2009)
Health services may be inaccessible by those most in need for several reasons:
e.g. gender, geographic distance from health care facilities, the costs associated
with receiving care and fear or stigma (WHO, 2010)](https://image.slidesharecdn.com/c-160222142226/75/Case-Study-of-Inequalities-22-2048.jpg)
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Case Study of Inequalities
This document discusses tuberculosis (TB) in Northern Ireland, including risk factors, epidemiology, and social determinants. It finds that non-UK born individuals and those living in deprived areas or crowded conditions have higher rates of TB. A case study examines a TB cluster among migrant workers from Timor-Leste living in poor housing and working conditions. The document calls for improved collection of health data and consideration of how social factors influence disease.
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Case Study of Inequalities
- 1. Tuberculosis Cathriona Kearns andMichael Devine ‘Health Protection Inequalities on the Island of Ireland’ Seminar, 18 February 2016 , Belfast
- 2. William Hogarth. Ginlane Tuberculosis – ‘The perfect expression of an imperfect civilisation’1 1.Dormandy T. The white death. New York: New York University Press, 2000.
- 3.
- 4. Risk factors forTB infection • Age: young adults/Young children/the elderly • Contact with a TB case • Immunocompromised patients • Ethnic minority groups: A large proportion of TB cases occur in those from ethnic minorities, In addition, those individuals born in, or arrived from, or returned from countries with a high incidence of TB within the last 5 years are at greater risk with a greater than average lifetime risk that extends to their children and close contacts born in the UK. • Lifestyle factors: alcohol or drug misuse. Less likely to access health services during the early stages of disease. • Living in crowded or unsanitary accommodation: (homeless, prison, poverty, malnutrition, overcrowding and poor housing encourage the spread of TB). • Smoking, diet: More than 20% of TB cases worldwide are attributable to smoking
- 6. Epidemiology of TBin Northern Ireland
- 7. 0.0 1.0 2.0 3.0 4.0 5.0 6.0 0 10 20 30 40 50 60 70 80 90 100 2000 2001 20022003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 NIrateper100,000 Numberofcases Non-UK UK born Rate/100,000 Mean rate TB case reports and rate (per 100,000) Northern Ireland, 2000-2014
- 8. 0.0 0.5 1.0 1.5 2.0 2.5 3.0 2008 2009 20102011 2012 2013 2014 Rateper100,000 UK-born 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 2008 2009 2010 2011 2012 2013 2014 Rateper100,000 Non-UK born Rates of TB in Northern Ireland in the UK and Non-UK born population
- 9. 0 2 4 6 8 10 12 14 2000 2001 20022003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Rate(per100,000) 0-14 15-44 45-64 65+ TB age-specific rates, Northern Ireland, 2000-2014
- 10. 1, 1% 8,3% 43, 18% 77, 32% 111, 46% 0-4 5-14 15-44 45-64 65+ 4, 2% 201, 80% 39, 15% 8, 3% 5-14 15-44 45-64 65+ Age profile of UK and Non-UK born TB cases 2008-2015 Non-UK born (n=252) UK born (n=240)
- 12. Distribution of NorthernIreland TB cases 2000-2015 by HSCT Monaghan Cavan Donegal Louth
- 13. 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 2000- 2002 2001- 2003 2002- 2004 2003- 2005 2004- 2006 2005- 2007 2006- 2008 2007- 2009 2008- 2010 2009- 2011 2010- 2012 2011- 2013 2012- 2014 Rateper100,000 BHSCT NHSCT SEHSCTSHSCT WHSCT Three year moving average rates of TB cases by HSCT in Northern Ireland, 2000-2014
- 14. 0.0 2.0 4.0 6.0 8.0 10.0 12.0 1 2 34 5 Rateper100,000 Deprivation quintile (1= most deprived, 5= least deprived) The Index of Multiple Deprivation (IMD) 2010, is an overall measure of multiple deprivation experienced by people living in an area and is measured at Super Output (SOA) level. Commissioned output is based on Small Area Population Estimates for 890 Super Output Areas in Northern Ireland. NISRA - Demography and Methodology Branch Rates of TB by deprivation, Northern Ireland 2014
- 15. 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 Q1 Q2 Q3Q4 Q5 Proportionofcases UK-born Non-UK born Proportion of Northern Ireland TB cases living in deprivation by country of birth (n=1063)
- 16. Distribution of NorthernIreland TB cases 2008-2015 by deprivation quintile and UK/Non-UK born UK born c
- 17. Distribution of TBcases in Belfast area 2008-2015 by deprivation quintile and UK/Non-UK born UK born
- 18. Distribution of TBcases in Southern area 2008-2015 by deprivation quintile and UK/Non-UK born UK born
- 19. The drivers behindincreasing numbers in the SHSCT- an example of a recent Investigation • In-migration increased rapidly in the period following EU enlargement in 2004- Migration inflows are concentrated in Belfast and the SHSCT, with Dungannon the most popular location in the latter. • Compared to the UK, NI based EU accession migrants are disproportionately found in manufacturing areas. • This area experienced a large influx of migrant workers first Portuguese and then A* nationals. • Migrant workers face poor quality housing largely in the private sector often resultant in overcrowding. Migrant worker households in this area tend to be large, younger, predominantly male with high employment rates but lower incomes than comparable households in the area (Campbell and Frey, 2010).
- 20. 205428 2014 pul smear-ve138843 2011non-pul Same house flat10 152619 2012 pul smear+ve 201478 2013 pul sputum smear-ve culture+ve 216230 2015 pul smear -ve 207558 2014 nonpul Same house different flat Same house flat11 202934 2014 pul smear-ve Factory 2 Factory1 vntr Legend VNTR cluster 1 Work colleagues Same address VNTR cluster 2 Same address Empl oyer N/K 141132 2012 Non-pul cervical node LTF 209102 pul. Labs all –ve:clinical 2014 Same address 207431 2014 pul sputum -ve 207335 2014 pul sputum -ve 214006 2015 CNS culture +ve smear N/K All live same area different address VNTR cluster 3 Cluster 3 213188 2015 Pulmonary culture & smear+ve 2012 152878 Non-pulmonary. Iso & Strp. Resistant 142894 2012 Pul. Smear +ve VNTR cluster 4 Same address 2013 Clinical Cluster 4
- 21. • With theexception of one case all cases are from a high incident country (Timor-Leste) • incidence rates of TB are estimated to be in the region of 400/100,000. • All cases lived in a similar area of Northern Ireland • All cases are male of working age • VNTR cannot infer timing or direction of transmission Anecdotal evidence of : • Shift work with multiple individuals sharing accommodation (same beds night v day shifts) • Poor accommodation – low rent to allow for sending money back home* • Most individuals in this community smoke – not known if cases did/did not * • Linguistic barriers. English not widely spoken in E.Timor* • Access to healthcare may be limited due to shift work- differential consequences relating to pay if absent • Cultural perceptions of the illness (stigma) and effectiveness of treatment* • Factory owners fair employers but concerns directed towards business /products reputation not just the health of the employees (source PHE). *Ref: G. Peake,2013
- 22. Considerations……. The social conditionsin which people live and work can help create or destroy their health. Lack of income, inappropriate housing, unsafe workplaces and lack of access to health care systems are some of the social determinants of health leading to inequalities. (World Health Organization [WHO], 2004) Prior to entry, a migrant’s health reflects the disease profile of his or her country of origin….. In a new country, living and/or working conditions can also affect a migrant’s health (ECDC, 2009) Crowded, unventilated living conditions facilitate the spread of TB infection. Poor housing conditions have been documented among migrants and ethnic minority groups in the EU (Bates et al., 2004; Wanyeki et al.,2006; ECDC & WHO Regional Office for Europe, 2009) Health services may be inaccessible by those most in need for several reasons: e.g. gender, geographic distance from health care facilities, the costs associated with receiving care and fear or stigma (WHO, 2010)
- 23. Health behaviours influencedby social/ personal/ environmental factors (peer networks, income or other resources, access to facilities and amenities, food production and promotion, work and living conditions, cultural practices, stress and isolation) • Improvements in the collection of relevant health data, on an all-Ireland basis, would make an important contribution to working for greater health equity. • The collective burden of TB on the Island of Ireland/ most affected populations/ identifying principal risk factors • The principal TB strain types (Types found in NI not similar to elsewhere in UK) • Identifying reason for non-compliance/late access to services • Analysis of patient trajectories, particularly those suffering from multiple morbidities, can complement quantitative analysis of health system functioning. • Not all associations between social determinants and epidemiological data can easily be accessed via statistical analysis (Blas & Sivasankara Kurup) Considerations…….
- 24. • Chris Nugent, Eamon Nancarrow, Paul Cabrey, Dr Declan Bradley, PHA • Dr Rory Convery, Nuala McNeice, Audrey Johntson, Respiratory Team SHSCT • Dr Colin Goldsmith and team, Regional Microbiology Laboratory Northern Ireland • Public Health England, TB and Microbiology Teams
- 25. Lönnroth K etal. (2009a). Drivers of tuberculosis epidemics: the role of risk factors and social determinants. Social Science & Medicine, 68(12):2240–2246. Campbell D. and Frey J. (2010) Migrant workers and the housing market a case study of Dungannon, NIHE Peake, G. (2013) Beloved Land -Stories, Struggles, and Secrets from Timor-Leste WHO (2004). Interim policy on collaborative TB/HIV activities. Geneva, World Health Organization (http://www.who.int/hiv/pub/tb/en/ Printed_version_interim-policy_2004.pdf, accessed 10 April 2010). ECDC (2009). Migrant health: background note to the ECDC report on migration and infectious diseases in the EU. Stockholm, European Centre for Disease Prevention and Control (http://www.ecdc.europa.eu/en/publications/Publications/0907_TER_Migrant_health_Background_ note.pdf, accessed 20 February 2010). Bates I et al. (2004).Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part 1: determinants operating at individual and household level. The Lancet Infectious Diseases, 4(5): 267−277. Wanyeki I et al. (2006). Dwellings, crowding, and tuberculosis in Montreal. Social Science and Medicine, 63(2): 501–511. WHO Regional Office for Europe. Plan to Stop TB in 18 High-priority Countries in the WHO European Region, 2007–2015. Copenhagen, WHO Regional Office for Europe (http://www.euro.who.int/document/E91049.pdf, accessed 25 January 2010). Blas E, Sivasankara Kurup A (in press). Synergy for equity. In: Blas E, Sivasankara Kurup A, eds. Priority public health conditions: from learning to action on social determinants of health. Geneva, World Health Organization. References