Health Inequalities

Inequality of Opportunity in Child Heath in the Arab World and Turkey

by Ragui Assaad

Health and nutrition during a child’s first years are crucial to his/her health and wellbeing later in life. Growth... more Health and nutrition during a child’s first years are crucial to his/her health and wellbeing later in life. Growth and development in childhood is determined by both genotype (nature) and phenotype (nurture), with the influence of the latter being particularly crucial during a child’s first few years (Martorell and Habicht 1986). In this paper, we examine the patterns of inequality of opportunity in health and nutrition outcomes, such as height-for-age and weight-for-height, for children under five in selected Arab Countries and Turkey, using Demographic and Health Survey (DHS) data. Our objective is to decompose inequality into a portion that is due to inequality of opportunity, and a portion due to other factors, such as random variations in health. Inequality of opportunity is defined as in Romer (1998) as the inequality that is due to differences in circumstances, such as parental characteristics, household wealth, place of birth and gender. We measure inequality using decomposable general entropy measures, such as Theil’s-L and Theil’s-T indices. We use both parametric and non-parametric decomposition methods to determine the share of inequality of opportunity in total inequality. The results show that different levels and trends are evident across countries in both overall inequality and in the share of inequality of opportunity. Inequality of opportunity is shown to contribute substantially to the inequality of child health outcomes, but its share in total inequality varies significantly, both across and within countries over time. To further highlight the relative contribution of circumstances to the inequality of child health outcomes in different countries, we simulate height and weight outcomes for a most and least advantaged child in each context. Since these simulations observed circumstances at their best and worst levels, the larger the difference in predicted outcomes between the most and least advantaged child, the greater the inequality of opportunity facing children in that country.

A politics of health glossary

by Clare Bambra

Immigration Status

by Sarah Willen

Willen, Sarah S. 2012. “Immigration Status.” In Sana Loue and Martha Sajatovic, eds. Encyclopedia of Immigrant Health. New York: Springer. 886-888.

Dışlanmışlık ile destek arasında – Depresif şikayetleri olan Türkiye kökenli göçmen kadınların ulusaşırı biyografilerinde eylem yeteniği

by Sina Motzek

Türkçe'de yazılmış doktora projesi özeti, Şubat 2012

Türkiye kökenli ulusaşırı göçmen kadınlar ulusaşırı alanda informel ve formel destek alarak, kendi depresif... more Türkiye kökenli ulusaşırı göçmen kadınlar ulusaşırı alanda informel ve formel destek alarak, kendi depresif hastalıklarıyla ve sosyal dışlanmışlık süreçleriyle nasıl başediyorlar?

Seeking out 'easy targets'? Tobacco companies, health inequalities, and public policy

by David Clifford

Richter, M., Vereecken, C.A., Boyce, W., Maes, L., Nic Gabhainn, S. & Currie, C. (2009). Parental occupation, family affluence and adolescent health behaviour in 28 countries. International Journal of Public Health, 54, 1-10.

by Saoirse Nic Gabhainn

How has social status been measured in health research? A review of the international literature

by Christo Albor

I contributed to this paper, and was a co-author. The paper was led by Baltica Cabieses, and the other co-authors were Pedro Zitko, Rafael Pinedo, and Manuel Espinoza. Published in Rev Panam Salud Publica 29(6), 2011

Social status (SS) is a multidimensional variable that is used widely in health research. There is no single optimal... more Social status (SS) is a multidimensional variable that is used widely in health research. There is no single optimal method for estimating social status. Rather, in each case the mea- surement may vary depending on the research subject, the base theory considered, the population of interest, the event of interest and, in some cases, the available information. This literature review develops the following topics related to SS measurement, based on the international scientific sources available electronically: i) identification of the role of SS in the context of social epidemiology research, ii) description of the principal indicators and methodological approaches used to measure SS in health research, and iii) analysis of the dis- tinct difficulties of SS measurement in specific populations such as ethnic groups, women, children, the elderly, and in rural vs. urban contexts. The review finally makes it possible to describe some of the implications of SS measurement in Latin American countries.

A review of the impact of ethnic density on adult mental disorders

by Christo Albor

In press with the British Journal of Psychiatry (2012). The lead author is Richard Shaw. I am a co-author along with Karl Atkin, Laia Bécares, Mai Stafford, Kathleen Kiernan, James Nazroo, Richard Wilkinson, and Kate Pickett

Background
The ‘ethnic density hypothesis’ is a proposition that members of ethnic minority groups may have... more Background
The ‘ethnic density hypothesis’ is a proposition that members of ethnic minority groups may have better mental health when they live in areas with higher proportions of people of the same ethnicity. Investigations into this hypothesis have resulted in a complex and sometimes disparate literature.

Aims
Systematically identify relevant studies, summarise their findings in a narrative synthesis, and discuss potential explanations of the associations found between ethnic density and mental disorders.

Method
A narrative review of studies published up to January 2011, identified through a systematic search strategy. Studies included have a defined ethnic minority sample; some measure of ethnic density defined at a geographical scale smaller than a nation or a US state; and a measure ascertaining mental health or disorder. Analysis was by narrative synthesis with the aid of semi-quantitative visualisation of data.

Results
Thirty four papers from 29 datasets were identified. Protective associations between ethnic density and diagnosis of mental disorders were most consistent in older US ecological studies of admission rates. Among more recent multilevel studies, there was some evidence of ethnic density being protective against depression and anxiety for African Americans and Hispanic adults in the US. However, Hispanic, Asian-American and Canadian ‘visible minority’ adolescents suffer higher levels of depression at higher ethnic densities. Studies in the UK showed mixed results, with evidence for protective associations most consistent for psychoses.

Conclusions
The results of this review indicate that the most consistent associations of ethnic density are found for psychoses. Ethnic density may also protect against other mental disorders, but presently, as most studies of ethnic density have limited statistical power, and given the heterogeneity of their study designs, our conclusions can only be tentative.

Ethnic density effects on physical morbidity, mortality and health behaviours: A systematic review of the literature.

by Christo Albor

This was a systematic review in which I contributed. It was led by Laia Becares (Manchester). Other co-authors were Mai Stafford, James Nazroo, Richard Shaw, Karl Atkin, Kate Pickett, Kath Kiernan and Richard Wilkinson. It is currently in press with the American Journal of Public Health (2012)

Examining the differential association between self-rated health and area deprivation among white British and ethnic minority people in England

by Christo Albor

The lead author was Laia Becares (Manchester). I co-authored this along with James Nazroo (Manchester), Tarani Chandola (Manchester), and Mai Stafford (MRC Unit for Lifelong Health and Ageing). It was published in 2012 at Social Science & Medicine 74(4).

Recent discourses in the area of neighbourhood effects on health have advocated for a relational perspective of space... more Recent discourses in the area of neighbourhood effects on health have advocated for a relational perspective of space and place, focussing on the mutually reinforcing and reciprocal relationship between the environment and the individual. An example of such relationship is that of the interaction between area deprivation and individual ethnicity on reports of self-rated health, which we explored using cross-sectional data from the 2007 Citizenship Survey linked to the 2001 UK census. We aimed to examine whether the association between area deprivation and poor self-rated health differs for ethnic minority groups, as compared to white British people. Following from this, we also examined whether possible differential associations were mediated by ethnic density effects and perceptions of and satisfaction with neighbourhood characteristics. Results of random effects multilevel logistic regression models showed the detrimental association between area deprivation and self-rated health to be of greater magnitude and stronger for white British people than for ethnic minority people. This differential association was not mediated by ethnic density effects or perceptions of and satisfaction with neighbourhood characteristics.

Highlights
► A detrimental association between area deprivation and poor self-rated health was found across all ethnic groups.
► However, area deprivation was less strongly associated for ethnic minority people, as compared to white British people.
► Local service satisfaction, neighbourhood disorder, and collective effects did not mediate this differential association.

Due, P., Merlo, J., Harel-Fisch, Y., Damsgaard, M.T., Holstein, B., Hetland, J., Currie, C., Nic Gabhainn, S., Gaspar de Matos, M. & Lynch, J. (2009). Socioeconomic inequality in exposure to bullying during adolesence: international comparative cross-sectional multilevel study in 35 countries. American Journal of Public Health, 99(5), 907-914.

by Saoirse Nic Gabhainn

Richter, M., Erhart, M., Vereecken, C., Zambon, A., Boyce, W. & Nic Gabhainn, S. (2009). The role of behavioural factors in explaining socioeconomic differences in adolescent health: a multilevel study in 33 countries. Social Science and Medicine, 69, 396-403.

by Saoirse Nic Gabhainn

Molcho, M., Kelly, C., Gavin, A. & Nic Gabhainn, S. (2008). Inequalities in health among school-aged children in Ireland. Dublin: Department of Health and Children.

by Saoirse Nic Gabhainn

Molcho, M., Nic Gabhainn, S., Kelly, C., Friel, S. & Kelleher, C. (2007). Food poverty and health among schoolchildren: findings from the Health Behaviour in School-aged Children (HBSC) study. Public Health Nutrition, 10(4), 364-370

by Saoirse Nic Gabhainn

Evaluation of the Healthy Living Centre Programme in Scotland: Report of phase 2.

by David Rankin

Platt S, Backett-Milburn K, Rankin D. (2007) Evaluation of the Healthy Living Centre Programme in Scotland: Report of phase 2. Edinburgh: NHS Health Scotland

This is the second and final report on the evaluation of the Healthy Living Centre (HLC) Programme in Scotland. The... more This is the second and final report on the evaluation of the Healthy Living Centre (HLC) Programme in Scotland. The Big Lottery Fund (BLF, previously known as the New Opportunities  Fund) established the HLC funding  programme in 1999. At its inception, this was the largest single investment in community-based health intervention  in the UK. The HLC programme was  established to address health inequalities by seeking to improve health and well-being among people living in deprived communities. To achieve this aim HLCs were funded to develop solutions  which were to be innovative and responsive to local health improvement needs, and complementary to local and national health policies and priorities. To evaluate the success of the programme, a series of national, regional and local evaluations of HLCs was commissioned. In Scotland, a longitudinal process evaluation of the HLC programme was conducted using a case study design over two phases.

In phase one (2002-2005), the pathways between activities, processes, contexts and outcomes were explored in a purposive  sample of six Scottish HLC projects.  The six case HLCs were selected to reflect the range of target groups, health problems, governance structures, partnerships, anticipated  health outcomes and geographical locations of the 46 HLC projects within Scotland. The second phase examined the longer term development of the HLC programme and its evolving contribution to addressing inequalities, changes to  community engagement practices, approaches to meeting local needs and addressing national priorities, involvement in wider health economy structures, and attempts to ensure sustainability.

Sustainability processes in community-level health initiatives: the experiences of Scottish healthy living centres

by David Rankin

Background
This thesis explores processes involved in stakeholders’ attempts to secure sustainability of three... more Background
This thesis explores processes involved in stakeholders’ attempts to secure sustainability of three short-term funded community health initiatives known as healthy living centres (HLCs). The overall aim was to identify and examine development of sustainability strategies in Scottish HLC organisations. In contrast to retrospective accounts examining influences on extent of sustainability little is known about how this concept is considered by organisations approaching the end of funding. Organisational development theorising has focused on organisational change, with no attention given to sustainability processes in short-term funded organisations. Building on a concurrent longitudinal evaluation of a larger sample of HLCs, the temporal nature of this PhD study offered scope to explore development of, influences on and changes to stakeholders’ sustainability strategies over time.

Methods
The study used a qualitative evaluation methodology. A case study approach framed the HLCs, permitting comparison between sites. An ethnographic approach using observations and in-depth interviews was employed. Interviews were undertaken with stakeholders (comprising managers, staff, partners and board members) from each HLC. Managers were interviewed on several occasions. Latterly, interviews were undertaken with respondents holding policy, practice and funding posts. A thematic analysis, informed by grounded theory, was carried out. This used a constant comparative methodology to understand the data against the backdrop of the PhD study aims and wider literature.

Findings
Findings examine stakeholders’ accounts of the impact of a range of issues on HLC sustainability strategies. These are located in the context of health and community sector restructuring. Especially challenging were: efforts to secure local partners and further lottery funding; consideration of new funding criteria and models of service delivery; and limitations in demonstrating effectiveness. Addressing such challenges, managers’ strategic positioning signified attempts to influence HLCs’ fit within local health structures. Stakeholders’ accounts highlighted attempts to secure continuation of HLCs’ original identity; ensuring continued accessibility of Centres to local communities; and, seeking continuation of developmental methods of work. External respondents’ perspectives illuminated how policy-driven changes restricted system-wide attention to HLC sustainability. Latterly, Government-provided funding offered a short-term fix, enabling continuation of attempts to secure sustainability.

Conclusions and implications
This study offers new perspectives on the temporal exploration of sustainability of short-term funded health initiatives. Analysis of stakeholders’ accounts over time provides insight into the effects of restructuring and ways in which system-wide flux impacted on influences known to enhance the likelihood of sustainability. Recommendations address programme design and wider responsibilities of health system actors in positioning and considering a future for such organisations after short-term funding ends.

Drop-in services: Findings from an evaluation of the Healthy Living Centre programme in Scotland

by David Rankin

Truman J, Rankin D, Platt S, Backett-Milburn K. and Petticrew M. (2007) Drop-in centres: findings from a case study evaluation of the Healthy Living Centre programme in Scotland. Health Education Journal, 66:22-31.

Objective: To explore the use of ‘drop-in’ centres in Healthy Living Centres in Scotland, in the context of attempts... more Objective: To explore the use of ‘drop-in’ centres in Healthy Living Centres in Scotland, in the context of attempts to tackle poor health in vulnerable communities.
Setting: Scottish Healthy Living Centres
Methods: Six Healthy Living Centres were purposively selected to reflect some of the diversity within the Healthy Living Centre programme in Scotland. Semi-structured interviews were undertaken with 10-15 respondents in each of the case studies.
Results: The term ‘drop-in’ was used to describe services which varied in respect of activities, aims, management and resources. This variation reflected the specific context and understanding of health in individual HLCs. Some addressed health lifestyles, reflecting an individualistic model of health based on risk factor assessment; others focused more broadly on the determinants of ill health, such as employment, education, poverty and social well being, reflecting a social model of health.
Conclusions: Our findings support and expand earlier work in the area. We have produced a revised typology of drop-in centres, identifying ‘user-defined’ in addition to the previously developed categories of ‘consumer run’ and ‘consumer involved’ services.

The contextual development of healthy living centres services: An examination of food-related initiatives

by David Rankin

Rankin D, Truman J, Platt S, Backett-Milburn K. and Petticrew M. (2006) The contextual development of Healthy Living Centres services: an examination of food-related initiatives. Health and Place, 12:644-655.

The Healthy Living Centre (HLC) programme was designed to address the wider determinants of health, in particular... more The Healthy Living Centre (HLC) programme was designed to address the wider determinants of health, in particular social exclusion and socio-economic disadvantage, through targeting services at the most deprived local communities. This paper draws on data collected during an in-depth process evaluation of six Scottish HLC case study sites. Food-related services, which were found to cross-cut all the sites, were used to address social exclusion and to promote health. Three types of service, each linked to a social model of health, were found to be in operation: those which enhance skills; those which promote social inclusion; and those which influence food accessibility. The paper illustrates how food-related services have developed in the case study HLCs to take account of the differing needs of the communities and neighbourhoods that have been targeted. Consideration is then given to how HLCs adapt to meet the practicalities of improving health while addressing social exclusion through targeting health inequalities.

Evaluation of the Healthy Living Centre Programme in Scotland

by David Rankin

Platt S, Backett-Milburn K, Petticrew M, Rankin D. and Truman J. (2005) Evaluation of the Healthy Living Centre Programme in Scotland: Report of phase 1. RUHBC Working Paper #3. University of Edinburgh: Research Unit in Health, Behaviour and Change.

The Big Lottery Fund (BLF) has invested £300 million in supporting 352 healthy living centres (HLCs) across the UK.... more The Big Lottery Fund (BLF) has invested £300 million in supporting 352 healthy living centres (HLCs) across the UK. These centres are expected to deliver services that respond to public health priorities, and promote and improve the health and general well-being of the most disadvantaged people. The Scottish Executive commissioned the Research Unit in Health, Behaviour and Change (RUHBC), University of Edinburgh, and the MRC Social and Public Health Sciences Unit (SPHSU), University of Glasgow, to conduct an evaluation of the Healthy Living Centre Programme in Scotland. The evaluation, conducted over a three year period (2002-05) has explored the pathways between activities, processes, contexts and outcomes in a purposive sample of six HLC projects, using a longitudinal research design. The sample of HLCs was selected to reflect the range of interests, anticipated health outcomes and geographical locations of the 46 HLC projects within Scotland. Findings cover six key aspects of HLC strategic and operational activity: initiation and development of the HLC; partnership working; community involvement; tackling inequalities in health; sustaining the HLC beyond the initial BLF funding period; and monitoring and evaluation. Learning points relating to each aspect are presented in the report.
The main research questions addressed in the study are:
• What are the projects’ objectives and anticipated outcomes?
• What is the context in which the projects operate?
• What are the processes and explanations of change by which intended outcomes are to be achieved?

Practitioner perspectives on tackling health inequalities: Findings from an evaluation of healthy living centres in Scotland

by David Rankin

Rankin D, Backett-Milburn K, and Platt S. (2009) Practitioner perspectives on tackling health inequalities: Findings from an evaluation of healthy living centres in Scotland. Social Science and Medicine, 68:925-932.

Little is known about how practitioners tasked with tackling health inequalities account for their own programmes and... more Little is known about how practitioners tasked with tackling health inequalities account for their own programmes and actions. This paper attempts to address this gap by drawing on data collected in the course of an evaluation of the Healthy Living Centre (HLC) programme, which was designed to address the wider determinants of health, in particular social exclusion and socioeconomic disadvantage, through targeting services at the most deprived local communities. Six Scottish HLC case studies explored in depth how HLC practitioners conceptualised ‘health inequalities’ and applied the construct to legitimate their public health and health improvement work. Practitioners drew on multiple explanations of health inequalities, sought to apply holistic approaches to service provision, and developed activities that took account of classed practices intended to overcome class-related disempowerment and stigma. They discussed the challenges of positioning services to appeal to and reach target groups and the difficulties in assessing the impact of their work on reducing health inequalities. Responses to tackling inequalities were variable across time and between HLCs, resulting from uneven learning about target groups and their changing needs, an evolving policy agenda and consideration given to the longer-term sustainability of HLC sites. Although practitioners’ work to address health inequalities was limited by the programme’s focus on working with disadvantaged groups, findings illustrate how classed practices are linked to the challenges of attracting and successfully engaging with such groups. Practitioner accounts highlighted the importance of gaining acceptance to overcome barriers to engagement with disadvantaged communities, the time required to achieve a satisfactory level of engagement, the proximity of service providers to clients and the adaptability of services necessary to address evolving needs.