Podcast series from the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
Anna Pearce:
Welcome to our latest edition of 15 Minutes on Health Inequalities. Today we have a slightly unusual setup. So, instead of there being an interview/interviewee format, we've got 3 authors on a recently published report on health inequalities and we're going to be having a chat about that. So, I'm Anna Pearce from the MRC/CSO Social and Public Health Sciences unit and senior author on the report. And with me are my colleagues also from the Unit.
Gillian Fergie:
I’m Gillian Fergie, and I led on stakeholder involvement and co-authored the report.
Naomi Miall:
Hi, I'm Naomi Miall. I led on the data analysis and also co-author.
Anna Pearce:
So, thank you both for joining us today. So, I'll start us off briefly by just talking through the background and aims of the report. So, it was work commissioned by the Health Foundation and our brief was to describe trends in inequalities and health in Scotland since 2000. We had around nine months to complete the task and so we were mainly drawing on readily accessible data. An important part of this work was to consult with various stakeholders to ensure the report was as helpful and accessible as it could be and we'll come on to that in a moment. In the report we cover, across different chapters, inequalities and causes and timing of death, physical and mental health outcomes, health related behaviours and health and social care services. So, Gillian, I think we'll start with you as the person who was driving the stakeholder involvement. Can you say a bit more about that?
Gillian Fergie:
Yeah, absolutely. So, we had a few strands to our engagement work with stakeholders and we engaged obviously with the founder of the report, the Health Foundation, to refine the brief for the report, and colleagues who are producing similar reports on different areas. We also had individual and group meetings with an expert advisory group brought together by the Health Foundation, and we also interviewed a range of people working in roles that might represent the report audience. So, people who could be considered evidence users represented third sector organisations, local government, Scottish Government, public health and media. And from these meetings, we wanted to refine our understanding of their preferences for key focus areas to be included in the report and how it should be presented. So, what did they tell us? Well, most stakeholders are very familiar with reports and evidence sources on health inequalities in Scotland, but they suggested there was a need for a contemporary picture of how inequalities are progressing in Scotland. Especially something wide-ranging, something covering lots of different outcomes, but with specific attention on synthesising that evidence and contributing a narrative and interpretation of it. And there was also an interest in making evidence accessible to non-specialist audiences, as well as concerns raised to consider the potential for reports to contribute to stigmatising particular communities and areas. So, we wanted to consider language carefully based on that feedback. And particular areas of focus that stakeholders highlighted included things related to the importance of the Scottish context, so things like drug deaths and wider deaths of despair, children and young people and inequalities across regions and within regions, including an interest in understanding the specific picture of inequalities in cities but also towns and rural areas. So, we ended up with a really big wish list and we had to take into consideration what data was available to allow us to meet that challenge.
Naomi Miall:
And so yeah, I will speak a bit about some of the data. So, we're really lucky that Scotland has already got a really good monitoring system for certain health inequalities and the results of that are published annually in long term monitoring of health inequalities reports. And so we were able to draw on all of that data, but we also really wanted to build on those existing reports by including a broader range of health topics. And so we wanted to include health behaviours, health and social care outcomes, health in childhood and in older ages, which are some topics that aren't already covered in these annual reports. So, to find out some data on these additional topics, we were looking to other published data sources from hospital records and also surveys in Scotland to things like the Scottish Health Survey. Most of these sources include pretty good information about deprivation levels in a participant’s local area. So that's measured using the Scottish Index of Multiple Deprivation, SIMD, and that gave us a pretty good picture of what health inequalities looked like between more and less deprived areas. And we were also able to pull in some data on age and sex and regional inequalities where this was possible, but there was a lot less data available on some other types of inequality that we also know are really important in Scotland, including inequalities related to ethnicity, migration status, individual income and employment. So, instead we tried to summarise what was known about these inequalities using more in-depth narrative sections using the academic literature.
Anna Pearce:
Thanks Naomi. So, the report covers an awful lot. I think we can agree. And we wanted to distil all of those results into some key findings for readers who were possibly not able to plough through all 140 pages, I think we had, in the report. So, in doing that, we identified nine headline findings. So, in short, these were that mortality rates and inequalities had been falling in the first decade of the 21st century, but these improvements stalled and in some cases inequalities are widening. Inequalities are greatest in the most severe outcomes. Health consistently worsens as deprivation increases, i.e. we have a social gradient in inequalities, but the most deprived faring particularly badly. Young and middle-aged men are also a group that are faring particularly badly for some of the outcomes we looked at. The early years is also an area where we see large inequalities, despite some improvements for some of those outcomes. We don't always see the same patterns for health behaviours, highlighting that the reasons behind health inequalities are complex. Likewise, health and social care services present only part of the picture. Social, demographic and other characteristics interact to shape experiences of health. And finally, deepening our understanding of health inequalities is dependent on the availability of the data. So, please do look to do the report and the executive summary to hear more detail about those key findings. We don't have time to talk through them all now. So, I think what we'll do is each pick one of those findings, one that's really stuck out for us and talk to that a little bit more. So, Naomi, can we start with you?
Naomi Miall:
Yeah of course. So, for me, something that really stood out was the complexity we see when we look at inequalities and health behaviours. While we see really consistent inequalities in morbidity and mortality outcomes, we don't always see the same thing for these health behaviours and I think a really good example of this is that while those who are living in more deprived areas are more likely to die from alcohol related harms, high alcohol consumption is actually less common in these areas than in more affluent areas. And another example of that kind of paradox, is that while children living in these more deprived areas are at higher risk of obesity, they're actually just as physically active as their more advantage peers when we measure total activity levels. So we can't always assume that inequalities in lifestyles and behaviours will match or explain the inequalities that we see in health outcomes. Instead, we see that less advantaged groups experience increasingly negative consequences from these health risk factors, and we think that this is probably due to the co-occurrence and clustering of other health risks among these less advantage communities. So, that includes risks such as food insecurity, targeted advertising of health harming products in these areas, and barriers to accessing quality health services, among other risk factors as well. But then on the other hand, we can't assume that the picture is the same for all health behaviours. So, for example, we see large and entrenched inequalities in smoking and pregnancy, which is 11 times more prevalent in the most deprived areas compared to the least deprived. And the reasons for these behavioural inequalities are really complex, as are their consequences. And I think we need to be mindful of their role in shaping stigma faced by some of these communities as well as their role in health. Gillian, do you want to go next?
Gillian Fergie:
So, one of the findings that interested me was around the progress that was being made in some areas. So, in general, we are presenting a picture of worsening trends and this was something that the stakeholders were engaging with were particularly conscious of that. Lots of evidence gets presented about Scotland's poor health and growing health inequalities. And that this narrative can be difficult for citizens, communities and those working to address, or at least mitigate inequalities. And they wanted to hear a lot about what could be done, so positive action. And we were not able to say lots about what works in reducing health inequalities or the specifics. But our findings that Scotland had previously been making progress in improving health and reducing inequalities but that this has now stalled is important. Because between the year 2000 and 2012, life expectancy was increasing and avoidable mortality was decreasing. Progress was being made in deaths from cancer and cardiovascular disease, alcohol deaths and suicides. And alongside these improvements, absolute inequalities in mortality outcomes were generally reducing. But since then there's been a stagnation in those improvements, and in some cases, outcomes and inequalities are getting worse. Child immunisation uptake, which was a previous success story in Scotland with inequalities almost eradicated, has started falling with winding inequalities since around 2012 or 2014. And despite these worsening trends we now face though, the period of health improvement and narrowing of absolute inequalities in the first decade of the 21st century, we think, shouldn’t be overlooked. They suggest that trajectories are amenable to change through policy decision making, that changes can be made for the better as well as for the worse.
Anna Pearce:
Thanks, Gillian. I think it's important for us to point out that it's not all doom and gloom. So, I think I'll go with the especially large risk of poor health in the most deprived areas of Scotland. And so this isn't a new finding, but we saw it across a range of the health outcomes that we looked at, including causes and timing of death and some aspects of health service uptake in use. Drug deaths really stood out to us. So, here we see that the gap between the most and the second most deprived fifth areas of Scotland is as large as the gap between the second most and the least deprived fifth of areas. A similar but less dramatic pattern was seen for some of the early years outcomes, like child development and birth weight. And worryingly, we're seeing some outcomes like infant mortality now going up in the most deprived areas. So, the big question is why this gap is occurring and why we're seeing these really big differences in the most deprived areas. So, we have a few hypotheses for why this might be, and we introduce those in the report, but we've not been able to explore those within the scope of this work. But hypotheses that we propose include that the levels of disadvantage are just disproportionately higher in these areas, that there might be accumulation of disadvantage occurring right across the life course or that some areas or neighbourhoods in Scotland have experienced high levels of disadvantage across generations. So, I think now I'll move us on to a conversation about some of the limitations of the report. So, as we've already mentioned, the work was carried out over a relatively short period of time and we were mainly restricted to using publicly available data. So, Naomi, what do you think were some of the biggest limitations that we came up against?
Naomi Miall:
Hmm, so, something we've already touched on briefly and that I think was quite a big challenge was how to deal with gaps in the available data. So, for example, we've already mentioned that there was not very much data available on inequalities related to individual characteristics like ethnicity, income, living with a disability. But what we haven't spoken about yet is that we know these different characteristics aren't experienced in isolation, and we know that they're combined effects aren't always uniform. But in most cases the data we have is quite siloed, so it reports on one type of inequality or another, but not their combination or their intersection. So, that was quite an important limitation for us. And similarly, we also found that the data available mostly gives us information on one health condition or another, but we don't have much information on their co-occurrence, which we call multimorbidity. So, understanding how these different social circumstances and different health conditions cluster and how they interact is something that we think could be better incorporated into health monitoring in Scotland. And in general, in the report balancing breadth against death was something that we found quite challenging. So we wanted to try and cover a really comprehensive range of outcomes, but also to be able to properly discuss some of the nuances that we've mentioned, and I think that maybe speaks to some of the stakeholder conversations.
Gillian Fergie:
Yeah, thanks Naomi. Absolutely that. And the challenge between balancing breadth and depth is something that we were constantly struggling with and especially in terms of some of the stakeholder suggestions. So, they offered up lots of interesting research questions and things like focusing on comparing areas with similar profiles and histories to investigate what local policies might be causing differences. There was also interesting topics that weren't particularly well covered in the available data. So, things like social care and healthy aging. There's also an interest in integrating more closely with communities to generate these types of reports and creating super accessible outputs, things like infographics and dashboards that most people could understand and read and engage with. But, unfortunately, because of the scope and time scale of the project we were unable to address some of these most innovative and ambitious suggestions. However, lots of them warrant much more thought from us and others I think.
Anna Pearce:
Yeah, agreed. Hopefully this is something that we can pursue ourselves and for others too in our future research. So, we normally end these podcasts by asking the question what are the implications for health inequalities? This feels like a good moment to talk about a final limitation of our report. So, we hope that through looking across a wide range of outcomes, we've shown that the reasons behind health inequalities are complicated and interrelated. Health behaviours and health services are only a small part of the picture, but what's really needed is a greater understanding of the policies and the upstream policies, in my view, hold the most potential for changing health inequalities, including the practicalities around how to best roll these out in terms of things like eligibility intensity and so forth. So, key to this will be working more closely with citizens and communities when generating this evidence. This is work that we are pursuing right across the Unit with several examples covered in other podcasts in the 15 Minutes on Health Inequality series. So, do look out for those. And so on that note, I think I'll bring this to a close. So, thanks Gillian and Naomi and thanks to all of you listening. Please look to the podcast notes for more information on the various outputs from our report, so they include recordings of presentations, a short film, and the report itself, as well as a very long list of acknowledgements to all of the people who have contributed to this work. Thank you.