Strategies to Improve Health

Improving the health of the citizens of Glasgow.

Health

The World Health Organisation (WHO) defines:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” This definition is unchanged since 1948.[1]

Demography of Glasgow

According to the 2002 census, Glasgow has a population of nearly 580,000. This is more than 10% of the total population of Scotland that is just over 5 million. The metropolitan area of Glasgow houses about 1.7 million people. It is the largest city in Scotland and 4th largest in the UK. Slightly fewer than 24% of the population of Glasgow are below the age of 20 and slightly more than 15% are aged over 65 with about 7% over 75. This is similar to the rest of Scotland.[2]

The ethnic mix is: 96.5% white, 2.5% Asian, 1% Black, Chinese and other ethnic groups.[3]

Indices of deprivation were updated in 2007[4] for England but slightly different indices are used for the four home nations of the UK. The Scottish index was produced in 2006.[5] Although there are slight differences in the criteria, eastern Glasgow has the most deprived areas in the whole of the UK. However, Glasgow is a mixed conurbation with many affluent areas too.

Health Inequalities

The NHS was supposed to remove health inequalities but has failed to do so. The Black Report, commissioned in 1977 and published in 1980 found that little had changed in terms of health inequalities.[6] Sir Donald Acheson’s Report of November 1998 found little evidence of improvement.[7] A seminal paper by Dr Julian Tudor Hart in 1971 coined the inverse care law.[8] “In areas with most sickness and death, general practitioners have more work, larger lists, less hospital support and inherit more clinically ineffective traditions of consultation than in the healthiest areas; and hospital doctors shoulder heavier case-loads with less staff and equipment, more obsolete buildings and suffer recurrent crises in the availability of beds and replacement staff. These trends can be summed up as the inverse care law: that the availability of good medical care tends to vary inversely with the need of the population served.”

Tackling health inequalities is a major component of the Government’s health policy. There are plenty of publications[9] but little evidence of change. Health and life expectancy have improved through all strata of society but the gradient down the social classes remains or has expanded. Some argue that this is a disgrace whilst others say that provided that there is improvement in all sections that this is an achievement.

The WHO Commission on the Social Determinants of Health[10] was chaired by Sir Michael Marmot and looked at health inequalities not only in poor nations but also in the rich. It found that children born in the Calton area of Glasgow will live, on average, 28 years less than a person living eight miles awayinLenzie, East Dumbartonshire. There the life expectancy is 82 years compared with 79 for the whole of the UK. A Calton resident has a life expectancy of 54 years. The report said adult death rates were generally 2½ times higher in the most deprived parts of the UK than in the most affluent. Throughout the country and through all social classes, women live, on average, five years longer than men.[11]

Mortality rates are high in Scotland, higher in Clydeside and even higher in Glasgow. They are especially high in areas of deprivation. Decreases in deaths from coronary heart disease (CHD) have been offset by increases in deaths from liver disease and suicide.[12]

The challenge

Glasgow is probably the most challenging city in the UK to improve health, if not the most challenging in the European Union (EU). The incidence of CHD and stroke is the highest in Western Europe and most of this is attributable to modifiable risk factors.[13] Rates of cancer are also high. The incidence of lung cancer is 77 per 100,000 in Western Scotland compared with 49 per 100,000 in the rest of the UK and most of this is accounted for by smoking habits.[14] Glasgow has been called “the UK’s fattest city”[15] Obesity is well known as a risk factor for CHD and diabetes but it also contributes to the risk of many cancers. The WHO says that obesity is second only to smoking as a cause of cancer.[16]

If improvement in the health of Glasgow was aimed purely at reducing smoking and obesity it could have a major impact on health. Other areas where there may be significant benefit are a reduction in drug and alcohol abuse and safe sexual practices. Substance abuse and sex are related. Most prostitutes work to fund a drug habit and much injudicious sex occurs when intoxicated by drugs or alcohol. Intravenous drug use and promiscuity spread hepatitis B and HIV. Hepatitis C is very common with intravenous drug use but is less commonly sexually transmitted. Accidents and much violence result from intoxication, especially with alcohol. Between 1960 and 2002, the death rate from cirrhosis in men rose by 69% in England and Wales and 106% in Scotland. Amongst women it rose by nearly half.[17] Improving mental health is also extremely important.[18] It is often linked to substance abuse but it is difficult to decide if mental illness is caused by drug or alcohol abuse or a result of it.

People often have more than one risk factor. This is why doctors use tables that examine several parameters to assess an individual’s risk.[19] Those in lower social classes are more likely to have multiple risk factors. For males, 30% in social class V have at least two or three high risk behaviours compared to fewer than 10% in social class I. For females, the figures are 20% and fewer than 5% respectively.[20]

Some benefit may be obtained from improved medical services. Governments may help with alleviating poverty and economic regeneration but most intervention will be aimed at getting the individual to take responsibility for his own health. He has to understand the problem. He must want to change. He must be empowered for his own good. There is a vast amount of health promotion material that is readily available.[21]

A single agency is limited in what can be achieved. It is important that many agencies and all levels of society should feel part of this great challenge to change the ways and the attitudes of the people of Glasgow.

Government action

Improving medical services to cope with those who suffer from the important diseases should improve outcome but disease prevention offers hope of a much greater improvement. Most of the risk factors for illness and premature death are modifiable and amenable to change by the individual.

Legislation may come from the EU, UK or Scottish Government. It may change behaviour as in banning smoking in public places or it may address poverty and bad housing. Poverty is bad for health but poverty applies only to the lowest in the social scale whilst there is a gradient of health and life expectancy right across the social classes.[22] The benefit of giving money to poor families is unclear.[23]

Laws may aim to curb tobacco or alcohol use. Raising taxation reduces tobacco consumption[24] and there are a number of ways of other ways of reducing alcohol consumption too.[25] Subsidy as well as taxation may make healthy food more attractive and unhealthy food less so.[26]

Governments must assure funding for health promotion campaigns and may help with coordination across various departments. The NHS is an obvious department to be involved in both health promotion and provision of medical services. Education may be important in trying to change both knowledge and attitudes amongst young people. It can help to develop an interest and knowledge in healthy eating and cooking. It can aim to change attitudes to tobacco, alcohol and drugs and encourage an ethos of exercise. The Department of Trade and Industry may be involved in economic regeneration. Both the police and courts may be able to direct people with problems related to drug or alcohol abuse towards care rather than just a punitive system.

The process of change

Health promotion aims to get individuals to change to a healthier lifestyle. This is not easy to achieve. Change is rarely easy. It involves the individual going through several steps on the way to achieve a lasting change in habit and attitude.

Health promotion initiatives

The mechanism for health promotion is usually mass media campaigns. They seem to work for smoking cessation[27] and even in changing sexual behaviour in young people.[28] However, there is very little evidence about long term effects.

Campaigns may be aimed at one facet or multiple risks. For example, diet, weight and exercise are intimately entwined. This may spill over into smoking, alcohol and drug abuse. Health promotion may be at a national, community or individual level. The individual level is usually when a patient is seen in a medical setting, especially general practice.

Simply exhorting people to change is not enough. It must be facilitated. Most general practices have antismoking clinics where support, advice and even prescriptions to help withdrawal may be had. The subject has been extensively reviewed by both CKS[29] and NICE.[30] People must be helped to appreciate what is healthy food and that it is not more expensive than their traditional diet. Fun runs are of limited value as they are an isolated event. Changes in diet and exercise must be for life. The individual must find a form of exercise that he can manage and he likes or he will not persevere. Counselling and support for substance abusers must be available. Methadone can give stability to the life of a heroin user[31] and acamprosate can reduce the craving for alcohol[32] but counselling must not be ignored.

Long term change

In Europe it is usually suggested that inequalities in health are the result of inequalities in income. In the USA they focus on health literacy[33] and suggest that it is inequality in education that is responsible. As income and education tend to be related it is possible that one is a surrogate for the other. Health is worse in those of lower intelligence but this does not account for all the discrepancy.[34].

People from poorer backgrounds are more likely to smoke.[35] Smoking is the main cause of differences in death rates in middle age across socio-economic groups. In men between 35 and 69 years, it accounts for 59% of social class differences in death rates.[36] They are more likely to be obese[37] and this may be linked to the higher incidence of diabetes.[38] Abuse of alcohol is more prevalent as is drug abuse. They are more likely to experience teenage pregnancy[39] and to be involved in accidents.[40] Accidents are a major cause of death and disability in those under 45.[41] They are more common in lower social classes and in males more than females. This is not just due to high risk jobs as both poverty[42] and lower social class[43] are risk factors for children too. There is also a relationship between poverty and poor mental health.[44] However, as poor mental health causes social decline the question of cause and effect arises.

Perhaps the most important aspect of long term health improvement is improvement in general education. Health literacy is closely related to general literacy.[45] People of poor health literacy have poor lifestyles, they present late with disease and are poor in compliance with management. Those with poor educational achievement have a dead end job or no job. They have low self esteem and are more likely to abuse drugs and alcohol, to smoke and have a poor diet. Teenage pregnancy is more common in low achievers. Improved education, improved job prospects and improved standard of living are the key to improving health.

Bibliography:

1. Social Determinants of Health by Michael Marmot and Richard Wilkinson. Oxford 2005.
2. Promoting Health: A Practical Guide by Linda Ewles and Ina Simnett. Balliere Tindall 2003.
3. Challenging Health Inequalities: From Acheson to Choosing Health (Health & Society). Elizabeth Dowler and Nick J. Spencer. University of Bristol 2007.

Footnotes:

[1] World Health Organisation. WHO definition of Health. http://www.who.int/about/definition/en/print.html

[2] Upmy street.com. http://www.upmystreet.com/local/my-neighbours/population/l/Glasgow.html

[3] DirectGlasgow.co.uk http://www.directglasgow.co.uk/glasgow-information/glasgow-information.asp

[4] Indices of Deprivation 2007. http://www.communities.gov.uk/communities/neighbourhoodrenewal/deprivation/deprivation07/

[5] Scottish Index of Multiple Deprivation. http://www.scotland.gov.uk/Topics/Statistics/SIMD/

[6] The Black Report. http://www.sochealth.co.uk/history/black.htm

[7] The Acheson Report. . http://www.archive.official-documents.co.uk/document/doh/ih/contents.htm

[8] Tudor Hart J The inverse care law. Lancet 27 Feb 1971. 1(7696):405-12.

[9] Department of Health. Search on “health inequalities”. http://www.dh.gov.uk/en/AdvanceSearchResult/index.htm?searchTerms=health+inequalities

[10] WHO. Commission on Social Determinants of Health – Final Report. 2008. http://www.who.int/social_determinants/final_report/en/

[11] Office of National Statistics. http://www.statistics.gov.uk/cci/nugget.asp?id=881

[12] Leyland AH, Dundas R, McLoone P, Boddy FA. Inequalities in Health – Inequalities in mortality. MRC http://www.inequalitiesinhealth.com/public/index.php?cmd=smarty&id=1_len

[13] Scottish Government Health Directorates. Coronary heart disease/ stroke task force report. September 2001 http://www.sehd.scot.nhs.uk/publications/cdtf/cdtf-05.htm

[14] National Cancer Intelligence Network. News release. 7th October 2008. http://www.ncin.org.uk/press/UKIM1008press.pdf

[15] The Scotsman. 10th March 2003. http://news.scotsman.com/obesity/Glasgow-digests-UKs-fattest-city.2409145.jp

[16] World Health Organisation. 2008. Cancer: diet and physical activity’s impact. http://www.who.int/dietphysicalactivity/publications/facts/cancer/en/

[17] Leon DA, McCambridge J; Liver cirrhosis mortality rates in Britain from 1950 to 2002: an analysis of routine data. Lancet. 2006 Jan 7;367(9504):52-6. [abstract] http://www.ncbi.nlm.nih.gov/sites/entrez/16399153

[18] Scottish Public Health Observatory. Mental Health: Policy Context. http://www.scotpho.org.uk/home/Healthwell-beinganddisease/MentalHealth/mental_keypolicy.asp

[19] British Hypertension Society. Proposed Joint British Societies Cardiovascular Disease. http://www.bhsoc.org/resources/prediction_chart.htm

[20] Department of Health. Health Survey for England 2003. Published December 2004. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_4098712

[21] Health Promotion. PatientUK. http://www.patient.co.uk/showdoc/16/

[22] Office of National Statistics. Variations persist in life expectancy by social class. October 2007. http://www.statistics.gov.uk/pdfdir/le1007.pdf

[23] Lucas P, McIntosh K, Petticrew M, Roberts HM, Shiell A. Financial benefits for child health and well-being in low income or socially disadvantaged families in developed world countries. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD006358. http://www.cochrane.org/reviews/en/ab006358.html

[24] Leverett M, Ashe M, Gerard S, Jenson J, Woollery T. Tobacco use: the impact of prices. J Law Med Ethics. 2002 Fall;30(3 Suppl):88-95. http://www.ncbi.nlm.nih.gov/pubmed/12508509

[25] Scottish Government. Effective and Cost – Effective Measures to Reduce Alcohol Misuse in Scotland: An Update to the Literature Review. 2005. http://www.scotland.gov.uk/Publications/2005/01/20542/50232

[26] Caraher M, Cowburn G. Taxing food: implications for public health nutrition. Public Health Nutr. 2005 Dec;8(8):1242-9. Review. http://www.ncbi.nlm.nih.gov/sites/entrez/16372919

[27] Bala M, Strzeszynski L, Cahill K. Mass media interventions for smoking cessation in adults. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD004704. http://www.cochrane.org/reviews/en/ab004704.html

[28] Delgado HM, Austin SB. Can media promote responsible sexual behaviors among adolescents and young adults? Curr Opin Pediatr. 2007 Aug;19(4):405-10. Review.

http://www.ncbi.nlm.nih.gov/sites/entrez/17630603

[29] CKS Library. Smoking cessation. 2007. http://www.cks.library.nhs.uk/smoking_cessation

[30] NICE. Smoking cessation. March 2006 http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11375

[31] Department of Health. Drug misuse and dependence. UK Guidelines on clinical management. http://www.nta.nhs.uk/areas/Clinical_guidance/clinical_guidelines/docs/clinical_guidelines_2007.pdf

[32] Kranzler HR, Gage A. Acamprosate efficacy in alcohol-dependent patients: summary of results from three pivotal trials. Am J Addict. 2008 Jan-Feb;17(1):70-6. Review.

http://www.ncbi.nlm.nih.gov/sites/entrez /18214726

[33] Committee on Health Literacy, Institute of Medicine, Nielsen-Bohlman LN, Panzer AM, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington DC: The National Academies Press; 2004.

[34] Batty GD, Der G, Macintyre S, et al; Does IQ explain socioeconomic inequalities in health? Evidence from a population based cohort study in the west of Scotland.; BMJ. 2006 Mar 11;332(7541):580-4. Epub 2006 Feb 1. [full text] http://www.bmj.com/cgi/content/full/332/7541/580

[35] Jefferis BJ, Power C, Graham H, Manor O. Changing social gradients in cigarette smoking and cessation over two decades of adult follow-up in a British birth cohort. J Public Health (Oxf). 2004 Mar;26(1):13-8. http://www.ncbi.nlm.nih.gov/pubmed/15044567

[36] Jha P, Peto R, Zatonski W, Boreham J, Jarvis MJ, Lopez AD. Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America. Lancet. 2006 Jul 29;368(9533):367-70.

http://www.ncbi.nlm.nih.gov/pubmed/11226355

[37] James WPT, Nelson M, Ralph A et al. Socioeconomic determinants of health: the contribution of nutrition to inequalities in health. BMJ 1997;314(7093):1545–1549.

http://www.bmj.com/cgi/content/full/314/7093/1545

[38] Office of National Statistics. Prevalence of diagnosed diabetes mellitus in general practice in England and Wales,1994 to 1998. http://www.statistics.gov.uk/CCI/article.asp?ID=1519&Pos=1&ColRank=1&Rank=224

[39] McCulloch A. Teenage childbearing in Great Britain and the spatial concentration of poverty households. J Epidemiol Community Health.2001 Jan;55(1):16-23. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=PubMed&dopt=Abstract&list_uids=11112946

[40] Khambalia A, Joshi P, Brussoni M, Raina P, Morrongiello B, Macarthur C. Risk factors for unintentional injuries due to falls in children aged 0-6 years: a systematic review.

Inj Prev. 2006 Dec;12(6):378-81. Review. http://www.ncbi.nlm.nih.gov/pubmed/17170185

[41] Royal Society for the Prevention of Accidents. General Accident. January 2007. http://www.rospa.org.uk/factsheets/general_accidents.pdf

[42] Khambalia A, Joshi P, Brussoni M, Raina P, Morrongiello B, Macarthur C. Risk factors for unintentional injuries due to falls in children aged 0-6 years: a systematic review.

Inj Prev. 2006 Dec;12(6):378-81. Review. http://www.ncbi.nlm.nih.gov/pubmed/17170185

[43] Kemp A, Sibert J. Childhood accidents: epidemiology, trends, and prevention. J Accid Emerg Med. 1997 Sep;14(5):316-20. Review. http://www.ncbi.nlm.nih.gov/pubmed/9315935

[44] Payne S. Poverty and Mental Health in the Breadline Britain Survey. 1999. http://www.bris.ac.uk/poverty/pse/99-Pilot/99-Pilot_4.pdf

[45] Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006-483). Washington, DC: National Center for Education Statistics, US Department of Education; 2006.