Health inequalities are avoidable differences in health between groups of people. These differences arise because the factors that influence our health, including food, housing, employment, education and transport, are not equally distributed throughout society. This means that some people are dying earlier than they should because, as individuals, they cannot change the way these things are distributed. By understanding more about the things that influence the distribution of health-creating factors, nurses and midwives can help people to live longer, healthier lives.
Social determinants of health
Social context, including where people are born, grow, live, work and age directly affect their health outcomes. The unequal exposure to environmental, behavioural and social risk factors can lead to physical health conditions, such as high blood pressure, which in turn can lead to the development of non-communicable and communicable diseases such as certain cancers and respiratory and cardiovascular conditions. Once present in a person's life, these factors combine and make it increasingly difficult to achieve good health. This is particularly true when a person experiences several related factors at the same time, making it difficult to change one without changing the others. For example, when a person lives in an area with limited access to affordable healthy food sources and has insufficient funds to travel to a place where availability is more prolific. As well as eating a poor diet, if this person also smokes cigarettes, takes very little physical exercise, and lives in housing that is sub-standard, the reality is that they are more likely get certain diseases (Public Health England (PHE), 2019a). Although some in society would suggest the impetus for health must come from the individual, research shows that, when simultaneously experiencing these inter-related factors of disadvantage, an individual requires practical assistance from external sources to achieve good health. Figure 1 sets out four domains of health inequality, which will be useful for readers when considering the actions that can be taken to address these within their practice.
CASE STUDY
As a community nurse working with the district nursing team, Ebrahim has been caring for two men both aged 65, with a diagnosis of multiple sclerosis*. Their disease has rapidly progressed to the point that they are no longer able to leave their home without assistance. Ebrahim's key focus for each person is to care for a leg wound, sustained following a fall.
While reflecting with the team leader, Ebrahim realises that Bill's wound is healing more quickly than Ahmed's, even though the wounds shared similar characteristics at the outset. Bill lives in a four-bedroom house, which he owns with his wife. Their daughter is self-employed, lives less than 10 miles away, visits twice a week and is always available to drive Bill to hospital appointments. She helps him to ask the questions that he has not yet considered and talks to the GP when he needs extra care and services. He also has a good network of friends who help him to get out and about and keep up with some hobbies.
Ahmed, on the other hand, lives with his wife in a one-bedroom flat in an inner-city tower block. Before he retired, Ahmed was a well-respected member of the local community, neighbours often came to him for advice as he always knew where to go for help. Ahmed has four children, who all lead busy lives. They try to help him to get to appointments, but this is made difficult when the lift isn't working in his tower block and Ahmed doesn't always want to bother them when appointments are changed at short notice.
Recently Ebrahim has noticed that Ahmed appears a bit down, he misses seeing his friends and wider family, and his role in the wider community. Having missed the last three appointments because of difficulties in getting out or getting to hospital on public transport, Ahmed has received a letter stating that he has been discharged.
Through discussion, Ebrahim can see that wound healing for each person is determined by many factors. However, until now his focus has been on the choice of dressing and the frequency of dressing changes. Ebrahim now recognises that, despite being offered the same services, some people must overcome obstacles before being able to use them. When he considers Bill and Ahmed, he can see that the amount of space in the home influences the extent to which they can mobilise, especially when unable to leave the home without assistance. He can also see the advantages of having friends and a support network as well as someone to accompany you to hospital appointments and to advocate on your behalf, especially when you are feeling unwell and lack the confidence to do so.
With the help of the team leader, Ebrahim thinks through what services and support may be available to help Ahmed. He contacts his GP's social prescribing service, whose staff arrange to visit Ahmed at home. They can link Ahmed with a voluntary driver scheme to help him get to hospital appointments, and to re-engage in social activity. Ahmed is encouraged to think about his own goals and strengths and, through this, has started to do some telephone volunteering as a community champion, signposting people to local community services, and befriending people who are lonely.
During his next visit to Ahmed, Ebrahim discusses whether Ahmed feels the changes are helping him. Ahmed indicates that he is delighted to feel useful once again, and he is happy to accept help from family and the community because he feels he is also giving something back. He has now also written to the council to ask for help with adaptations to his flat and to get problems with the lift addressed.
Ebrahim can see that the additional help will enable Ahmed to use the available services, which until now he was unable to do. He can also see, as a registered nurse, the importance of speaking on behalf of people who would otherwise be unaware of the help available, and of recognising the strengths and talents of his clients and their community, which can help to generate shared solutions.
*This is an illustrative case study with fictitious patient names
Providing high-quality care and addressing unwarranted variation
Throughout the 20th century, health policies for illness prevention (including childhood immunisation, smoking cessation and universal health care) as well as treatment (for example, for heart disease and cancers) have led to a steady increase in the number of years people spend in good health (PHE, 2021).
Nationally, health policy seeks to engage and equip practitioners across health and social care to act in ways that help reduce health inequalities and address the reasons why some people die earlier than others (NHS England/NHS Improvement, 2019). Data tools and resources, including local authority Joint Strategic Needs Assessments, and local health profiles are available to help nurses and midwives understand more about the causes and impact of health inequalities at a national and local level (PHE, 2019b; 2021).
Research conducted during the COVID-19 pandemic has also shone a spotlight on health inequalities (PHE, 2020). It has shown us that people experiencing inequalities because of their employment, income and living conditions are more likely to be exposed to the virus and vulnerable to infection (PHE, 2020). Furthermore, we have seen how the burden of health inequalities has reduced people's ability to manage the consequences of the disease, which has increased the severity and duration of ill health following infection (PHE, 2020).
Using health promotion theory and health needs assessment nurses and midwives can focus their actions and prioritise interventions so that people with access to the least health enhancing factors have the opportunities they need to achieve longer healthier lives (NHS England/NHS Improvement, 2019). Nurses and midwives must understand that, to achieve health, a person must have sustained access to each building block for health, including employment (work), housing, education and skills, food, family, friends, communities, money, and resources (Health Foundation, 2022).
Enhancing our knowledge and action on health inequalities
To support all health and care professionals to enhance their knowledge and, more importantly, to take greater action on key public health issues such as health inequalities, the Office for Health Improvement and Disparities has published free online e-learning resources as part of a programme entitled All Our Health (Health Education England (HEE), 2022). The health inequalities e-learning resource aims to support professionals by providing bite-sized learning, focusing on the evidence for what works and provides links to helpful data sources, guidance, and further training resources. These resources can be located at https://www.e-lfh.org.uk/programmes/all-our-health.