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Monday, 10 September 2012

Inequity after health events - the determinants of recovery

A conversation with a colleague who is doing marvellous public health work using Twitter tweaked a topic that deserves deeper consideration. Follow her @Monika_Dutt.  
It is through the support of such colleagues that today's posting will mark a total of 9,000 views to the blog - thanks everyone 

We make much of the inequities in health as a precursor to illness and associated demand on health services.  For those that have argued the case to senior echelons the response is often “that is the function of the education system, employment, social services etc. – that is not the role of health”.  A Deputy Health Minster once openly stated that “poverty is not a health issue” even if it is an important social issue. 

How to reverse the tide and engage health decision makers in the discourse that the determinants of health are in fact  a health issue for those that have come in the front doors of the bastions of health services?
Those very determinants of health (and social determinants of health) are the determinants of recovery.  Determinants verses social determinants.  Low socioeconomic status and ethnicity  are clearly associated with such outcomes as poorer cancer survival Science daily 2008, even when adjusted for stage at the time of diagnosis   Science daily 2010

This extends to long term outcomes of cardiac events.  Several studies suggesting this was due to lower participation in cardiac rehabilitation eg. Danish study which begs the questions why is there a difference in participation rates and what are the barriers to those with lower income and education? 

This sort of analysis has also been done for cancer outcome and education eg Finnish study,  eg Swedish study.   Noting that the impact from the two studies was in the range of 6-25% improvement of highest education level compared to lowest.

Social support (including pet ownership) is found as a correlated of one year survival post coronary events eg CAST study

While the evidence is clear, the quality of the studies has room for improvement.  Perhaps the more important questions are:

·         Why is relatively little research on “determinant” impact on survival when the magnitude of the impact is greater than the comparisons between various pharmacological options? 
·         Why of the research, is there so little from North American contributions?
·         Why is so little written about inequities in recovery and the determinants when the impacts are so notable?
·         How can these effects be mitigated through targeted intervention?

It should not be a stretch to imagine the mediators for why social determinants like income, education, social support, housing, and food might impact both short term and long term health outcomes after health care interventions.  Compliance with medication may require adequate funds to purchase combined with supports in the home.   Cardiac rehabilitation is benefited by education, diet choices, and a supportive social environment.  

More basically, how can those struggling with basic social issues like low income, lacking food security, unemployed, poor housing, overcrowding, and social situations that engender hopelessness are going to have the resiliency to cope with a significant threat to their wellbeing.  While the studies mentioned relate mostly to cancer and cardiac, it does not take much to identify similar patterns for hip fractures, mental illness and congestive heart failure. COPD is impacted by the poorer air quality found in lower income areas of communities and poorer housing environments.  Ted Schrecker recently blogged on diabetes and its relation to income as a function of management of the illness Health as if everybody counted August 17 in particular as it relates to access to medications. 

So yes, the determinants of health are also the determinants of recovery.
And yes, as health professionals, administrators and governors -  we all have a role in measuring and mitigating such impacts.  

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