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Health inequality, looking at geographical area as a socio-economic status and it’s

influence on lifestyle diseases.
Geographical location - GL

Health inequality - HI

Socio-economic status – SES

Social determinants – SD

Deprived area – DA

Health risk – HR

Health literacy – HL

Health promotion – HP

Social capital - SC

This essay entails socio-economic factors specifically regarding GL that negatively impact HI.
Focusing on the societal contexts of health and linking to the specific measurable indicator of HI:
lifestyle diseases.

Socio-economic status - Geographical location

SES can be defined in a multitude of ways, (Baker, 2014) describes it as a measure of one’s combined
economic and social status positively associated with better health, examples of socio-economic
factors include: occupation, education, income, and GL. This essay will focus on GL and it’s
association as a SD on HI.

Circumstances of which we are born, grow, live and work can impact our health and well-being (NHS
England, 2019). Individuals with area-level socio-economic disadvantage are more vulnerable to HI,
local variations in concentration of pre existing health conditions show those living in affluent areas
are less likely to experience poorer health or challenges in accessing care than those in socio-
economically DA (RCSLT, 2021).

Within HI there’s: SD of health, specific indicators of HI, and consequential HR. The (Whitehead and
Dahlgren, 1991) model on main determinants of health
nicely explains complex factors and processes of which cause
HI. Displaying in the centre basic unavoidable structural
determinants of health – biological, genetic, and
constitutional factors with unamenable health impacts
(age, sex, race, ethnicity). Then in outer circles; individual
lifestyle factors(e.g diet, exercise, smoking), social and
community networks and examples of general socio-
economic, cultural, and environmental conditions (e.g
education, employment, GL). These SD influence HR – they
don’t exclude individuals from good health, but rather act as
barriers to accessing it.
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What causes HI to persist? HI are complex, and persist throughout society due to lack of; equal
access to healthcare, knowledge and awareness of HR, social, economic and cultural capital
addressing HR, and access to healthy food/lifestyle. Societal flaws which contribute include
structural educational differences in HL, the fallacy of HP and SC on a local and national level. To
have strong SC is to live in an area with strong social links around you, used in reference to benefits
arising from access to shared assets from being in a group that accrues resources. It’s a societal
reinforcer of inequality, as those from affluent areas have better assets and from privileged groups
gain greater tangible access to resources. SC can be looked at in reference to: structural SC (social
networks, links within society), cognitive SC (perceptions of people – intelligence, trustworthiness),
bonding capital (family, friends – reinforces exclusive identity, personal specific reciprocity), and
bridging capital (reinforces diversity, links to greater external assets, generates broader identity)
(Bourdieu, 2021). Differences in SC is a significant factor in HI.

Health literacy

HL is defined by (Weiss, 2016) as “the ability to obtain, read, understand and use health-related
information, to navigate the healthcare system, and make informed decisions about medical care”.
There’s association between HL and risk of morbidity and premature death, individuals likelihood of
adopting unhealthy lifestyle choices like smoking or poor diet can be influenced by disproportionate
provision of clear accessible health services and information on HL. As patterns in application of HL
coincide with SES (e.g low educational attainment, poor quality jobs or low SC), HL is a fundamental
inequality that’s interlinked throughout different SD having substantial impact on differing HI (Public
Health England, 2015). Lacking HL can result in risky health behaviours due to lack of
knowledge/awareness, differing risk management/balancing, perception of risk, or simply because
it’s fun; lack of motivation about long term health ensues more willingness taking risks (e.g reckless
driving). Essentially, low HL significantly raises likelihood of living in poor health and ultimately
lowers life expectancy, but means also your less likely to have good employment, less likely to high
SES, more likely to be a victim of crime, all sorts of negative implications consequently.

It's important as SLT to understand implications of HL, limited HL can reduce opportunities for
individuals from vulnerable/disadvantaged groups developing capabilities required to be actively
involved in decisions about health. As SLT’s it’s important to understand risks low HL has on
individuals being undermined by healthcare workers in ability to take control of their health in
decisions and changing circumstances. Consequently quality of care is so important in SLT role;
understanding service users experience, tailoring care to individuals (different cultures, language
use, SES), and have cultural awareness of communication. More can be done in enabling service user
involvement, SLT’s should engage service users appropriately in goal setting, planning meaningful
intervention and evaluating incomes in an inclusive manner (RCSLT, 2021).

Behavioural risks to health - lifestyle diseases

Smoking

In statistics from 2016 people living in the most DA of England were four times more likely to smoke
than those in affluent areas, results showed 25.7% of people in Hastings smoked, a highly ranked DA,
compared to just 4.9% in Surrey, one of the least DA in England (Office For National Statistics, 2018).
These statistics represent massive divide in smoking prevalence between the most deprived and
affluent, causing significant differences in death rates and illness highlighting HI. These are
population differences, they don’t apply to all individuals categorised but are rather seen across
populations as a whole – higher smoking prevalence is associated with majority of deprivation
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indicators (e.g lower income, unemployment, social housing, lack of qualifications, single parents)
and is one of the largest drivers in HI. Those effected by smoking addiction are consequently more
predisposed to lung cancer or respiratory disease. Likelihood of smoking is impeded in cycles of
social norms, familiarisation and addiction; lack of social support, stress, boredom, or focusing on
present needs rather than future are examples of factors that influence quitting/picking up smoking
(ASH, 2019).

But what causes significant differences in smoking prevalence? Disparities in smoking across the UK
isn’t by chance, there’s hosts of inequalities that play in peoples ability/motivation to make good
decisions, for example, neoliberalism. Neoliberalism is a free market, promoting privatization of
public goods and services, shifting distribution of income, wealth and opportunities for social
mobility (Smith, Hill and C Bambra, 2016). In terms of health, neoliberalism means the state isn’t
wholly responsible in providing the best health for individuals but rather shows a shift towards
individual/personal responsibility. There’s arguments towards neoliberalism, expectations are
individuals are free, empowered, and positively encourages the values: choice, autonomy,
independence and self realisation – arguably increasing ambition and want to achieve, pushing
society to evolve and develop. Politically it’s much easier and financially cheaper having a neoliberal
stance, urging people on their own responsibility to stop smoking by using HP and marketing, but,
inequality’s built into a neoliberal system, causing extensive negative impacts on HI (Smith, Hill and C
Bambra, 2016).

The neoliberal idea of individual responsibility, relying on ‘choosing’ good health is problematic, as
it’s never a neutral choice. Constraints of SD and impacts on health immediately puts people on an
un-level playing field, those negatively impacted by SD aren’t simply making poor choices there’s an
unfair disadvantage. For example lack of HL, making informed choices on health is hindered by
structural educational differences, majority of people in the UK aren’t endowed with strong HL
especially profound in DA geographically. This can result in those: being unaware of help available,
less success managing long-term health conditions, less recall and adherence to medical instructions,
and lacking knowledge to make all round good decisions on health (Marmot and Wilkinson, 2005).

Public health social marketing improves people’s physical and mental health by advertising HP and
encouraging change in lifestyle in traditional marketing form. Although government HP is important
in stabilising socio-economic health equality and HL, more needs to be done. To reduce the socio-
economic divide, measures focusing on reducing smokers in high prevalence groups with
prioritization on population level targeted interventions should be put in place helping reduce a big
driver in HI. Though it’s important to acknowledge this divide can never be reduced completely,
raising standards of those worse off is vital (ASH, 2019). SLT’s role in behavioural risks to health is
through adjustments in communication needs supporting service users in understanding HR and
choices, and signposting appropriate services.

Obesity

There’s inequality for obesity prevalence in socio-economically DA, health surveys in England from
2019 showed those from the most DA were most likely to be obese, highlighted profoundly in
women where 39% from the most DA were obese compared to 22% in most affluent areas (NHS
England [NS], 2020).

There’s vast amounts of negative health affects obesity causes – type 2 diabetes, coronary heart
disease, cardiovascular disease, types of cancer(e.g breast or bowel), stroke and osteoarthritis as
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examples. Not only physically, obesity can impact mentally with stigmas, bullying, and negative
effects on self-image inducing mental health conditions like depression (Luppino et al., 2010).

But why does SES increases likelihood of obesity? Biopsychosocial factors associated with area level
deprivation can result in challenges acquiring healthy food, due to higher expenses of healthy foods,
labouring long hour jobs resulting in lacklustre to cook and area level food deserts make providing
perpetual balanced healthy meals more difficult. Then additionally fewer opportunities for physical
activity those from DA have, because of less access to parks/green space, crime rates/unsafe
outdoor space, cost of gym memberships, these factors massively reduces motivation to exercise
(Rosenbaum and White, 2016). Using the (Money and Thurman 1994) means reasons opportunity
model for reference, individuals from DA don’t have means to exercise (less green space access,
unaffordability of gyms), reasons to exercise are reduced significantly when HL is lower and outdoor
space is considered unsafe, and opportunities to exercise are limited if pressure for income results in
working long labouring hours/shifts. Another factor to consider in obesity rates of DA in the UK is
obesogenic environment – looking at the role environmental factors in determining nutrition and
physical activity (Jones et al., 2007). Commercial interests in lifestyle matters generally work against
healthy living, fast food companies for example don’t care consuming masses of their food is
unhealthy, rather are looking at profits. Referring back to neoliberalism in terms of HP and political
changes, it’s much easier putting emphasis on individuals mandating HP than take responsibility
themselves.

Furthermore, obesity’s a massive risk factor for multimorbidity. Multimorbidity is two or more
chronic conditions, illnesses or disorders or present in an individual simultaneously (Olutende et al.,
2021). The (Agborsangaya et al., 2013) study on multimorbidity prevalence looks at correlations
between obesity and multimorbidity, research showed cause to believe obesity greatly increases
multimorbidity risk and is a gateway to multimorbidity. Multimorbidity comes with it’s own HR – risk
of sub-optimal care, frequent/longer hospitalizations and higher healthcare costs.

Looking at the research methods of this study, the sample was large with just under 5000
participants with fairly ratioed males and females, providing more reliable results as larger studies
typically have lower error margins and standards of deviation. There was generalizability with an
unbiased gender sample, a vast age range of 18-65, although pervasiveness wasn’t entirely equal
with higher volume of participants from 45-64 age range, this was rationalized with results showing
correlation between old age and obesity. Additional socio-demographic predictors of multimorbidity
and extraneous variables analysed were: household income, education level and GL.

Although the study’s sample shows standardization and generalizability, the research article had
limitations. In the report numerous chronic conditions weren’t included, meaning result outcomes
could have drastic variation with more conditions present. Participants also submitted data in self-
report format, respondent characteristics can effect validity of results as self-declaration bias can
cause under reporting diagnoses, or over-estimation of single conditions and alternative symptoms
(Agborsangaya et al., 2013).

To prove the point further displaying the knock on effect SD have on health regarding obesity, the
(Olutende et al., 2021) journal on influence of socio-economic deprivation on multimorbidity
showed SES having clear associations with multimorbidity. Factors like limited
availability/accessibility to health services, lack of social support, infrastructure deprivation or poor
transport networks increases prevalence in socially DA. The systematic review by (Olutende et al.,
2021) used clear operationalizing definitions between multimorbidity and co-morbidity which are
commonly used interchangeably. This established reliability of information from the source.
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These two epidemiology studies represent perfectly the social gradient and unfair playing field SES
enforces on HI. SES increases obesity likelihood, obesity increases multimorbidity risk,
multimorbidity reduces life expectancy. The knock-on effect of SD shows clearly we’re not equally
able to make good health choices. As SLT, looking at health status is important in understanding co-
occurring health needs or intellectual disabilities, in planning appropriate healthcare, and the
structural barriers accessing health services due to diagnostic overshadowing and institutional
ableism (RCSLT, 2021).

Wider determinants of health

Poverty and poor housing conditions are associated with multitudes of health problems: respiratory
infections, lung problems, asthma, poor mental health. Standard of living can cause this due to black
mould for example, those from DA in social housing or low incomes are more susceptible to damp if
they can’t afford heating on regularly, and don’t have choice to move from insufficient living
conditions if they develop, consequently left vulnerable to detrimental HR due to wider determinant
HI out of their control. In his review article on HI, (Scambler, 2011) wrote of material assets and
relations between relative poverty or deprivation due to impoverishment meagre standard of living,
and influence on health and life expectancy. He additionally wrote of SC in aspects of social
integration, networks and support, that political manipulation shouldn’t result in these inequalities
and neglect – promoting relation between SC and health.. He gives ‘recommendations of WHO
Commission on Social Determinants of Health’- a commission aimed at governments to address
social factors leading to ill health and HI (World Health Organisation [WHO], 2005).
Recommendations included: social protection policies supporting income level healthy living,
strengthening public financing action on SD and responsibility for action on health equity on highest
level of government - removing neo-liberal social formation driving inequality. The (Scambler, 2011)
article was a selective review, with references primarily quantitative over qualitative and generally
theoretical. Although selective reviews can be misleading with increased susceptibility of bias,
there’s many advantageous traits such as: specificity in research, explicit methodology, and
providing reliable accurate results.

Geographical determinants of health are proven with differing life expectancy. It’s fact that DA have
lower life expectancies, the (Office for National Statistics, 2020) published regional life expectancy
statistics between 2017-2019 displaying 11.3 years gap for males and 8.7 years for females between
local UK areas. To understand the geographical life expectancy differences it’s important to look at
contexts of individuals, local areas have differences in: access and quality of healthcare, SC, HL or
physical environment (e.g climate/pollution) - industrial incidents for example effect people
disproportionally depending on where they live, a geographical determinant of health. These
circumstances factor into the point that we’re not all equally able to be healthy.

In conclusion, the main points from this writing is that lifestyle diseases show as evidence in the
massive divide in HI determined unjustly by intersectionality of SES. A final point to coincide with the
argument that we are not all equally able to ‘chose’ to be healthy is children. If neo-liberal ideologies
indicate healthy living is a personal responsibility determined by good choice making, children who
grow up in the most DA suffer from significant HI disadvantages without having the opportunity to
make good health choices.
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