Lecture 6: Health Inequalities

health (WHO definition)

-a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity

biopsychosocial model of health

-brings together three areas that contribute to health:

1. biomedical → genetics, viruses, bacteria

2. psychological → beliefs, behaviour, stress

3. social → status, ethnicity, friendship groups

-recognises that these elements interact and impact on our health

-the person and the context in which they live is taken into account as well as the influence of biology

life expectancy variation

-Japan is highest → 84.3 years

-Lesotho is lowest → 50.7 years

social determinants of health

-circumstances in which people are born, grow up, live, work and age

-the systems put in place to deal with illness

-shaped by economics, social policies and politics

equality

-everyone gets the same resources

equity

-everyone gets the same outcomes, with resources distributed according to need

equal outcomes

-achieved through the removal of structural barriers

covid inequalities

-found factors other than underlying health status might mean you are more likely to get seriously ill from coronavirus:

• age

• being a man

• living in poorer areas

• BAME

• being born outside UK or Ireland

• living in a care home or having certain jobs

HPV

-human papillomavirus

-sexual transmitted infection

-more than 200 types

• low risk types → cause genital warts

• high risk types → cause cervical and other cancers

impact of HPV on health

-genital warts

-implicated in 5% of all cancers

-incidence of head and neck cancers is attributable to HPV 16/18 is five-fold higher in men

-90% of anal cancers

-cervical cancer

90-70-90 targets (WHO)

-defines cervical cancer elimination as <4 cases per 100,000 women and has set 90-70-90 targets for countries to reach

• vaccination against HPV which is responsible for 90% of cervical cancers

• 70% of women have cervical cancer screening which aims to detect and treat pre-cancerous cells before they develop into cancer

• treatment for cancerous cells for 90% of women

cervical screening in Uganda

-not routinely offered but is available through obstetric and HIV clinics

-main approach used is visual inspection with VIA, treated with cryotherapy at the same appointment

-major barrier is access in remote or rural areas

-screening rate is between 5-30% and most women are diagnosed with advanced disease

Black - barriers to cervical screening

-embarrassment, fear of procedure or outcome

-residing in a remote or rural area

-limited resources/health infrastructure

-most frequent facilitator was having a recommendation to attend screening

cervical screening in UK

-saves >2000 lives per year

-HPV primary screening:

• replaces cytology-based screening

• sample tested for HPV, if positive then sent to cytology

• opportunity for self-testing

dimensions of inequity

-ethnicity socioeconomic status, sexual minorities, age, sexual trauma, disability

-less likely to attend cervical screening

-at risk of worse adverse emotional responses to testing positive

-colposcopy attendance → more likely when older and wealthier

disability and health inequality

-women with disabilities often have difficulty with physical access to health services

-at risk of delayed diagnosis and cancer mortality, partly due to lower screening

medical model of disability

-problem is the disabled person

-medically focussed on condition/symptoms and person

social model of disability

-problem is the disabling world, rather than the person’s condition

-oppression and exclusion people with impairments face is caused by the way society is run and organised

-key disabling barriers:

• attitudinal barriers

• physical barriers

• information/communication barriers

Edwards (cervical screening and physical disability)

-systematic review of barriers and facilitators to cancer care

• only 5 studies between 1997 and 2015 explores cervical screening for physically disabled women

• all reported a decrease in screening attendance associated with disability

Chan (cervical screening and physical disability)

-systematic review of factors influencing screening uptake

• lack of knowledge of cervical cancer screening and how it can be accessed

• difficulties and inconveniences in accessing cancer screening providers and undergoing the screening procedures

• uncomfortable experiences during the screening procedures

UK report 2019 (cervical screening and physical disability)

-88% said it is harder for disabled women to attend or access cervical screening

-63% had been unable to undergo cervical screening because of their condition

-49% had chosen not to attend cervical screening for reasons such as previous bad experiences related to their disability

-20% reported they were assumed not to be sexually active

Sherman - method (cervical screening and physical disability)

-cross-sectional online survey

-eligible for cervical screening

-identified as having a physical disability, condition, impairment or difference

-rated statements developed with patient and public involvement stakeholders:

• included screening-related problems and solutions, questions about self sampling and preferences for future screening

Sherman - results (cervical screening and physical disability)

Problem	% endorsed Sherman et al 2024	% endorsed Waller et al 2009
I worry that a cervical screening test will be painful	83	14
Cervical screening tests are embarrassing	70	28
I’m scared of what a cervical screening test might find	69	12
The examination table is uncomfortable	66	N/A
I’ve had a bad experience of cervical screening in the past	63	9
Having to lie on my back with my legs apart is a problem	61	N/A
I worry about having a male doctor or nurse do the test	60	N/A
I intend to go when I’m due, but don’t always get round to it	52	21
Doctors and nurses lack understanding of disability	46	N/A
It is difficult to get an appointment to fit in with work/childcare commitments	46	7

-Waller looked at non-disabled women

-Sherman looked at disabled women

-shows disabled people have the same issues but these are highly exacerbated in a disabled community

Sherman - endorsed facilitators (cervical screening and physical disability)

Solution	% endorsed
A doctor or nurse who discusses my specific needs	86
A doctor or nurse who is willing to try different solutions	85
A doctor or nurse who understands my physical disability	82
A smaller speculum	80
A cervical screening passport	74
Being invited by email or text	69
An examination couch that can be lowered	69
Having a conversation with the doctor or nurse before the appointment	69
Being offered medication that prevents muscle cramps and spasms (antispasmodic)	62
Being offered the left lateral position for the screening test	55

self sampling results (self-screening and disability)

HPV vaccination in UK

-school based vaccination programme introduced for girls aged 12-13

-boys later added to programme

-has led to 88% reduction in CIN grade 2 or worse in young women

-a substantial reduction in cervical cancer and incidence of CIN3

HPVC and men

-vaccinating boys:

• protects female partners

• protects themselves

-incidence of anal cancer is similar to estimated rate of cervical cancer without a screening programme

head and neck cancer

-risk factors:

• excessive alcohol consumption

• smoking

• HPV

-does not include brain

oropharyngeal cancers

-rising incidence

-in UK + USA, incidence of HPV oropharyngeal cancer in men has surpassed that of cervical cancer in women

social ecological model (screening and vaccination)

-inner to outer circle:

1. individual → knowledge, attitudes, behaviours

2. interpersonal → perceived norms among family/friends

3. community → cultural values, religion, public transport

4. health systems → screening accessibility, school-based vaccination, cultural safety

5. politics → national or regional screening + vaccination policies