Health Inequalities - Case Study Example

Environmental Health Practitioners’ Contribution to Community Regeneration in Order to Impact on Wider Determinants of Health and Inequalities Introduction Environmental health practitioners are “applied scientists and educators who use the knowledge and skills of the natural, behavioral and environmental sciences to prevent disease” and improve the health of populations in a wide range of areas (Koren & Bisesi, 2002: 66). These include public health, environmental sustainability, pollution and noise control, housing, indoor environment, infection and pest control, occupational health and safety, food processing, waste management, water supply, terrorism, accident prevention and many more factors towards improving community health and living conditions. The government’s policy drive to tackle inequalities in health fuels change and innovation in environmental health practice, towards community regeneration to impact on the wider determinants of health (Watkins et al, 2003: 40). This paper proposes to discuss the expected changes in the role of the environmental health practitioner in the future, the new emphasis on health inequalities, the requirement of a social model of health, how health inequalities are being addressed, the importance of health promotion through the emergence of the new public health, the methods and approaches of environmental health and public health based on the policy context of Community Regeneration, Neighbourhood Renewal, Local Strategic Partnerships, and other approaches. Further, Community Development, empowerment, participation and other methods will be analysed, as well as potential problems in relation to the developing role of the environmental health practitioner (EHP), will be identified. Raising social capital, networking and partnerships as essential strategies will be discussed. Lastly, the methods by which the EHP can conduct Health Needs Assessment for achieving the goals of the new public health agenda will be determined. Discussion The major determinants of health are: social class, income, housing, employment, gender, health of ethnic minorities, place of residence, social cohesion or exclusion (Naidoo & Wills, 2000: 27-50). Public health has a long history of working on the wider determinants of health to improve health and reduce health inequalities. In the nineteenth century, the focus was on improving sanitation and on communicable disease control. After a long period of decline in public health and practitioners’ functions, public health has been reinforced with new life in current times. This is due to government policy initiatives on health inequalities, and refocusing on the role and functions of public health in a modern context (Watkins et al, 2003: 40). Future Role of the Environmental Health Practitoner A vision of the future role of the environmental health practitioner (EHP) would include necessary changes in the knowledge, skills and work functions that he/ she would carry out. The main challenges will be in environmental sustainability and community regeneration, while other areas which will necessitate continuing work will be in primary care, tackling ill-health and the major diseases, control of communicable disease, pollution and nuisance management, housing, transport, community safety and crime prevention, managing local, national and international disasters, substance misuse, improving people’s quality of life, and training and continued professional devleopment (Burke et al, 2002: 7-12). It is crucial that the EHP who is a specialist and scientist of the future, must have essential knowledge of health and the environment, and recognize the pressures that impact natural resources by rising population levels. “These pressures are far more severe than have ever been previously suspected” (Koren & Bisesi, 2002: 75-76). Significant research evidence reveals that a problem of increasing concern is ground water contamination. Hazardous waste dumps and other ground storage generate toxic chemicals which cause serious health and environmental threats and create public health problems. Toxic chemicals which are growing in quantity and complexity are potentially dangerous to humans and to the ecosystem. Hence, the role of the EHP will focus on the increasing need to address impacts on natural resources, and control rising levels of pollution and contamination of the natural environment (Koren & Bisesi, 2002: 76). The vision for the role of environmental health practitioners in the future, will include organizing inter-disciplinary interventions towards reducing health inequalities and implementing risk management for improving health and quality of life of individuals and communties. They will apply their expertise to meet the needs of the public by maintaining direct interaction, being involved in local authority development, implementation of community health and wellbeing strategies through local strategic partnerships, and will contribute to the NHS’s Primary Care Trusts’ public health agenda (Burke et al, 2002: 2). Health Inequalities There are extensive inequalities in health both within and between countries. The difference in life expectancy is up to forty eight years among countries, and twenty years or more within countries; which is a fundamental indicator of health inequality. Research evidence indicates social factors such as poverty to be the main cause of inequalities in health, resulting in both communicable and non-communicable diseases. Hence, health status needs to be of concern to policy makers in all sectors, focusing on social and economic development for fighting against major disease and improving population health (Marmot, 2005: 1099). According to research evidence, a significant explanation for inequalities in health lie in spatial dimensions related to where individuals live. The “place” or neighbourhood plays an important role in influencing individuals’ and families’ levels of exposure to health risks, as well as their chances of being healthy. The national strategies for community regeneration emphasize closing the health gap between the rich and the poor; which highlights an area-based approach for tackling health inequalities (Hunter & Killoran, 2004: 2). Thus, an effective social model of health is community regeneration with neighbourhood renewal. Research shows that regeneration makes a positive contribution to improve health and to address health inequalities and health disadvantages of the poor by impacting on the wider determinants of health. In order to use scarce resources efficiently and to ensure that interventions based on public policies optimize benefits for the poor and minimize negative outcomes, evidence-based policy is the most effective. The core features of the Neighbourhood Renewal Strategy are: local strategic partnerships between various agencies which develop and implement renewal strategies in an integrated manner; maintaining focus on integrated programmes and services based on the bigger picture, for achieving the main goal; implement “what works” using evidence from extensive research; employ local learning action plans that develop skills and resources; organize a Neighbourhood Renewal Fund to fuel crucial changes; and establish a support system for implementation efforts through a Neighbourhood Renewal Unit. It is essential that a rapid assessment of the health consequences should form an integral and initial part of the regeneration and renewal strategy (Hunter & Killoran, 2004: 2). The Acheson Report by Sir Donald Acheson published in November 1998 which presented the position on health inequalities, and identified possible reasons, provided the foundation for policy development on health inequalities in the United Kingdom and beyond. Emergence of the New Public Health and Health Promotion The practice of public health has always been determined by political and cultural factors. The paradigms in relation to the levels of responsibility and involvement required from the individual, the community and the state keep changing. The eighteenth and nineteenth centuries which were dominated by industrialization gave rise to increasing populations and crowding in the urban areas with underpaid workers. There was increasing poverty, filth, squalor and diseases. “Poverty and disease work in a vicious circle in which cause and effect often change places” (Newsholme, 1919: 909). The evolution of public health in England, based on crucial needs, progressed slowly. The Poor Law Amendment Act of 1884 gave the Central government control over undertaking programmes of local relief such as integrating several parishes into unions for providing poor relief including medical treatment. From providing medical relief, the law was amended to include cure and prevention. The impact of public health increases every year, embracing prevention and cure of diseases, improvement of living conditions, working environment, ecological preservation, pollution, contamination of natural resources, public safety, education and training of the general public and healthcare professionals in the science and practice of public health (Newsholme, 1919: 907-908). According to the Ottawa Charter (1986: 1), “health promotion is the process of enabling people to increase control over, and to improve their health”. Optimal health is a state of complete physical, mental and social well-being. To achieve this condition of health, an individual or group must be able to identify and realize aspirations, to satisfy needs, and to change or cope with the environment. Health is an important resource for everyday life, which helps in physical capabilities and for obtaining other essential social and personal resources (Ottawa Charter, 1986: 1). Promotion of health is based on the following basic factors that contribute to health: peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity. Health promotion action includes building health policy in all sectors of the government and creating supporting environmental systems such as the conservation of natural resources as a global responsibility. Further, working and living conditions should be healthy and safe. Strengthening and empowering communities for taking ownership and control of their own destinies by setting priorities, making decisions, planning strategies and implementing them to achieve better health. Health promotion also supports personal and social skills development by providing information, education and training for enhancing life skills. Reorienting health services, through the integrated working of professional, commercial and voluntary bodies, to form a healthcare system based on caring, holism and ecology (Ottawa Charter, 1986: 3). Health Promotion Policy Three complementary types of action to improve health, based on the policy Saving Lives: Our Healthier Nation (Secretary of State for Health, 1999), are: 1) Individuals and families taking action to resolve their health issues, 2) Communities working together in partnership, and 3) Government action to address the major determinants through policy on areas such as jobs, housing and education. The National Health Service (NHS) Plan (DH, 2000: 6) and subsequent papers from the Department of Health such as Tackling Health Inequalities: A Programme for Action (DH, 2003) have continued to map out the civic responsibilities of the community and cross-government, for resolving health inequalities (Adshead & Thorpe, 2006: 30). Further, policies such as the NHS Improvement Plan (DH, 2004) and the Choosing Health delivery plan (DH, 2005) provide a map for the future and answer the criticism that the NHS needed to reduce demand on its resources by increasing the promotion of health and the prevention of disease. The policies express the need to focus on people, connecting with their lives and empowering them to develop on their own efforts towards improved health and behavioural changes (Adshead & Thorpe, 2006: 30). Strategies in Implementing Environmental Health and Public Health A community development approach to service delivery focuses on communities taking charge, identifying and meeting their own requirements. The aim is to change the culture of “dependency” when tackling concerns about health and health services in Britain (Burke et al, 2002: 12). While applying the theory of change, local strategies for community regeneration are multi-faceted and complex community interventions (Hunter & Killoran, 2004: 3). Policy Context of Community Regeneration “Policy has moved from the piecemeal, project-based and compartmentalized towards the integrated, strategic and mainstream” (Russell, 2001: 4). Critical to partnerships at a strategic level and integration of a range of national and local organizations, is an approach developed by the Local Government Association called New Commitment to Regeneration (1999). Applicable to both urban and rural areas, it involved whole local authorities or combinations of local authority areas; the mainstream budgets and programmes of all the public sector agencies in the area; national government as a key partner; and used freedom and flexibilities in developing national programmes. The above approach to community regeneration took into account that deprived areas cannot be treated in isolation since they are part of the wider economic scene, and need to be seen in the context of their inter-relationships with other neighbourhoods. Further, more poor and excluded people live outside than inside deprived neighbourhoods. Equity issues need to be tackled through “wider interventions, mainstream programmes and a different deployment of resources at a wider spatial level” (Russell, 2001: 2). The policy integrates coherent strategies and focuses on responsibilities of area-based regeneration schemes and core public services, while balancing social, economic and environmental goals in areas widely differing from each other. Policy Context of Health and Neighbourhood Renewal The Department of Health published the national health inequalities strategy as Tackling Health Inequalities: A Programme for Action (DH, 2003). This set out plans to tackle health inequalities over the next three years to reduce the gap in infant mortality across social groups and to raise the life expectancy in the most disadvantaged groups at a faster rate than for other groups. The Programme for Action was developed, taking into account that health inequalities are persistent and difficult to change, and the inequalities are widening and will continue to do so until a different approach is adopted. Further, not only the short-term consequences of avoidable ill health, but also the long-term causes had to be addressed. The four themes of the strategy for completion by 2006, included supporting families, mothers and children; obtaining the services of communities and individuals; preventing illness and providing effective treatment and care; and addressing the fundamental determinants of health (Dowler & Spencer, 2007: 24). The Neighbourhood Renewal National Strategy Action Plan is based on the government’s response to deal with deprivation in England’s poorest communities which are impacted by “poor economies, unemployment, poor health, educational failure and crime” (DH, 2007). The action plan aims at narrowing the gap between deprived areas and the rest of England, so that serious disadvantages caused by the area where individuals live, will be removed. The government’s purpose is to ensure for the poorest parts of the country: economic prosperity and reduction of unemployment, safe communities with less crime, high quality schools and better educational facilities, improved housing and better health. Thus, through the action plan, neighbourhood renewal focuses on communities, and works in partnership with commercial enterprises, local government, service providers and the voluntary sector. Participation by individuals in the community is ensured, for identifying and solving local problems. The programme uses funds from key government departments, rather than depending on an occassional regeneration budget. Policy Context of Local Strategic Partnerships Local Strategic Partnerships (LSPs) emerged from the Local Government Act 2000, for the purpose of improving local quality of life in deprived localities. Extensive progress has been made in terms of representation, establishing a common vision, and shifting to genuinely collaborative working among local groups. Local Strategic Partnerships have a critical role in continued development of consistent service provision and genuinely sustainable communities. In England there are at present, over 360 LSPs, out of which eighty six are in areas that currently receive Neighbourhood Renewal Funding (Forum, 2006). The LSPs operations are based on policy areas covering economic, social and environmental well-being, community development, labour market and social inclusion. They include the Sustainable Community Strategy, Local Neighbourhood Renewal Strategy, Local Area Agreement, Local Development Framework, implementing performance management systems, and developing techniques for monitoring and reporting progress to the partnership and local people. Further, LSPs are seen as the “partnership of partnerships”, working in area-based or thematic partnerships and the wider community and in the local area. It has a board made up of senior personnel from the public sector as well as representatives from the private, community and voluntary sectors (Forum, 2006). In relation to Environmental Health and Public Health, the policy contexts of community regeneration, neighbourhood renewal and local strategic partnerships support the crucial need for community initiatives, individuals’ participation and local partnerships to address inequalities in neighbourhood conditions and health status. Interventions for environmental sustainability, civic safety and security, pollution control and public health covering all aspects of natural, behavioral and environmental sciences, help to prevent and treat diseases and improve quality of life. Community Development, Empowerment and Participation Community development through regeneration initiatives involve empowerment of local people as well as their participation along with partnerships with relevant local groups, organizations and service providers. “Community development aims to build social capital which are the ties within and across communities, and promote the active involvement of people in the issues that affect their lives” (Russell, 2001: 40). Community development involves empowering groups of people to plan and carry out a programme of action based on their concerns. Examples are: improving playing space in a neighbourhood, providing a medical centre to meet the health needs of residents, undertaking teaching and training of skills, etc (Naidoo & Wills, 2000: 99). Empowerment is different from participation and involvement, and makes it possible for people to exercise power and have more control over their lives. This includes having a greater right to have a voice in institutions, agencies and situations which affect them. Empowerment is taken, rather than given as a gift from a higher power. Hence, user groups need to challenge and claim power for achieving self-empowerment (MacDonald, 2003: 46). Empowerment enables people to take charge of their lives including changing their behaviour, and work towards achieving community regeneration (Naidoo & Wills, 2000: 82). Participation and community involvement increases the effectiveness of regeneration programmes by improving decision making, supporting more effective programme delivery, and ensuring that the benefits of regeneration programmes are sustained over the long term. Regeneration partnerships based on community participation are unsuccessful if participation structures are unsatisfactory, participation is limited to certain policy and programme areas, or participation is only in a token form, without any power or influence. Participation does not have beneficial outcomes when mutual expectations and understandings about the parameters, purpose and likely outcomes are not clearly planned (Russell, 2001: 40). Analysis of Concepts Related to the Developing Role of Environment Health Practitioner It is clear that the EHP has to take into consideration the fact that individual factors like poverty are the primary cause of inequalities in health, however, the area where people live and work also play an important part. When people have a higher exposure to various forms of pollution, traffic volume, reduced access to public services, and other similar factors, their quality of life is comparatively worse. Another important factor is the influence of housing; together with area the impact is more direct than the “more generalized effects of income and social class” (Hunter & Killoran, 2004: 11). Community regeneration initiatives which focus on housing, health, transport, employment, and the economic, social and physical environment in neighbourhoods, can make a positive contribution for improving the health of economically disadvantaged groups in the community. Since there is a possibility for negative impacts on the health of these groups, and widening of health inequalities, it is essential that assessment of the health consequences of the schemes should form an integral part of the community regeneration plan. Problems Faced by the Environment Health Practitioner in Community Regeneration Initiatives Community regeneration strategies can be considered as successful only when they are equally effective for all members of the community, especially for those in the lowest socio-economic group. Interventions that are generally effective may not have any impact on the disadvantaged group. The inverse care law states that in areas where the need is greatest, the supply and quality of provision is the poorest. Inequity and poor access is frequently seen in primary care and prevention services. For example, there are fewer general practitioners to attend to the health needs in more deprived areas, as compared with the more affluent areas. In inner cities, among the black and minority communities, healthcare is inadequate, because recruitment and retention of staff in medical facilities is lower (Hunter & Killoran, 2004: 14). Raising Social Capital: The Role of Networking and Partnerships. Social capital plays an important role in developing healthy communities. People are healthier when they have supportive social bonds and networks, hierarchies and inequalities in society are reduced to a minimum. In partnership working for community regeneration, social capital involves the building of networks to aid communication and mutual cooperation. In a community, such networks facilitate social cohesion and consequently promote health. Four areas in which social capital increases the development of health promotion are: 1) Since social capital is developed by the interaction of individuals with the social system, thereby creating networks and partnerships, it focuses on the community and not on the individual. 2) Social capital incorporates the broad determinants of health, for finding solutions to the inequalities. 3) It highlights the processes for networking between people and organizational structures which are crucial for enhancing partnership working. 4) Social capital works across disciplines and could help develop new theoretical frameworks to enhance partnership development for health promotion (Balloch & Taylor, 2001: 190). Achieving the Goals of the New Public Health Agenda, Using Health Needs Assessment Identifying and assessing unmet health needs is believed to be better with the help of an inter-agency approach (Balloch & Taylor, 2001: 107). Developing shared information systems, internal and interagency help in obtaining complete information about health needs. The goals of the new public health agenda have to be combined with an assessment of health needs in each locality, and strategies and services have to be developed to meet them as effectively and efficiently as possible (Coote & Hunter, 1996: 46). The EHP and the “public health organization require a thorough understanding of the current as well as potential health needs within the populations they serve”(Novick & Mays, 2005: 266). Through the procedure of assessment, the information is transferred into practical knowledge about population health needs. Besides health information, an effective assessment process is used for group process facilitation, negotation, interorganizational decision making, and consensus development. Public health assessment is dependent on, and yet different from the processes involved in producing and managing population health, including public health surveillance and health information systems development. In order to determine the priority among multiple public health issues among a defined population, assessment is carried out as a critical, comparative analysis and interpretation of health information, using both qualitative and quantitative skills. Assessment is widely recognized as a central public health function. The EHP is required to incorporate the following features when designing an assessment process to fit the needs of the community they serve: define and delineate the assessment process, monitor health status to identify and solve community health problems, diagnose and investigate health problems and health hazards in the community, and evaluate the effectiveness, accessibility and quality of personal and population based health services (Novick & Mays, 2005: 267-268). These steps will help the EHP to engage with the new public health agenda, using health needs assessment as the basis for operations. Conclusion This paper has highlighted the role of the environmental health practitioner, the increasing focus on health inequalities, the importance of health promotion emerging from the new public health agenda, the methods and approaches of environmental health and public health based on the policies of Community Regeneration, Neighbourhood Renewal, Local Strategic Partnerships, and others. It is found that to reduce the gap between the poorer sections of society and the more affluent, it is important to strengthen community involvement through encouraging participation in various aspects such as decision making, governance, and democratic cooperation. An integration of multiprofessional and multiagency working is seen to be vital for achieving social change and improvement in the health of disadvantaged populations. The initiatives by the British government and international projects such as by the World Health Organization to improve community health and the growing inequalities among populations, is creditable (Balloch & Taylor, 2001: 196). However, to monitor and assess, and increase the effectiveness and efficiency of the initiatives, further research and development is urgently required, especially to identify the social processes that impact health. Social processes are especially important in initiating and maintaining partnerships and alliances in health promotion and care. Social capital is an important resource in health promotion. It also needs to be developed in the formation of partnerships for the purpose of social cohesion, health improvement and reduction of health inequalities; especially when disadvantaged and socially excluded groups are taken into consideration. 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