Inequalities in non-communicable diseases and effective responses

TL;DR: Effective actions to reduce NCD inequalities include equitable early childhood development programmes and education; removal of barriers to secure employment in disadvantaged groups; comprehensive strategies for tobacco and alcohol control and for dietary salt reduction that target low socioeconomic status groups.

About: This article is published in The Lancet.The article was published on 2013-02-16 and is currently open access. It has received 544 citations till now. The article focuses on the topics: Socioeconomic status & Health care.

Summary

Introduction

• Non-communicable diseases (NCDs) cause 35 million of the 53 million annual deaths worldwide; more than three-quarters of these deaths occur in low-income and middle-income countries.
• The scarcity of similar worldwide evidence for NCDs creates diffi culties in formulation and implementation of actions that reduce NCD inequalities, and in assessment of how these actions might help to decrease the total NCD burden.
• See Comment page 509 Reduction of dietary salt intake by regulation, well-designed public education, and mass media campaigns that target disadvantaged and marginalised social groups, and perhaps negotiated voluntary actions by food manufacturers .
• In examples the authors refer specifi cally to cancers, cardiovascular diseases, diabetes, and chronic respiratory diseases—four disease groups that together account for more than 80% of NCD deaths and are included in global goals.

NCD outcomes

• Studies in high-income countries, especially those outside Asia, have shown that NCD mortality is higher in people with low education, income, or social class;8–17 those in marginalised ethnic groups ;18–21 and those living in poor and deprived communities.
• 22–25 These socioeconomic gradients are generally smaller, and for some diseases even reversed, in southern Europe and Asia.9,10,49,50 Figure 3 shows age-standardised cancer and cardiovascular disease death rates in the lowest and highest quintiles of community socioeconomic status in Eng land, Japan, New Zealand, and South Korea—four countries with complete death registration and medical certifi cation of cause of death.
• Nonetheless, the more pro-equity policies and programmes seem to have helped to reduce health inequalities compared with their peak in the 1990s.
• By contrast with New Zealand’s eff orts to reduce health inequalities, recent policy choices could worsen health inequalities between Canada’s indigenous population (the First Nations) and other groups.

NCD risk factors

• The socioeconomic patterns of major NCD risk factors show similarities and important diff erences across countries on the basis of region and stage of economic development.
• By contrast with smoking, concentration of serum total cholesterol and body-mass index had positive associations with education in low-income countries and, for men, in middle-income countries,62–64 whereas in high-income countries, both risk factors were inversely associated with education in women but neither risk factor had an association with education in men (fi gure 5).
• Investigators have studied how risk factor inequalities change over time in the same community or country.
• Thus, equitable reductions in risk factor exposure are essential to reduce social inequalities in NCD outcomes.

NCD healthcare

• People in low-income and middle-income countries have less access to NCD care and treatment, especially to primary care, which can eff ectively reduce some NCD risk factors and prevent advanced-stage disease and complications at relatively low cost by early detection and treatment.
• Low access to treatment leads to poor prognosis and survival in patients with NCDs in developing countries.
• Patients with cancer in high-income countries have up to twice the survival rate of those in middle-income countries, and survival rates are even lower in India and Africa.
• Vol 381 February 16, 2013 lower blood pressure and lipids,38 whereas, with the possible exception of anti platelet treatment, coverage is systematically lower in low-income and middle-income countries, and is as low as 5% for statins.

NCD health care

• Inequalities also exist in fi nancial and physical access to health care, and health-care use and quality, based on individual and community characteristics.
• Further reduction of global inequalities will need actions and targets that focus on countries where NCD mortality and risk factors are presently highest—ie, generally low-income and middle-income countries.
• Past work into the causes of health inequalities has drawn attention to the roles of environmental, political, and psychosocial factors; health behaviours and proximal risk factors; and health-care access and quality.
• Social policies and programmes that improve opportunities and capabilities for economic productivity and social participation, and facilitate healthy lifestyles and environments, are essential to improve health and reduce inequalities.
• Even when such data are collected, data quality and comparability issues will need to be addressed, as has been done for the measurement of health outcomes and risk factors.

Contributors

• MDC, Y-HK, PA, TB, CK, JWL, MGM, and ME helped to identify relevant studies.
• ME oversaw the research and wrote the fi rst draft of the report.
• MDC, Y-HK, PA, TB, CK, and JWL helped to write specifi c sections of the article.
• All authors provided input into the fi nal report.

Acknowledgments

• The author alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy, or views of WHO.
• The authors thank June Atkinson and Peter Hambly for data, analysis, and methods related to mortality in England and New Zealand; Jorge Duarte for analysis of risk factors in Colombia; and Robert Beaglehole, Ruth Bonita, Pascal Bovet, Shah Ebrahim, Christopher Millett, participants in The Lancet Non-Communicable Disease Series review meetings, and anonymous reviewers for valuable comments on earlier drafts.
• ME is supported by a Strategic Award from the UK Medical Research Council and by the National Institute for Health Research Comprehensive Biomedical Research Centre at Imperial College Healthcare NHS Trust.
• Analysis of data from England was done by the Small Area Health Statistics Units, funded by the Health Protection Agency in England as part of the Medical Research Council–Health Protection Agency Centre for Environment and Health at Imperial College London.

Figures

Figure 4: Contribution of selected non-communicable diseases to the absolute inequality in total (all-cause) death rates between the lowest and highest quintiles of community socioeconomic status in four countries with complete vital statistics and medical certifi cation *In South Korea, 72% of the excess death rate in the lowest quintile compared with the highest quintile is attributable to deaths assigned to senility as the underlying cause; these are likely to be mostly from cardiovascular diseases.

Figure 2: Diabetes and hypertension treatment coverage by education level in adults aged 25–64 years in selected countries This fi gure shows treatment coverage in all people with diabetes (A) or hypertension (B), irrespective of whether the disorders are diagnosed or undiagnosed, thus representing both under-diagnosis and under-treatment. Data are crude estimates; see appendix (pp 1–3) for results by age groups. In South Korea, and to a lesser degree in Iran, the age-specifi c associations of treatment coverage with education were a mix of direct, inverse, and no association. Education was categorised into three or four groups in each country, from lowest to highest. Cambodia: no formal schooling 23·1%; less than primary school 41·0%; primary school completed 20·2%; secondary school or higher 15·7%. Colombia: no formal schooling or less than primary school 23·9%; primary school completed 39·0%; secondary school completed 30·1%; university completed 7·0%. Iran: no formal schooling 27·4%; primary and middle school 40·7%; secondary school 21·9%; undergraduate and graduate 10·0%. Malawi: no formal schooling 22·3%; less than primary school 34·4%; primary school completed 27·7%; secondary school or higher 15·6%. South Korea: middle school or less 24·3%; secondary school 39·3%; college or higher 36·4%. USA: below secondary 17·2%; secondary/General Educational Development or equivalent 23·2%; college or higher 59·6%. Data are from an analysis of fi ve nationally representative health examination surveys (Cambodia: STEPS 2010; Colombia: Encuesta Nacional de Salud 2007; Iran: Non-Communicable Disease Surveillance Survey 2005; Malawi: STEPS 2009; South Korea: three rounds of National Health and Nutrition Examination Survey between 2008 and 2010; USA: three rounds of National Health and Nutrition Examination Survey between 2005 and 2010).

Frequently asked questions

Q1. What are the contributions in "Inequalities in non-communicable diseases and effective responses" ?

Within-country NCD inequalities in equalities have not received explicit attention in global NCD discussions this paper, and their interventions are large and reduction of these inequal ities will help to achieve the 

Q2. What are the key steps to reduce NCD inequalities?

Social policies and programmes that improve opportunities and capabilities for economic productivity and social participation, and facilitate healthy lifestyles and environments, are essential to improve health and reduce inequalities. 

Q3. What are the important social policies and programmes to address NCD inequalities?

The most important are those that enhance early childhood development, improve access to highquality education, create home and school envir onments that facilitate good educational outcomes, and remove barriers to secure employment for disadvantaged groups. 

Q4. What are the key actions needed to reduce NCD inequalities?

global and within-country inequalities in blood pressure mean that actions are needed to reduce salt intake in disadvantaged groups to help to reduce NCD inequalities. 

Q5. How can the authors ensure that data is linked across multiple sources?

In high-income and even middle-income countries, data can be linked across multiple sources that incorporate information about socioeconomic status and place of residence, but implementation of safeguards is necessary to ensure confi dentiality and to overcome political and especially bureaucratic barriers. 

Q6. What is the CSDoH’s recommendation to reduce NCD inequalities?

The Commission on Social Determinants of Health’s (CSDoH) recommendation of health equity in all policies, systems, and programmes aims to reduce NCD inequalities by equalising distributions of power, fi nan cial resources, education, housing, and other environ mental factors, nutrition, and health care. 

Q7. What are the main reasons for the inequalities in health care?

Social inequalities in risk factors account for more than half of inequalities in major NCDs, especially for cardiovascular diseases and lung cancer. 

Q8. What are the main factors that contribute to the burden of NCDs?

A substantial amount of the world wide NCD burden is attributable to behavioural, dietary, environmental, and metabolic risk factors3–5—a fact that has attracted worldwide attention to NCDs as a major global health issue and has shown the need for improved prevention and treatment. 

Q9. What is the role of social policies in reducing health inequalities?

careful assess ment of health inequalities in high-income countries indicates that welfare states, and their social policies, do not necessarily reduce health inequalities,98 partly because existing policies only partially redistribute income and wealth. 

Q10. How much should the authors measure the success and failure of their societies and governments?

The authors should measure the success and failure of their societies and governments by how quickly, how widely, and how well the authors take these actions, and how much they reduce health inequalities. 

Q11. How many countries have a health inequalities debate?

As the debate about why inequalities arise and whether they are unjust continues, the authors should constantly recall that the existence, and persistence, of inequalities suggests failure to develop, enact, or implement policies and programmes that create healthy household and community environments, facilitate healthy lifestyles and diets, and deliver universal high-quality health care. 

Q12. What is the evidence for a reduction in the relative tax burden of unhealthy foods?

Despite industry eff orts to portray taxes on harmful and unhealthy products as regressive, evidence suggests that groups with low socioeconomic status are responsive to price changes, leading to both health benefi ts and to a reduction in the relative tax burden. 

Q13. In what countries did the mortality inequalities in the elderly be small?

in South Korea, the mortality diff erential was very small at older ages, with a weak inverse relation for cardiovascular disease mortality. 

Q14. What factors are important in determining health inequalities?

the data also show the importance of social, cultural, epidemiological, and health-care factors as determinants of health inequalities. 

Q15. What is the important source of inequalities in mortality in New Zealand?

Vol 381 February 16, 2013 589NCD inequalities are the most important source of inequalities in total mortality and life expectancy. 

Q16. What are the key actions to reduce NCDs and inequalities?

On the premise that both progressive social policies and NCD prevention and treatment programmes are necessary to address NCD health inequalities, other key actions to reduce NCDs and NCD inequalities are described in the following paragraphs.