What is health

Session 3
Health in SEA

This session explores participants own views on health, working from what this may
mean to them personally and then thinking about this in the wider context of what health
may mean at the level of a city, town or rural community.

This moves onto exploring the WHO definition of health (1948) and how this is linked to
an understanding of the determinants of health.

Health inequalities are introduced and participants understanding of health and

inequalities is extended to an application in SEA objectives.
 Drugs Food Safety
Smoking
Older people
Meningitis
Blood Family
Bad Housing
Pressure
Accidents

Dog
Suicide Diabetes excrement
Waiting
Lists
Parenting
Water
Feeling good Fluoridation

HIV/AIDS Positive health

Exercise

Teenage Heart Disease

Pregnancy

Everyone considers health differently. Things which are important to your health will
vary over time and is context dependent; if a member of your family is ill your view
of what it means to be healthy will be different to the time when this person is not ill.

When people are asked, What does health mean to you?, they may well give
responses relating to:

-feelings (feeling good, feeling full of energy),

-functions (e.g. sleeping well, able to do daily chores),

-lifestyles (e.g. not smoking, not drinking),

or resonses relating to the absence of things such as - not being in pain

- not being ill.

Other responses will relate health to the factors which influence health (known as
health determinants)

e.g. not living in a damp house,

-living in a clean environment.

 Exercise: What does health mean?
Which factors are most important for health?
For you
For your town/city/county
With your group, how can this factor be acted
upon to improve health?

Can you turn this into a Health Objective for an

SEA?

For this exercise take some time (15 minutes) to think about what factors are
important to your health and work through the exercise in groups.
 Definition of Health
WHO Constitution 1948
A state of complete physical,
mental and social well-being and
not merely the absence of disease
and infirmity

(Short debrief)

It is easier to think about what things are important to health than come up with a
definition. Have the groups thought through how health impacts could be addressed
in SEAs?

Here is the WHO (1948) definition of health which is used a lot. Is anyone familiar
with this definition? Would anyone describe themselves as healthy if they applied
this definition to themselves?

It has been described as being utopian and unobtainable but it does extend our
thinking beyond the consideration of illness and disease to cover social effects,
mental health and feelings as being important for health. There are many definitions
of health.
 Definition of Health
A state in which people are able to
work towards attaining their realistic
chosen and biologic potentials
Seedhouse (1986) Health: the foundations for achievement Chichester. John
Wiley

This definition is by Seedhouse who has written a lot on health promotion and
developed a model of health. The definition includes an acknowledgement that health is
dynamic, something to be attained and is about our potential and self will.
 Definition of Health
Health is the persons capacity to function
to the greatest capacity, to maintain a
balance appropriate to age and social
needs; to be reasonably free of gross
dissatisfaction, discomfort, disease or
disability; and to behave in ways that
promote survival as well as self-fulfilment
or enjoyment (Blum 1972)
(Blum H.L. 1972, p213 in Goldsmith S.B. (1972) The status of Health Status Indicators. Health Service
Reports, 87(3), 212-220)

This definition is from an Australian author and recognizes that health is about our
capacity to function in relation to age and need, and emphasizes feelings such as
enjoyment. Health is considered to be in some sort of balance which can be upset.
 Understanding Health
Variety of definitions and interpretations

Complex and contested concept

Need to extend boundaries beyond

consideration of the health service and ill
health

Health vs Health and wellbeing?

Health is difficult to define but it is important to consider this as we all have our own
views on health. Different professions have their own definitions and we need to be
clear what these are (SEA guidance doesnt provide any definitions for health).

We need to be able to discuss with others what definition of health we will use in our
work. It is important that we are not assuming that others share our personal views
on health but work with an agreed definition and broad understanding of health.

Health is complex and a contested concept.

Need to consider aspects beyond illness, disease and consideration of health

services.

The term Health can be used as an umbrella term (to cover wellbeing, mental
health as well as physical health) or increasingly in Local Authorities you will see the
terms, Health and wellbeing. Whatever your views on health using health and well-
being is taking a pragmatic approach to health; using the term health alone -
people may not consider health as part of their remit (this is the responsibility of the
Health Authority and relates to health service provision) but including wellbeing it
becomes their responsibility and part of their remit.
 General socioeconomic, cultural and environmental conditions

Living and working conditions

Social and community influences

Individual lifestyle
factors

Age, sex &

hereditary
factors

A broad definition of health acknowledges that many factors may influence health
directly and indirectly. There are again many models on how these influences on
health, also known as determinants of health, are presented. This is a diagrammatic
representation based on the Dahlgren and Whitehead (1991) model showing the
different layers of influence on health, some of these cant be changed (hereditary
factors).

Age, sex & hereditary factors

Individual lifestyle factors: smoking, exercise, diet etc

Social and community influences: social support, crime and community safety and
education.

Living and working conditions: housing, employment, transport, income physical

condition of local neighbourhoods

General socioeconomic, cultural and environmental conditions: economic

activity, government policies, climate, built environment (Neighbourhood design;
Housing; environmental noise; Air and water quality; Attractiveness of area; Gross
Domestic Product; Economic development).

Policies and actions formulated in these non-healthcare sectors have a significant

impact on peoples health and wellbeing. For example, a housing sector scheme on
damp proofing is likely to significantly improve respiratory health, particularly for
vulnerable residents such as the elderly and young children. Similarly, a transport
sector policy to promote active forms of travel is likely to improve levels of physical
activity with subsequent health benefits.
 Statements of
Health Inequalities
People living in the most deprived neighbourhoods will:
die on average 7 yrs earlier than those in the richest
neighbourhoods
spend more of their lives feeling unwell
Those living in the greenest areas have longer life
expectancy
Those with no or poor quality employment have a higher
risk of poor physical and mental health
Those with low perceived social support have lower health
status measures

Definition of Health Inequalities: systematic differences in health status between

different socio-economic groups (Dahlgren and Whitehead 2007).

Usually measured in terms of socio-economic class and actions to address health

inequalities usually targeted at this level. People living in the most deprived
neighbourhoods will:

die on average 7 yrs earlier than those in the richest neighbourhoods

spend more of their lives feeling unwell

BUT there are other dimensions to Health inequalities:

e.g. relating to geographical space and employment. Or relating to gender, ethnic

background or age:

Women in deprived wards have poorer health 13.6 yrs earlier than those in the
least deprived wards;

Pakistani and Bangladeshi men have the highest rate of poor health and long
term illness than any other group including white males;

Older people receive poorer treatment and denied access to procedures.

As health inequalities often mirror social inequalities, addressing the social

determinants of health can impact positively on health inequalities.
 Health Inequalities
Douglas Black
report on inequalities
in Health, 1980
Paperback edited
version published
1982
Growing concern for
major social causes of
ill health and
inequalities in health

Studied for decades with efforts directed at more resources given to poorer
areas.

Black report 1980: (This is not the Black Report but a paperback version
published 2 yrs later). What the report found:

NHS had not abolished or reduced inequalities in health despite increase in

health in the UK

Class was the major determinant of health outcomes

Growing concern for social causes of ill health (mass unemployment, poor
housing)

Significant inequalities in health status across populations, and many of

these causes were underpinned by social determinants of health such as
income, taxation, education, employment, housing, and not related to
Health Service provision.

The report was largely ignored by the Government.

 Published 1998
Call for action on a broad front to tackle health inequalities
Close collaboration with Local Authorities and other sectors
to promote health and prevent disease
Basis for other policy documents

Acheson Report 1998: the Acheson report demonstrated the existence of

health disparities and their relationship to social class. Among the reports
findings were that despite an overall downward trend in mortality from 1970-
1990, the lower social classes experienced a more rapid mortality decline. The
report contained 39 policy suggestions in areas ranging from taxation to
agriculture, for ameliorating health disparities and called for close colaboration
with Local Authorities to improve the nations health.

It largely influenced the 1998 government green paper Our Healthier Nation: A
Contract for Health which had a stated aim of reducing health inequalities; and
the 1999 white paper Saving Lives: Our Healthier Nation.
 Strategic review of
Health Inequalities in
England post 2010

Strategies to
reduce health
inequalities in
England
Action on social
determinants of
health
Local Authorities
have a key role

Marmot review 2010, published February 2010 is an independent Review to

establish the most effective strategies for reducing health inequalities from 2010
onwards. It draws further attention to the evidence that most people in England
arent living as long as the best off in society and spend longer in ill-health.
Premature illness and death affects everyone below the top tier of society.

It argues that, traditionally, government policies have focused resources only on

some segments of society. To improve health for all of us and to reduce unfair
and unjust inequalities in health, action is needed across the social gradient.

Central to the report's approach is to create the conditions for people to take
control of their own lives. This requires action on the 'social determinants' of
health. These are described as the conditions in which people are born, grow,
live, work and age. The report covers material which is of vital importance to
local government; Local councils have a vital role in building the wider
determinants of good health and working to support individuals, families and
communities. The report relates strongly to the core business of local councils
as local leaders for health improvement and the reduction of health inequalities.
 Marmot Review
Policy Objective E
Create and develop healthy and
sustainable places and communities
Reducing health inequalities compatible with climate
change mitigation, health benefits from:
sustainable neighbourhoods active transport

sustainable food production zero carbon houses

Integrate planning, transport, housing, environmental and

health policies to address the social determinants of
health

Here is one of the Policy Objectives from the Marmot review to address health
inequalities. Addressing Health Inequalities is compatible with climate change
mitigation.
 Health inequalities
Government policy is to reduce health
inequalities

Logic of this is that where negative impacts

are unavoidable they should fall on
populations most able to bear them

But is this politically acceptable?

Conclusion:

The Government is committed to addressing Health Inequalities, but if this thinking

is taken further then, where negative impacts are unavoidable they should fall on
populations most able to bear them e.g. siting of waste incinerators, should these
by built in the least deprived areas? And is this politically acceptable?

The intention is not to spend time debating this but provide some ideas to reflect
on.
 Screening questions
Will the proposal:
Have an impact on the physical or mental health and well being
of the whole population or of particular sub groups in the
population?
Affect individual ability to improve their own health and
wellbeing?
Proposal produce a change in demand for or access to health and
social care services?
Have an impact on social, economic or environmental conditions
that could affect health?
Have an impact on global health?
One or more positive response indicates need for HIA

These slides are optional.

What guidance is there to help a practitioner decide if a proposal will have

significant impacts on health?

Here is one such screening tool from the Governments Regulatory Impact
Assessment Guide, this does relate to HIA but can be equally applied to SEA.
 Watch Out For
Health Checklist
Housing Accessibility and transport
Access to public services Crime reduction and
Opportunities for physical community safety
activity Access to healthy food
Air quality, noise, Access to work
neighbourhood activity Resource minimisation
Social cohesion and social Climate change
capital
For example Yes
Does the proposal provide opportunities for local businesses? No

N/A

Here is another decision making tool from the Healthy Urban Development Unit,
Watch Out For Health Guide (available from the HIA Gateway).

Each proposal is assessed against a set of questions posed under these

determinants of health. E.g. Under Access to work: Does the proposal provide
opportunities for local businesses?