The chapter has provided an exploration of concepts of disadvantage (in Section 2.2) and health (in Section 2.3). It is now appropriate to give some consideration to the way in which disadvantage and health interact. These interactions will be considered in more detail in the publications which appear in subsequent chapters.
One aspect of disadvantage which is well described is the association between low income, poor health status and worse health outcomes. This health disadvantage has been linked to low levels of literacy, poor diet, and difficulty in accessing care. The association between disadvantage and poorer health outcomes is now well understood, and generally accepted, although causation is less obvious (and the distinction between the two may sometimes be missed).
Mackenbach et al (2008) used data on mortality, education and occupational class to review the as- sociation between socioeconomic inequality and health in 22 countries in Europe. They found sig- nificantly higher levels of mortality and self-reported ill health in groups with a lower socioeco- nomic status. This relationship held in most countries, although the magnitude of the effect varied. The authors found that the variations were to some extent associated with smoking and alcohol use, and the degree of medical intervention. These findings were largely confirmed by Marmot, Allen, Bell, Bloomer and Goldblatt (2012), who found that, despite significant improvements in liv- ing conditions in Europe, persistent health inequities remain both within and between countries of the WHO European region. Their report recommends health policies which are effective across the whole social gradient, as well additional services for those at the bottom of the gradient. They also identify as need to address the process of exclusion, rather than focusing on excluded groups.
In a report for the UK’s Joseph Rowntree Foundation, Karen Rowlingson (2011) explored the rela- tionship between inequality and health and social problems. She found that there was a clear asso- ciation between the level of income income inequality within a country and a range of health and social problems. Although the evidence of a causative chain was less clear-cut, several of the stud- ies she reviewed identified small but statistically valid causative effects. She also noted that the rela- tionship between disadvantage and poor health may be worsening as the gap between the richest and the poorest in society becomes wider.
The relationship between socioeconomic status and mortality has also been observed in Australia. Clarke and Leigh (2011) used data from the Household, Income and Labour Dynamics in Aus- tralia (HILDA) survey to evaluate the association between socioeconomic status and mortality. They found that the relative mortality risk for the poorest quintile in the survey was 1.88 times that of the richest quintile, equivalent to a difference in life expectancy of 6 years (at 20 years of age). They also observed an association between attaining a higher level of education (more than 12 years) and a reduced risk of death. However, after controlling for individual level factors, they were
unable to identify an association between mortality and area-based measures of socioeconomic dis- advantage.
A study by Schoen et al (2010) of health insurance arrangements in 11 OECD member states, con- ducted between March and June 2010, found that 22% of Australian respondents reported cost-re- lated problems with access to healthcare in the preceding year. They found that 18% had avoided a visit to a doctor, or did not get recommended care, while 12% did not fill a prescription, or missed doses of medication.
In Tasmania, the State of Public Health 2013 report (Population Health, 2013) compared health indicators for quintile measure of socioeconomic status. Some results are shown in Table 3 below.
Table 3: Health indicators (Tasmania, 2011)
Lowest quintile (%)
Highest quintile (%)
Self reported health status
Excellent or Good 31.0 51.7
Fair or Poor 31.7 12.1
Smoker 20.6 10.9
‘Obese’ BMI 25.8 13.2
Experienced food insecurity 10.0 0.6
Multimorbidity
There is good evidence that the problems which are associated with multimorbidity (both for the patient and for the healthcare system) can be greater for groups with a lower socioeconomic status Marengoni et al. (2011) used a literature review to summarise evidence about multimorbidity in the elderly, and its causes and effects, and also explored aspects of the care of patients with multimor- bidity. They summarised their findings as follows:
(1) multimorbidity affects more than half of the elderly population; (2) the prevalence in- creases in very old persons, women and people from lower social classes; (3) very little is known about risk factors for multimorbidity... (4) functional impairment, poor quality of life and high health care utilization and costs are major consequences of multimorbidity; and (5) data are insufficient to provide scientific basis for evidence-based care of patients affected by multimorbidity.
(Marengoni et al., 2011, p. 436) (p436) Barnett et al. (2012) used data from Scottish general practice records to evaluate the extent and dis- tribution of multimorbidity in a cohort of 1.75 million patients (around one third of Scotland’s population). They found that the onset of multimorbidity in the most deprived areas occurred 10 - 15 years sooner than in the most affluent areas.
Health literacy
Berkman, Sheridan, Donahue, Halpern, and Crotty (2011) updated a 2004 systematic review of the impact of poor health literacy on health outcomes. Their review found moderate evidence that patients with low health literacy had higher levels of hospital and emergency department use, and lower uptake of preventative services; were less able to take medications appropriately and inter- pret labels and health messages. The review also found evidence of poorer health status and higher all-cause mortality among older patients with low health literacy.
Low literacy is acknowledged as a contributor to low health literacy, and a barrier to effective healthcare. What has not previously been recognised is the extent to which low literacy can also in- terfere with verbal communication in a healthcare setting, an effect which appears to be associated with the personal stigma attached to low literacy. For individuals with poor literacy, the problem of- ten remains hidden from healthcare providers, through the individual's poor awareness of the problem, and low awareness in healthcare staff of literacy as an issue. In addition, the stigma asso- ciated with poor literacy may lead low literacy individuals to hide the problem (Easton, Entwistle, & Williams, 2013).
Using semi-structured interviews and focus groups, the authors explored the origins of the fear of being 'found out', which often stemmed from experiences in childhood. The fear of being exposed as illiterate during a healthcare interaction would often result in stress, diminished attention, or a keenness to terminate the appointment early.