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Inequalities and Inequities in the Health of People With Intellectual Disabilities  

Eric Emerson

Children and adults with intellectual disabilities have poorer health and are more likely to die sooner than their non–intellectually disabled peers. There is growing evidence that some of these inequalities in health are avoidable, unjust, and unfair, given that they are driven by the higher rates of exposure of people with intellectual disabilities to well-established social determinants of poor health. People with intellectual disabilities are more likely than their peers to: live in poverty, not be employed (or if employed to work under precarious conditions), be exposed to discrimination and violence, face significant barriers in accessing effective health care, and be less resilient when exposed to adversities. In other words, they are examples of health inequities that arise from “the societal conditions in which people are born, grow, live, work and age, referred to as social determinants of health. These include early years’ experiences, education, economic status, employment and decent work, housing and environment, and effective systems of preventing and treating ill health” (World Health Organization). Future research needs to address three key issues. First, most of the existing evidence is based on the experiences of people with intellectual disabilities in the world’s high-income countries. In contrast, the vast majority of the world’s population live in middle- and low-income countries. The limited evidence available suggests that children with intellectual disabilities growing up in middle- and low-income countries are much more likely than their peers to be growing up in poverty and to be exposed to specific social determinants of poorer health associated with poverty such as undernutrition, poor sanitation, low levels of parental stimulation, violent parental discipline, and hazardous forms of child labor. Second, little research has focused on health inequalities and inequities among two important groups of people with intellectual disabilities: people with intellectual disabilities from minority ethnic communities and people with mild intellectual disabilities. Third, very little research has attempted to test the proposition that people with intellectual disabilities may be more or less resilient than their peers when exposed to social determinants of health. While much remains to be learned about the inequalities and inequities faced by people with intellectual disabilities, the existing knowledge is sufficient to guide and drive changes in policy and practice that could reduce the health inequities faced by people with intellectual disabilities. These include: improving the visibility of people with intellectual disabilities in local, national, and international health surveillance systems; making “reasonable accommodations” to the operation of health care systems (e.g., introducing annual health checks into primary care services, making “easy read” materials available, employing intellectual disabilities liaison nurses in acute hospitals) to ensure that people with intellectual disabilities are not exposed to systemic discrimination; and ensuring that people with intellectual disabilities (along with all other people with disabilities) are included in and benefit equally from local and national strategies to reduce population levels of exposure to well-established social determinants of poor health.


Health Inequities in Aging Adults from a Public Health Perspective  

Steven Wallace

Inequities in the United States have gained renewed attention as a result of social movements such as Black Lives Matter (racism), Me Too (sexual abuse and gender), and immigrant rights. Yet despite the growing awareness of inequality across major social categories, there has been little or no public attention paid to the persistent inequities facing older adults. The news media in the 2020 presidential elections uncritically reported charges that one, or both, candidates were “too old” for the job or had some other liability tied primarily to their age. There is a whole field of “anti-aging” medicine that claims to slow the biological process of senescence (distinct from fighting specific diseases), even as the greatest challenges of growing older are rooted in social and political processes. This reflects the ageism in society that results in undervaluing older adults’ lives and often marginalizes them. In addition, there are serious inequities within the older population based on class, race, gender, and citizenship status. Health inequities involve conditions that are avoidable, are not the result of informed choice (e.g., injuries among extreme sports participants), and which differ by membership in groups that hold different levels of power and resources. As such, inequities also include an element of “unfairness” such that the disadvantage is in groups with less power and resources than others.


Time in Health Promotion and Public Health  

Lyndall Strazdins

Being physically active and eating fresh foods could reduce the growing burdens of cardiovascular disease, cognitive decline, obesity, some cancers, diabetes type II, depression, and anxiety. Increasing these health behaviors has been a public health focus for decades, yet over one half of adults around the world remain insufficiently physically active and four in ten are overweight or obese. When people are asked why they don’t exercise more or eat healthy food, the most common reason they give is lack of time. Everyone has 24 hours in a day, so why do so many people say they lack time to be healthy? Time is a challenging (and intriguing) concept. Usually, time is thought about in terms of hours and minutes which evenly divide a day, and its lack a consequence of misguided priorities. This assumes that all hours are equal and available for use and that every person has agency over their time. Although having sufficient time is fundamental to health (exercising, preparing healthy food, resting, accessing services, and maintaining social bonds all take time), other dimensions such as control, flexibility, intensity, and timing are essential for understanding how time and health are connected. Like income, time is exchanged and given within households, so it can be fruitful to view time as a household resource rather than an individual’s resource. In the labor market, time is exchanged for payment, and this underscores time’s potency as a social and economic resource. Historically, research on the social determinants of health and health equity have focused on the harms linked to work hours, including the length and timing of the work day and flexible hours. Yet this research missed the importance of time outside the labor market, which alters the health consequence of work hours, delivering only a partial analysis of how time shapes health. Research since the early 2000s is supplying new evidence of the interplay between work, care, and other non-market time, allowing a more accurate insight into how time shapes health and how this relationship connects to social and gender equity. Debates remain, however, and these include the extent to which time pressure and time scarcity are problems of motivation and perception and whether time scarcity is a problem of only the affluent. There are precedents to address time costs and inequities. A first step for health prevention and health promotion practitioners is to value time in ways comparable to how the field values money. This would mean limiting the time costs of health interventions and services, including the requirement to “find time” outside of work or care roles to be healthy. The field also needs to challenge the idea that the income-poor are time-rich since this is rarely the case if they are caregivers. As well as minimizing time burdens, policies to address the social determinants of time from urban planning, transport systems, and work-hour regulations will be critical to achieving a fairer and healthier world.


The People’s Health Movement  

Ravi Narayan, Claudio Schuftan, Brendan Donegan, Thelma Narayan, and Rajeev B. R.

The People’s Health Movement (PHM) is a vibrant global network bringing together grass-roots health activists, public interest civil society organizations, issue-based networks, academic institutions, and individuals from around the world, particularly the Global South. Since its inception in 2000, the PHM has played a significant role in revitalizing Health for All (HFA) initiatives, as well as addressing the underlying social and political determinants of health with a social justice perspective, at global, national, and local levels. The PHM is part of a global social movement—the movement for health. For more than a century, people across the world have been expressing doubts about a narrowly medical vision of health care, and calling for focus on the links between poor health and social injustice, oppression, exploitation, and domination. The PHM grew out of engagement with the World Health Organization by a number of existing civil society networks and associations. Having recognized the need for a larger coalition, representatives of eight networks and institutions formed an international organizing committee to facilitate the first global People’s Health Assembly in Savar, Bangladesh, in the year 2000. The eight groups were the International People’s Health Council, Consumer International, Health Action International, the Third World Network, the Asian Community Health Action Network, the Women’s Global Network for Reproductive Rights, the Dag Hammarskjold Foundation and Gonoshasthaya Kendra. All these groups consistently raised and opposed the selectivization and verticalization of Primary Health Care (PHC) that followed Alma Ata leading to what was called Selective PHC (i.e., not the original comprehensive PHC). These groups came together to organize the committee for the first People’s Health Assembly and then to form the Charter Committee that led to the People’s Health Charter, which finally led to the actual PHM. Within PHM, members engage critically and constructively in health initiatives, health policy critique, and formulation, thus advancing people’s demands. The PHM builds capacities of community activists to participate in monitoring health-related policies, the governance of health systems, and keeping comprehensive PHC as a central strategy in world debate. The PHM ensures that people’s voices become part of decision-making processes. The PHM has an evolving presence in over 80 countries worldwide, consisting of groups of individuals and/or well-established PHM circles with their own governance and information-sharing mechanisms. It additionally operates through issue-based circles across countries.