NIHR CLAHRC North West Coast
Health Inequalities Assessment Toolkit

What HIAT is and how to use it

  • Why focus on health inequalities?
  • Making the links
  • The implications for action
  • The HIAT structure
  • How to use the HIAT
  • Why focus on health inequalities?

    Due North1, the report of an enquiry set up by Public Health England, recently documented the scale of the health divide between the North and the rest of England. (The North is made up of the North West, North East, Yorkshire and Humberside.) Since 1965 this ‘health gap’ has widened, resulting in 1.5 million premature deaths (see Diagram 1 below).

    This regional health divide masks inequalities in health between different socio-economic groups within every region in England. Wherever people live in the country, health declines with increasing socioeconomic disadvantage. However, while the North has 30% of the population of England, it has 50% of the poorest neighbourhoods. More shockingly, poor neighbourhoods in the North have worse health than places with similar levels of disadvantage in the rest of England (see Diagram 1 below).

    These stark differences between the North and South of England, and between poor neighbourhoods in the North and South, are due to a more uneven balance of wealth in the North. This, in turn, is caused by higher unemployment rates, lower wages and higher levels of chronic illness and disability, limiting people’s ability to take paid work. This combination of social and economic circumstances has negative effects on people’s lives. It limits the resources people have to pay for food and housing, and decides the wider environment in which people live and work. Also, it limits the control people have over their lives, helping to shape behaviour that can damage health. We call these conditions the socio-economic causes of health inequalities.

    Diagram 1: Health inequalities in the North
    Diagram 1: Health inequalities in the North - Years of life lost (YLL), from deaths under the age of 75, 2008-2012.
    Source: PHE and DCLG in Whitehead et al. (2014: 28).

    1 Whitehead, M.C., et al. Due North: Report of the Inquiry on Health Equity for the North. (University of Liverpool and Centre for Local Economic Strategies, Liverpool and Manchester, 2014).

  • Health inequalities and socio-economic inequalities in health: making the links

    Whitehead and Dahlgren2 define social inequalities in health as “systematic differences in health status between socioeconomic groups”.

    A large body of research has shown that the socio-economic conditions in which people live and work are the main causes of inequalities in health. So, our toolkit uses ‘socio-economic inequalities in health’ interchangeably with ‘health inequalities’ to emphasise the effect socio-economic conditions have on people’s health. It is vital that, when deciding which health problems to tackle, and when finding and evaluating possible solutions, our work places the greatest importance on the inequalities in the health problem and in the possible socio-economic causes of these health inequalities. Only by doing this will we make the most of our potential to contribute to a reduction in health inequalities.

    Other social factors, such as gender, ethnic background and disability, also contribute to health inequalities. However, we want to emphasise that inequalities in socio-economic conditions produce significant inequalities in health associated with other social factors3,4. For this reason, we expect all of our work will focus on the socio-economic causes of health inequalities, whatever other social factors we consider.

    Diagram 1: Health inequalities in the North
    Diagram 1: Health inequalities in the North - Years of life lost (YLL), from deaths under the age of 75, 2008-2012.
    Source: PHE and DCLG in Whitehead et al. (2014: 28).

    2Whitehead, M. & Dahlgren, G. Concepts and principles for tackling social inequities in health: Levelling up Part 1. Vol. 2 (World Health Organization: WHO Regional Office for Europe (Studies on social and economic determinants of population health, No. 2), Copenhagen, 2006).

    3Farmer, P. On suffering and structural violence: a view from below. Daedalus, 261-283 (1996).

    4Whitehead, M. The Concepts and Principles of Equity in Health. (WHO, Reg. Off. Eur. (EUR/ICP/ RPD 414 7734r), Copenhagen, 1990).

  • The implications for action

    Much of the responsibility for reducing health inequalities and their socio-economic causes lies with central government. However, a lot can be done locally, despite cuts in public spending. Reducing health inequalities requires all sectors – local people, the NHS, local government, the voluntary and private sectors – to work together.

    The Due North report sets out a range of actions public agencies in the North can take. These are shown in Diagram 2, below, and include:

    • targeting social factors that can affect health, such as poverty, economic inequalities and poor housing;
    • preventing the onset of chronic illness;
    • making sure people have prompt access to high-quality healthcare;
    • creating social and physical environments that promote good health; and
    • preventing the unequal consequences of ill-health.
    Diagram 2: Acting locally to reduce health inequalities
    Diagram 2: Acting locally to reduce health inequalities (courtesy of Ben Barr)

    Health and social inequalities place a considerable burden on public services. For example, it costs the NHS at least £2.5 billion a year to treat people with illnesses caused by living in cold, damp and dangerous homes.

    The evidence shows that the NHS has reduced the effect socio-economic inequalities have on health. In recent years, for example, the risk of dying from amendable conditions (conditions that can be treated by the NHS, such as heart disease and cancer) has been falling rapidly and some inequalities have reduced.

    People living in disadvantaged areas in the North are still more likely to die prematurely from these conditions, but the mortality gap (the difference in death rates across socioeconomic groups) with the rest of England has narrowed slightly, particularly for men (see Diagram 3 below).

    As the Due North report concludes, reducing health inequalities and their socio-economic causes in the North West Coast area will be challenging but can be done. This toolkit was developed to increase awareness and knowledge of health inequalities and how they can be addressed through applied health research.

    Diagram 3: The gap in mortality amendable to health care. Graph shows how the mortality gap from causes amenable to health care between the North and rest of England has reduced
    Diagram 3: This graph shows how the mortality gap from causes amendable to healthcare between the North and the rest of England has reduced.
    Source: HSCIC. Population weighted averages of local authority rates in Whitehead et al. (2014: 65).
  • The structure of the Toolkit

    The toolkit has four sections:

    Section 1 helps you to clarify the inequalities associated with the health problem you want to tackle, and to identify the socio-economic causes of these inequalities.

    Section 2 helps you consider how you can plan your work to address some of the socio-economic causes of inequalities identified in section 1.

    Section 3 aims to make sure that you monitor or evaluate the effect of your activity on health inequalities and their socio-economic causes.

    Section 4 asks you to consider how your activity will have effects on the socio-economic causes of health inequalities that you are not directly considering.

    Each section includes the following:

    • An explanation of its purpose;
    • Questions to help you carry out an assessment of your planned work;
    • Questions to make sure you involve appropriate members of the public in all aspects of your work (this is required by our steering board);
    • Resources such as readings, real HIAT assessments, films and activities providing more information about issues covered in the section.

    In each section, the toolkit questions are applied to a hypothetical outline proposal to evaluate an intervention to increase the uptake of health checks. This example aims to show how using the toolkit could increase the potential for this intervention to reduce health inequalities.

  • How to use the Toolkit

    1. Interpret the language used in the toolkit flexibly to ‘fit’ your activity
    The toolkit aims to be relevant to all of our work–applied research, evidence synthesis, capacity building, knowledge exchange and implementation. The focus might be on biomedicine, health care, social care or wider social factors that lead to health inequalities.
    Finding a language that applies across all of these activities is difficult. However, the issues we are dealing with are relevant to all of our work. So please focus on the purpose of each section set out in the introduction rather than the precise wording of questions.
    2. Use the toolkit to suit your needs
    You do not need to follow the sections and the questions in them in order. You may find it helpful to move backwards and forwards between sections and questions as you focus on the health inequalities aspect of your work.
    3. Record how your plans have changed as a result of using the toolkit or why you feel no changes are needed
    Our steering board requires all proposals to include a health inequalities assessment report. It may be helpful to keep notes of your assessment and its effect on your work to help you complete the report. You can find a report template in the Resources section.