Health inequalities have long been deeply engrained in society. If we are to address these inequalities, we need to reflect on what has driven them, and critically review the approaches that do and do not work. This Monograph brings together leading experts and up-and-coming researchers, in a collection of state-of-the-art articles, discussing the drivers and consequences of respiratory inequality.
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- Page 1AbstractCorresponding author: Anna Pearce (Anna.Pearce@glasgow.ac.uk)
Health inequalities in respiratory disease are widespread, and monitoring them is important for advocacy, the design and delivery of health services, and informing wider health policy. In this chapter, we introduce the different ways in which health inequalities can be quantified, including measures that quantify absolute and relative inequalities, and those that measure gaps between groups or differences across the entire social gradient. We consider the strengths and limitations of these different approaches and highlight things to look out for when reading a paper on health inequalities in respiratory health. These include how common the outcome is and whether other factors have been adjusted for, as both can have a crucial impact on interpretation and can lead to misleading conclusions.
Cite as: Pearce A, Katikireddi SV. How to read a paper about inequality in respiratory disease: basic epidemiological principles and how inequalities are measured. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 1–10 [https://doi.org/10.1183/2312508X.10003122].
- Page 11AbstractCorresponding author: Alice Lee (arlee@doctors.org.uk)
Poverty at an individual level is experienced when individuals or households cannot access sufficient resources to meet their needs and participate in wider society. At a societal level, poverty can be understood as either absolute on a global scale, or relative to the society or country. Countries with higher levels of relative poverty are more likely to have worse health outcomes than countries with better social equality. Those living in poverty are priced out of healthy living and face barriers to accessing healthcare, and exposures directly related to poverty work synergistically to change an individual's physiology. Respiratory health is particularly influenced by these mechanisms: living in poverty causes respiratory disease by limiting material and societal resources for good health, and through increased exposures to risk factors. These same risk factors that cause respiratory disease also cause worse respiratory disease outcomes including morbidity and mortality.
Cite as: Lee A, Hawcutt DB, Sinha IP. What causes poverty and how does this contribute to respiratory inequality? In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 11–25 [https://doi.org/10.1183/2312508X.10003222].
- Page 26AbstractCorresponding author: Aziz Sheikh (aziz.sheikh@ed.ac.uk)
Disparities in the incidence, prevalence, and morbidity and mortality rates of many respiratory diseases are evident among ethnic groups. Biological, cultural and environmental factors related to ethnicity can all contribute to the differences in respiratory health observed among ethnic minority groups, but the inequalities observed are most commonly due to lower socioeconomic position. People who migrate within a country or across an international border may experience an improvement in respiratory health associated with improvements in socioeconomic position. However, migrants may also experience worse health outcomes in destination countries, as they are faced by barriers in language and culture, discrimination, exclusion and limited access to health services. While some high-quality studies investigating ethnicity and respiratory health are available, further research into ethnic differences is needed. Improving the recording of ethnicity in health records, addressing barriers to accessing respiratory healthcare and improving cultural literacy more generally are some of the ways that inequalities can be tackled.
Cite as: Tibble H, Daines L, Sheikh A. Ethnic, racial and migrant inequalities in respiratory health. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 26–39 [https://doi.org/10.1183/2312508X.10021622].
- Page 40AbstractCorresponding author: Jennifer Quint (j.quint@imperial.ac.uk)
There is a growing body of literature showing that sex and gender affect the incidence, susceptibility, presentation, diagnosis and severity of lung diseases. However, despite the availability of data on differences in health outcomes, current medical practice does not take sex and gender sufficiently into account in relation to disease management. In this chapter, we explore the importance of considering sex and gender relative to outcomes in chronic respiratory diseases to promote disease prevention and better management for respiratory patients.
Cite as: Zhang X, Quint JK, Whittaker H. Inequalities in respiratory health based on sex and gender. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 40–50 [https://doi.org/10.1183/2312508X.10003522].
- Page 51AbstractCorresponding author: Jonathan Grigg (j.grigg@qmul.ac.uk)
Within urban areas in HICs, zones of increased air pollution occur along heavily used roads. As high-pollution zones are more likely to be located in the most-deprived neighbourhoods, and people living in these neighbourhoods are more likely to have long-term respiratory health conditions, which tend to be more severe than those experienced by people in higher socioeconomic groups, the role of air pollution in driving health inequalities is an important question. This chapter draws on published data, mainly from Europe and the USA, and considers the evidence for inequalities in air pollution exposure, and how this translates into inequalities in respiratory health.
Cite as: Grigg J. Air pollution and respiratory inequality: lessons from high-income countries. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 51–60 [https://doi.org/10.1183/2312508X.10003622].
- Page 61AbstractCorresponding author: Elissa Abrams (elissa.abrams@gmail.com)
Food insecurity is a significant public health outcome that contributes to the prevalence and severity of chronic respiratory conditions in both childhood and adulthood, including asthma, cystic fibrosis and COPD. Food insecurity influences health outcomes through multiple mechanisms, including poverty, poor dietary diversity and inadequate nutrition. However, it can be difficult to untangle the solitary effects of food insecurity from the broader associated adverse determinants of health. The goal of this chapter is to review the impact of food insecurity on respiratory outcomes in children and adults, as well as outline steps that can be taken to mitigate these effects at local, regional and national levels.
Cite as: Abrams EM. Food insecurity and respiratory ill health. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 61–67 [https://doi.org/10.1183/2312508X.10003722].
- Page 68AbstractCorresponding author: Tyra Bryant-Stephens (stephenst@chop.edu)
Housing quality and affordability are well established as social determinants of health through direct and indirect mechanisms. Respiratory illnesses related to housing are nearly all the result of housing disrepair that allows intrusion into the home of environmental agents that are directly or indirectly associated with disease. Structural deficiencies such as leaks, cracks in the foundation or holes in the home's exterior can facilitate the presence of mould, which is causally linked to the development of asthma and is associated with exacerbation of asthma symptoms in children and adults. Indoor cleanliness can also contribute to the presence of mice and cockroaches. Proper ventilation can improve air quality, reducing exposure to PM, VOCs and infectious respiratory agents. Disparities in exposure to the housing conditions associated with respiratory disease are readily apparent across socioeconomic lines. Low-income families are less likely to be able to afford the costs of maintaining a home, which prevents them from making repairs that could improve respiratory health.
Cite as: Strane D, Bryant-Stephens T. Housing and respiratory health: exposures, health effects and interventions. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 68–79 [https://doi.org/10.1183/2312508X.10003822].
- Page 80AbstractCorresponding author: Filippos T. Filippidis (f.filippidis@imperial.ac.uk)
Tobacco smoking and exposure to second-hand smoke have been shown to negatively impact human health, including, but not limited to, increased risk of lung cancer, COPD, asthma and lower respiratory tract infections. Novel tobacco and nicotine products, such as e-cigarettes and heated tobacco products, are promoted as less harmful, but whether they actually pose significantly lower health risks is contested. Use of all tobacco and nicotine products is higher among disadvantaged groups and contributes to health inequalities among people in different socioeconomic levels. Tobacco control policies have been shown to substantially lower the prevalence of tobacco use and reduce inequalities within and among countries, while different policies may be needed to address concerns regarding novel products.
Cite as: Filippidis FT, Laverty AA. Tobacco, novel tobacco and nicotine products, and respiratory health. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 80–88 [https://doi.org/10.1183/2312508X.10003922].
- Page 89AbstractCorresponding author: Ruth E. Wiggans (ruth.wiggans@mft.nhs.uk)
Workplace exposures contribute significantly to the global burden of respiratory disease. Despite the knowledge that occupational lung diseases (OLDs) such as asthma, pneumoconiosis, COPD and cancer are directly attributable to work, the incidence of such conditions remains high and is increasing in some countries. The distribution of OLDs is not equal among populations. Poverty, education, sex/gender and ethnicity all contribute to the risks. Work and employment reflect and reinforce social gradients of health. OLDs can intersect with other social determinants of health, resulting in worse outcomes for those affected. Workplaces present a unique sphere in which to intervene to improve health outcomes.
Cite as: Wiggans RE. Work and respiratory health: lessons from occupational lung disease. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 89–98 [https://doi.org/10.1183/2312508X.10004022].
- Page 99AbstractCorresponding author: Karl A. Holden (Karl.Holden@liverpool.ac.uk)
There are several important antenatal factors including maternal stress, tobacco smoking, air pollution and nutrition that have been shown to influence lung development in utero and beyond. Exposure to these is associated with detrimental lung function and respiratory morbidity in childhood that can persist into adulthood. Environmental factors in utero may influence adult disease, referred to as fetal programming. This chapter reviews the proposed underlying mechanisms behind the effect on lung development including neurohormonal, immune, inflammatory and epigenetic pathways. There is a significant impact of sociodemographic inequalities on each of these antenatal determinants of child lung development, even in countries with a universally free healthcare system. As such, it is important that we do not refer to these simply as “lifestyle choices of expectant mothers”, but rather aim to tackle these inequalities and provide equitable antenatal care and education to women in pregnancy to improve lifelong respiratory health.
Cite as: Holden KA, Gibson M, Sinha IP, et al. Antenatal determinants of child lung development. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 99–115 [https://doi.org/10.1183/2312508X.10016222].
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- Page 116AbstractCorresponding author: Susanna A. McColley (SMcColley@luriechildrens.org)
There are marked inequalities in health and life expectancy for people with cystic fibrosis (CF) across the world. Unequal outcomes in HICs are related to demographic, sociopolitical, scientific and healthcare system factors. Barriers to diagnosis, multidisciplinary CF care programmes and advanced therapies are pervasive in LMICs. In this chapter, we describe progress in our understanding of CF, the origins of inequalities in CF and the need for comprehensive strategies to improve equity in diagnosis and treatment of CF worldwide.
Cite as: McColley SA. Inequalities in cystic fibrosis. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 116–128 [https://doi.org/10.1183/2312508X.10004122].
- Page 129AbstractCorresponding author: Tom Wilkinson (t.wilkinson@soton.ac.uk)
COPD is a leading cause of morbidity and mortality globally, but its incidence and burden vary considerably, and outcomes are unequal, further compounded by inequity in access to diagnosis and treatment. COPD is a preventable condition, and risk factors for its development have been identified for many decades. Attempts to reduce exposure to key factors such as cigarette smoking have been successful in developed healthcare settings but are less likely to have an impact in areas of poverty where the need is greatest. Even in HICs, variation in outcomes and the impacts of poverty on COPD are stark. Late presentation and diagnosis, inadequacy in access to optimal treatment and failure to deliver the fundamentals of care track with societal and health inequalities and are affected by income, age, ethnicity and geography. Strategies to prevent, diagnose and treat COPD more effectively that address these important inequalities head on are now vital to address the growing burden that COPD drives globally.
Cite as: Fazleen A, Freeman A, Kong A, et al. Health inequality and COPD. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 129–140 [https://doi.org/10.1183/2312508X.10004222].
- Page 141AbstractCorresponding author: Mohammad Alsallakh (m.a.alsallakh@swansea.ac.uk)
Inequalities in asthma outcomes and care quality between socioeconomic, ethnic/racial and sex/gender groups are widely documented worldwide. Social stratification is the main source of these inequalities, which have been observed in the diagnosis of asthma, symptoms, disease control, healthcare utilisation, asthma exacerbation and death. As one of the most common chronic illnesses, asthma inequalities involve avoidable and significant human and economic cost. To reduce asthma inequalities, targeted health and social policies are needed to ensure that the most disadvantaged groups receive adequate care. These include urgent action to reduce exposure to asthma triggers, such as air pollution, poor housing and smoking, and to promote health education among disadvantaged populations.
Cite as: Alsallakh M, Holden KA, Davies G. Inequalities in asthma. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 141–152 [https://doi.org/10.1183/2312508X.10022522].
- Page 153AbstractCorresponding author: Georgia Hardavella (georgiahardavella@hotmail.com)
There are significant inequalities affecting patient access to lung cancer services worldwide. Inequalities affect the entire lung cancer pathway, from lung cancer screening and prevention to diagnosis, treatment and palliative care. There are various patient- and service-related factors contributing to inequality. In this chapter, we will unravel these factors and review their impact on the lung cancer pathway.
Cite as: Hardavella G, Charpidou A, Frille A, et al. Lung cancer and inequalities in access to multidisciplinary lung cancer services. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 153–166 [https://doi.org/10.1183/2312508X.10004422].
- Page 167AbstractCorresponding author: Thomas Hampton (Thomas.hampton@lstmed.ac.uk)
Antimicrobial resistance is caused by and exacerbates social and health inequalities. Human and animal antimicrobial use is contributing as much as societal failures to dispose of and manage our waste and respect our environment. A multisector, multidisciplinary approach is required to resolve these issues.
Cite as: Hampton T. Societal drivers of antimicrobial resistance. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 167–179 [https://doi.org/10.1183/2312508X.10004522].
- Page 180AbstractCorresponding author: Emily J. Tweed (emily.tweed@glasgow.ac.uk)
Inclusion health refers to efforts to address profound health inequalities experienced by people facing social exclusion. People who experience social exclusion (e.g. people affected by homelessness, criminal justice involvement and/or sex work) experience very poor health outcomes. Outcomes for chronic respiratory conditions have been studied less than those for infectious diseases, but available evidence suggests very large inequalities between people affected by social exclusion and the rest of the population. Policies and interventions are required to prevent social exclusion in the first place, undo social exclusion for people who are experiencing it, and mitigate its adverse health impacts through healthcare and other services.
Cite as: Tweed EJ, Katikireddi SV. Inclusion health: respiratory health among people affected by social exclusion. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 180–193 [https://doi.org/10.1183/2312508X.10004822].
- Page 194AbstractCorresponding author: Justus M. Simba (maingij@gmail.com)
Paediatric respiratory conditions in LMICs disproportionately contribute to preventable global deaths. Socioeconomic factors that impact on nutrition, household air pollution and access to healthcare negatively affect lung health and influence the epidemiology and severity of illness. These factors occur significantly more in LMICs. Concerted efforts by these countries and by HICs would help reduce these deaths and improve the future of these children. In this chapter, we centre on preventable deaths from respiratory diseases including pneumonia, chronic pulmonary diseases such as bronchiectasis, asthma, sickle cell disease-associated lung diseases, HIV-related lung diseases, rare lung diseases and neonatal respiratory disorders. We will demonstrate that LMICs have a greater burden of these conditions and give views on what ought to be done to reverse these worrying trends.
Cite as: Simba JM, Irungu A, Otido S, et al. Preventable deaths from respiratory diseases in children in low- and middle-income countries. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 194–202 [https://doi.org/10.1183/2312508X.10005022].
- Page 203AbstractCorresponding author: Om P. Kurmi (om.kurmi@coventry.ac.uk)
Air pollution is a major environmental risk factor for increased morbidity and mortality worldwide. LMICs bear a disproportionate burden of ambient and household air pollution. High exposure to air pollution, unhealthy lifestyles, and other social, economic and demographic factors that can affect a population's health status and vulnerability are some of the reasons for increased mortality in LMICs. As a result, 91% of premature deaths attributable to ambient air pollution occur in LMICs. Similarly, household air pollution is a major problem in LMICs, particularly in rural areas with limited access to clean domestic energy. Both acute and long-term exposure to air pollution leads to adverse health outcomes, mainly respiratory and cardiovascular effects. The impact of air pollution exposure also extends to the neurological, reproductive and immune systems. The major causes of mortality include ischaemic heart disease and stroke, respiratory infection, COPD and lung cancer. Other causes of morbidity include other cancers, diabetes and birth disorders.
Cite as: Aithal SS, Bhargava V, Adekoya A, et al. Air quality in low- and middle-income countries: what is the impact on respiratory morbidity and mortality? In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 203–213 [https://doi.org/10.1183/2312508X.10005122].
- Page 214AbstractCorresponding author: Helen Nabwera (helen.nabwera@lstmed.ac.uk)
The global burden of TB disease is characterised by inequalities throughout the cascade of care. These inequalities are evident across regions and within countries. Indeed, populations with the highest burden of TB disease have the least access for TB health services for prevention, timely diagnosis, appropriate treatment and follow-up. In the face of global health emergencies such as COVID-19, these inequalities increase, resulting in worse outcomes for key populations that are already disproportionately affected by TB disease. Children bear the biggest brunt of the inequalities in the TB cascade of care. There is therefore an urgent need to address these, in line with the United Nations SDGs for improving health and well-being for all.
Cite as: Egere U, Nabwera HM. Global inequalities in tuberculosis. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 214–219 [https://doi.org/10.1183/2312508X.10005222].
- Page 220AbstractCorresponding author: C. Michael Roberts (mike.roberts@safercare.vic.gov.au)
Since the 2013 European Respiratory Society/American Thoracic Society declaration to address respiratory health inequalities, the evidence has demonstrated a further widening of that gap. A change in methodology is required to translate policy into better outcomes. Quality improvement (QI), a technique adapted from commercial industry, has been applied effectively to this end to a range of health challenges globally. QI offers an opportunity to address health inequalities for respiratory patients if the following principles are adopted: 1) agree on clear aims to align efforts across the respiratory community, 2) tailor approaches to each target population, 3) agree on the metrics collected to demonstrate success at scale, 4) build improvement capability in the respiratory community, and 5) rigorously evaluate the effectiveness of QI initiatives at tackling disparities in respiratory health outcomes. Establishing communities of practice that work collectively on these agreed aims through sharing data, leveraging research, progressing a portfolio of QI initiatives and rapidly disseminating knowledge offers a practical approach to reduce inequalities in outcomes across patients with respiratory conditions.
Cite as: Pham J, McKenzie L, Martin L, et al. Can a quality improvement approach reduce inequalities in respiratory health? In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 220–227 [https://doi.org/10.1183/2312508X.10005322].
- Page 228AbstractCorresponding author: Sarah Mayell (sarah.mayell@alderhey.nhs.uk)
The right to health and well-being was outlined in the Universal Declaration of Human Rights and adopted by the United Nations in 1948. However, inequalities across social, cultural and economic factors continue to impact the daily lives of people across the world and are drivers of poor respiratory health. In this chapter, we review how systemic inequalities result in inequities in respiratory health, and how these infringe upon the right to life and health. Themes of women's and children's rights, environmental rights and the right to life are used to illustrate why a human rights-based approach is relevant. The right to live a dignified and healthy life cannot be realised without addressing the fundamental rights and needs of all human beings to food, housing, healthcare, education, work and culture. Infringements of these rights begin early, affecting fetal and childhood lung development, and persist through environmental and social exposures. Using a human rights-based approach to consider respiratory health throughout the life course provides an opportunity to address inequity; the goal should be to empower the respiratory health community to ensure that all human beings are achieving the highest attainable standard of respiratory health.
Cite as: Mayell SJ, Jones CL, Sinha IP. A human rights-based approach to equity in respiratory health. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 228–235 [https://doi.org/10.1183/2312508X.10005422].
- Page 236AbstractCorresponding author: Warren Lenney (w.lenney46@hotmail.co.uk)
Childhood asthma remains one of the commonest global diseases, with significant morbidity everywhere and considerable mortality in some countries. Both diagnosis and management are often of poor quality and in some countries almost nonexistent, particularly in disadvantaged populations. Global inequalities abound and paint a tragic picture given that, for a relatively low cost, it is possible to transform the lives of children with asthma, not only improving their own health but enriching their environment and benefiting the public health of their community throughout their lifespan. What is needed is a united effort and a determination to succeed in improving outcomes that must involve politicians, healthcare workers, community leaders, officials and patients. Such strategies are feasible and have been shown to work but will differ from country to country. Indeed, they will differ within each country depending on the nature of its rural and urban communities, the specifics of its inequalities and where in that country these inequalities are greatest.
Cite as: Lenney W, Bush A, Fitzgerald DA, et al. Global inequalities in children with asthma. In: Sinha IP, Lee A, Katikireddi SV, et al., eds. Inequalities in Respiratory Health (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 236–248 [https://doi.org/10.1183/2312508X.10023122].