Contemporary Health Studies. Louise Warwick-Booth

way to address population growth is to deliver effective family planning services. However, some cultural, moral and religious objections to contraception can pose practical barriers in the development of these services. WHO (2020b) reports that 214 million women of reproductive age in lower-income countries who want to avoid pregnancy are not using a modern contraceptive method. This is for a variety of reasons, such as limited choice, restricted access, fears associated with side-effects, cultural and religious barriers as well as gender-based barriers.

      Ageing populations Viewing the population pyramids for Zambia, it is evident that most societies are projected to have higher life expectancy and have larger proportions of the population who live to much older ages. Storey (2018) estimate that in the UK by 2068, there are likely to be an additional 8.6 million people aged 65 years and over. Globally, estimates of the ageing world population are that by 2050, one in six people in the world will be over age 65 (UN 2019). To some degree this should be seen as the success of health improvement programmes and an economically developed world. However, it does require a revision of what may be needed to provide healthy older age. This is influenced by two main factors:

Increasing life expectancy and related ageing of populations poses a significant threat to individual health and health service provision across society.

       The changing patterns of illness and disease to conditions associated with fragility, chronic diseases and disorders such as dementia.

       Universal state pension schemes to keep older people out of extreme poverty may not be able support the increased growth in over-65s.

      Preparing health providers and societies to meet the needs of elderly people is essential: training for health professionals on old-age care; preventing and managing age-associated chronic diseases; designing sustainable policies on long-term care; and developing age-friendly services and settings. Work around promoting positive images of older people, social isolation and quality of life may be also be crucial for older populations.

Safety, security and fear A whole range of related issues can be considered under the terms ‘safety and security’. These all impact upon health and are summarized in table 2.3.

      The above issues are commonly not perceived as being public-health threats in their own right but are seen superficially in terms of how public health should be providing health-care responses (Geiger, 2001). Crime and terrorism are constructed as media/moral panics that potentially exaggerate the risks and create a culture of fear but in some areas of conflict there is great evidence that fear impacts upon holistic health, while the direct effects also have a large health impact (Bleich, Gelkopf and Soloman, 2003).

Table 2.3 The impact of safety and security upon health

Issue	Potential effects	Reference
Conflict and war	Deaths and injuries on the battlefield Displacement of populations (internally and externally) Breakdown of health and social services Sexual violence Heightened risk of disease transmission Psychosocial impact of living with conflict Reduction on development and maintenance of infrastructure Disruption of subsistence agriculture Increased risk of further violence	Murray et al. (2002) Levy and Sidel (2016)
Domestic violence	Effects upon health fall into four categories: physical impact (injuries and death); sexual and reproductive consequences (unwanted pregnancies, infections); mental health (depression); and behavioural issues such as self-harm and substance misuse	Campbell (2002) WHO (2012)
Crime	Death and injury Emotional impact of long term stress – lower personal well-being and increased anxiety Loss of work earning Property destruction	Dubourg et al. (2005) ONS (2015)
Terrorism Bombing Bioterrorism Kidnapping	Direct death and injury Rape as an instrument of war Direct effect of psychological impact of trauma and fear (long-term physical and mental-health effects) Indirect effect on society living in fear of terrorism even if the actual threat is low Physical and mental health impacts on first responders	Bleich, Gelkopf and Soloman (2003) Alexis-Martin (2018)

War and conflict pose a major threat to health, not only in direct ways as we may expect, but also as economic and social development are impeded. Basic infrastructure such as roads, sanitation and commercial settings can be devastated, affecting the ability for basic human needs (e.g. food and shelter) to be satisfied. Displaced persons who have been fleeing their homes in order to avoid the effects of armed conflict and violations of human rights experience much poorer health as a result of this displacement, which can exist for generations (UN, 2017).

      Poverty and inequality There is a large amount of evidence to show that among all threats to health risks, it is poverty and inequality that are much more likely to limit the achievement of full health. Lewer et al. (2019) report that over 900,000 deaths in England have occurred prematurely as a result of social inequalities, and if everyone in England had the same mortality rate as those residing in the richest locations, there would have been 877,000 fewer premature deaths between 2003 and 2018 (see chapters 10 and 12 for more on this).

      In recent years, evidence has been used to demonstrate that material deprivation plays a huge role in the causation of disease (see chapter 4 for further discussion of health inequalities). This social determinants of health model shows a strong social gradient for most diseases, with those who are poorer experiencing higher rates of disease than those who are richer (Wainwright, 2009a; CSDH, 2008; Marmot 2019). WHO (2017) data demonstrate this when discussing the global burden of disease statistics, which illustrate large differences in health and disease burden, depending upon level of socio-economic development. Schrecker (2019) points out that there is no talk about inequality as an emergency because its consequences are less visible, with lives ending sooner and more painfully than they should.

Health inequality refers to the differences in health status between people and/or places and manifests in many ways, as box 2.2 demonstrates.

Box 2.2 Examples of wide-ranging health inequalities

       Gender health inequalities, e.g. risk behaviours such as drinking alcohol, are more prevalent among men, and older groups of the population.

       Social class inequalities, e.g. people in high social classes have better health outcomes compared to those in the lower social classes.

       Geographical inequalities, e.g. health is generally poorer in the north of England compared to the south of England.

       Ethnic inequalities, e.g. suicide rates in young Asian women are more than double those for young white women in the UK.

       Age inequalities, e.g. many risk factors for poor health, such as obesity, hypertension, disability and poverty increase with age, and the importance of adverse childhood experiences in shaping