Transcript Health inequalities: Measurement of deprivation and its

Inequalities, deprivation and health
Chris McManus
11th September 2012
Learning Objectives
By the end of this session you should know
more about:
– What are health inequalities?
– Why are health inequalities important?
– History and current drivers/targets
– Examples of past and current ways of
measuring deprivation
• Individual level
• Area level
What do you think we mean
by ‘health inequalities’?
What do we mean by ‘health
inequalities’?
Generally: differences between groups of people
in terms of their health outcomes
Specifically: health and illness are related to
social and economic position
“Inequality in health is the worst inequality of all.
There is no more serious inequality than knowing
that you’ll die sooner because you’re badly off”
Frank Dobson, 1997
“People with higher socioeconomic position in
society have a greater array of life chances and
more opportunities to lead a flourishing life. They
also have better health.
Reducing health inequalities is a matter of fairness
and social justice”
Michael Marmot 2010
health inequality .... and health equity
• Health inequality
– Differences in health experience between population groups differing in
terms of e.g. geography, age, sex, ethnicity, socio-economic status
• Health equity
– “Fair” distribution of health/health care resources or opportunities
according to population need
– Allocating relatively more resources where there is relatively more need
– Equal quality of care for all
If all PCTs in England have a Coronary Artery Bypass Graft rate of 750
operations per 1,000,000 pop this is equality but is probably not equitable some PCTs will have a higher level of need.
But the variations in life expectancy in
England are unacceptable
Determinants of health
Long history …….
some important milestones
Some historical evidence comparing
occupations…
Edwin Chadwick
Table 1: Age at death among different social orders, by district
District
Gentry and
Farmers and
professional
tradesman
Rutland
52
41
Bath
55
37
Leeds
44
27
Bethnal Green
45
26
Manchester
38
20
Liverpool
35
22
Source: Chadwick (1842) cited in Macintyre (1999)
Labourers and
artisans
38
25
19
16
17
15
Respiratory
Genitourinary
Circulatory
Digestive
Cancers
Accidents
Evidence from the Acheson Report, 1998
Death rates by occupational social class, men aged 20-64, 1991-93
Lung cancer
All causes
806
1000
800
600
400
280
300
I
II
426
493
492
200
0
IIINM
IIIM
IV
100
80
60
40
20
0
82
17
24
I
II
V
Coronary Heart Disease
250
200
150
100
50
0
81
159
52
IIIM
IV
34
IIINM
V
Stroke
235
136
54
156
45
50
40
30
92
20
14
13
I
II
19
24
25
IIIM
IV
10
I
II
IIINM
IIIM
IV
V
0
Source: Independent Inquiry into Inequalities in Health, 1998
Death rates per 100,000
IIINM
V
Current important drivers …….
•The Marmot Review (Fair Society,
Healthy Lives)
•Public Health Outcomes Framework
Marmot review
www.ucl.ac/marmot review
The Marmot Review
•
•
•
•
Independent Strategic Review of Health
Inequalities in England post-2010
Commissioned by Secretary of State for Health
in November 2008
Chaired by Prof Sir Michael Marmot
“Does not necessarily represent the stated policy
of the Department of Health”
The Marmot Review: Terms of Reference
The Review had four tasks:
•
•
•
•
Identify, for the health inequalities challenge facing
England, the evidence most relevant to underpinning
future policy and action
Show how this evidence could be translated into
practice
Advise on possible objectives and measures, building
on the experience of the current PSA target on infant
mortality and life expectancy
Publish a report that will contribute to the development
of a post-2010 health inequalities strategy
Reducing health inequalities will require
action on six policy objectives
1. Give every child the best start in life
2. Enable all children young people and adults to
maximize their capabilities and have control
over their lives
3. Create fair employment and good work for all
4. Ensure healthy standard of living for all
5. Create and develop healthy and sustainable
places and communities
6. Strengthen the role and impact of ill health
prevention
Public Health Outcomes
Framework
Two high-level outcomes
• Increased life expectancy
• Reduce differences in life expectancy and healthy life
expectancy between communities
Male life expectancy at birth inequality
gap
What do we mean by socioeconomic deprivation?
How can we define and measure
‘badly off’?
Key concepts and measurements in health
inequality
PART 1: Individual level: socio-economic position
Ethnicity, occupation, employment status, social
class, education, income
PART 2: Ecological/Area level: deprivation
Index of Multiple Deprivation, Geodemographic
classifications
Individual level: socio-economic position
Socio-economic position: an umbrella term
for the way that people are ordered into a
hierarchy based on their social and economic
circumstances. Encompasses a range of
concepts with different theoretical and
disciplinary origins.
Individual level measures
•
•
•
•
•
•
Ethnicity
Employment status
Occupation
Social Class
Education
Income
Ethnicity
Source: 2001 Census
Other Ethnic Group
Chinese
Black Other
Black African
Black Caribbean
Asian Other
Bangladeshi
Pakistani
Indian
Mixed Other
White & Asian
White & Black African
White & Black Caribbean
White Other
White Irish
White British
Health status
Standardised ‘not good’ health ratios, London 2001
200
180
160
140
120
100
80
60
40
20
0
Ethnicity or lifestyle?
Migrant studies
First wave, or subsequent settlers?
Don’t confuse ethnicity
with socio-economic issues
Employment status
EMPLOYMENT STATUS
Economic activity / whether someone is
employed/unemployed.
Strong link to outcome
Work-related benefits
Social isolation and loss of self-esteem;
status, purpose and structure to day; respect
of others; physical and mental activity; use of
skills
Work insecurity and self-reported
general health at age 23 (NCDS)
Source: Blane et al 1996, Health and Social Organisation
Occupation
OCCUPATION
Reflects an individuals social standing in society, status,
privilege, intellect, parental background, income/living
standards, educational background, working relations &
conditions…
Current occupation
Longest held occupation
Occupation of head of household
Commonly excluded groups include: retired, people
whose work is inside the home (mainly affecting women),
the unemployed, students, and people working in unpaid,
informal or illegal jobs.
Work
Self-reported level of job
control and incidence of
coronary heart disease in
men and women
Social determinants of health: The
solid facts edited by Richard Wilkinson
& Michael Marmot
http://www.euro.who.int/InformationS
ources/Publications/Catalogue/200208
08_2
Social class
Social Class based on Occupation
(previous to 1990 known as The Registrar
General’s Social Classes)
First devised 1911, social grades based on
prestige or social standing; initial purpose –
analysis of mortality and fertility data.
Used in official statistics and vital statistics,
over long time period.
The Registrar General’s Social Classes
I
Professional, e.g. lawyer, doctor, accountant
II
Intermediate, e.g. teacher, nurse, manager
III-NM
Skilled non-manual, e.g. typist, shop assistant
III-M
Skilled manual, e.g. plumber, electrician
IV
Partly skilled manual, e.g. bus driver.
V
Unskilled manual e.g. cleaner, labourer
VI
Armed forces
UK National Statistics Socio-Economic
Classification (NS-SEC)
As of 2000 this has replaced the Registrar
General’s social classes for use in official
statistics and surveys.
It is explicitly based on differences
between employment conditions and relations
UK National Statistics Socio-Economic
Classification (NS-SEC)
1.
Higher managerial and professional employees
2.
Lower managerial and professional employees
3.
Intermediate employees
4.
Small employer and own account workers
5.
Lower supervisory, craft and related employees
6.
Employees in semi-routine occupations
7.
Employees in routine occupations
Never worked and long–term unemployed
Infant mortality rates by socio-economic group
2002-4
Self-reported health of women aged 16-74 by NSSEC, %, England and Wales, 2001 (Census, ONS)
Occupation based measures limitations
• Information often not captured:
Women
Those not in paid employment
(including those not of working age)
• What is someone’s occupation?
• Changes over time
• Population availability
• Possibility of reverse causality – downward
mobility with ill-health
Education
Education: knowledge-related assets of an
individual
Continuous variable: years of completed
education
Categorical variable: educational
achievements, such as completion of
secondary education, attainment of
qualification
Variations in rates of self-reported ill health
among those aged 16 years or more by level of
education, The Netherlands, 1981-85
Highest level of formal
education completed
Primary school
Lower secondary school
Secondary education
Vocational college
University
Chronic
Self-rated
conditions health less than
‘good’
1.12
1.41
1.00
0.98
0.95
0.81
0.85
0.62
0.71
0.64
Source: Blane et al 1996, Health and Social Organisation.
Education
• Captures those not in workforce
• Socio-economic position in early life, material resources
of family or origin
• Determinant of employment and indicator of future
material resources
• Knowledge, literacy, receptiveness to health education
• Beware cohort change (changes over time)
Income
…some
more
historical
evidence
Source: Merlo et al, 2003 International Journal of Equity in Health
Income
• Direct measure of material circumstance
• Individual, household, equivalized
• Doesn’t take into account accumulated
assets (wealth)
• Not (currently) measured in the census
Response rates
Liable to fluctuate
• Model-based estimates for small areas
Other measures of individual
socio-economic position …
Amenities
often used as an indicator of income and
wealth / living standards
Car access / ownership
Sole use of bathroom/toilet
Telephone, fridge etc
Are these still important?
Minimum Income for Healthy
Living
Sufficient to support
• Adequate nutrition
• Physical activity
• Housing
• Social interactions
• Transport
• Medical care and hygiene
Individual measures of socioeconomic position
•There is no single best indicator of SEP
• What is your research question / aim?
• Is the measure equally relevant to all
subgroups?
• Is there a cohort effect to consider?
Key concepts and measurements in health
inequality (and some evidence)
PART 1: Individual level: socio-economic position
Ethnicity, occupation, employment status, social
class, education, income
PART 2: Ecological/Area level: deprivation
Index of Multiple Deprivation, geodemographic
classifications
Ecological fallacy
• People within an area share the same environmental
characteristics (William S Robinson)
• The Ecological Fallacy is a situation that can occur when
a researcher or analyst makes an inference about an
individual based on aggregate data for a group
• All deprived people are not living in deprived areas
• All people living in deprived areas are not deprived
• Employment status is an individual indicator.
Unemployment rates are area-level indicators.
Area level: deprivation
Deprivation: a relative and broad concept,
referring to not having something that others
have.
“a state of …observable and demonstrable
disadvantage relative to the local community or the
wider society or nation to which an individual, family
or group belong.” (Townsend, 1987).
Area based measures
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Townsend
Carstairs
Jarman
Index of Multiple Deprivation
• Geodemographic classifications
English Indices of Deprivation
Department of Communities and Local Government
Lower Super Output Area level
38 separate indicators
7 domains in total
health, crime, housing, education, income,
employment, living environment
Combined in the Index of Multiple Deprivation
- summary measure at LSOA level
two supplementary Indices
Income Deprivation Affecting Children
Income Deprivation Affecting Older People
http://www.communities.gov.uk/publications/corporate/statistics/indices2010
Domains of IMD 2010
Health Domain
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Year of potential life lost
Comparative illness and disability ratio
Emergency admissions to hospital
Adults suffering from mood or anxiety
disorders
Geodemographics
• “analysis of people by where they live” – assumes
“birds of a feather flock together”
• Use a combination of Census and commercial
data to identify groups with similar lifestyles, eg
where they shop, what papers they read
• APHO technical briefing 5: Geodemographic
Segmentation
Geodemographics
•
Which geodemographic systems have you
met?
Common geodemographic tools
Supplier
Tool
Smallest
geographical
level
CACI
ACORN
postcode
Census + survey
subscribe
CACI
Health Acorn
Output area
Census + survey
subscribe
Census + survey
subscribe/
free academic
use
construction
variables
cost
Experian
Mosaic UK
Postcode/
Household
ONS
Output Area
Classification
OA
Census
free
2001 area
Classification
SOA
Census
free
Beacon
Dodsworth
People and Places,
P2
OA
Census + survey
free NHS
Axicom
Personix Geo
Census + survey
subscribe
postcode
Structure of People and Places
Tree
A
B
C
D
E
F
G
H
I
J
K
L
M
U
Mature Oaks
Country Orchards
Blossoming Families
Rooted Households
Qualified Metropolitans
Senior Neighbourhoods
Suburban Stability
New Starters
Multicultural Centres
Urban Producers
Weathered Communities
Disadvantaged Households
Urban Challenge
Unclassified
Branch
H22
Student In the Community
H25
Working Singles
H26
Student Life
Leaf
Prevalence of hospital admission for mental health
conditions North West residents 1998-2002
What are the limitations of
geodemographic tools?
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Birds of a feather don’t always flock together
Largely Census dependent
Other data largely modelled
Not suitable for monitoring trends
Geodemographics in themselves do not provide
the answer.
– They are simply one of a range of tools and approaches that can
be used to generate insight and health intelligence to support
social marketing decisions
Social marketing
•
Use of geodemographics to target socially
desirable messages in a way appropriate
to an audience
Summary
• Differences in health outcome (health
inequalities) can occur between many
groups - gender, ethnicity, place
• Frequently refers to the markedly worse
health outcomes seen with higher
socioeconomic deprivation
Summary 2
• A variety of approaches can be used to
measure health inequalities either
between two groups or many
• A comprehensive picture of health
inequalities requires the use of more than
one approach.
Some references
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Compendium of Clinical and Health Outcomes NCHOD nww.nchod.nhs.uk
www.euro.who.int/InformationSources/Publications/Catalogue/20020808_2
Social Determinants of Health: the solid facts Wilkinson & Marmot
Wanless: Securing Good Health for the Whole Population - Population Health Trends
www.doh.gov.uk/wanless/wanless_health_trends.pdf
Tackling Obesity in England: National Audit Office 2001
Essential Public Health, second edition L J Donaldson & R J Donaldson 2000 Petroc
Press
The Spirit Level: Why More Equal Societies Almost Always Do Better by Richard
Wilkinson and Kate Pickett, Penguin March 2009 or www.eqaulitytrust.org.uk
Health Profile for England, DH 2008 JSNA – the APHO Resource Pack 5. Measuring
Health Inequalities http://www.yhpho.org.uk/resource/item.aspx?RID=9957
World Class Commissioning Assurance Framework - Health Inequalities Indicator
APHO http://www.apho.org.uk/resource/view.aspx?RID=75050
Health Inequalities Intervention tool
http://www.lho.org.uk/HEALTH_INEQUALITIES/Health_Inequalities_Tool.aspx