Transcript Health inequalities: Measurement of deprivation and its

Inequalities, deprivation and health
Allan Baker
Acknowledgements
• This presentation has been adapted from
the original presentation provided by the
following contributors:
– Helen Cooke
– Mary Shaw
– Bruna Galobardes
– Mildred Blaxter
Learning Objectives
• What are health inequalities?
• History of examining health inequalities
• Measures of socio-economic position and
deprivation
– Individual level
– Area level
• Explanatory mechanisms
What are health inequalities?
Differences in health experience or
outcome between population groups
Types of health inequality
GENDER
GEOGRAPHY
DISABILITY
AGE
Social-economic environment
e.g. jobs, housing, education, transport
Lifestyles/health behaviour
e.g. diets, smoking, social networks
Access to effective health/social care
e.g. services that result in health benefits
Health outcomes
e.g. increase/reduce mortality, ill health, disability
ETHNICITY SOCIAL CLASS
Differences in Life Expectancy within a small area in London
Travelling east from Westminster, each tube stop represents nearly
one year of life expectancy lost –Data revised to 2002-06
Male Life
Expectancy
78.6 (CI 76.0-81.2)
Canning Town
Female Life Expectancy
84.6 (CI 82.5-86.7)
Male Life
Expectancy
72.8 (CI 71.1-74.6)
Female Life
Expectancy
81.4 (CI 79.3-83.6)
Westminster
London Bridge
River Thames
Canada
Bermondsey Water
Canary
Wharf
North
Greenwich
Waterloo
Southwark
London Underground
1
Jubilee Line
Source: Analysis by London Health Observatory using Office for National Statistics data revised for 2002-06. Diagram produced by Department of Health
Life expectancy at birth 1841
Males
Females
England
40
42
Surrey
London
Liverpool
44
35
25
46
38
27
Some historical evidence comparing
occupations…
Edwin Chadwick
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
The widening health gap
Death ratios by social class
Log scale
160
1.2 times greater
Social class
100
Unskilled
2.9
times
greater
50
Average for
working age men
Professional
25
1930-32
1959-63
Year
England & Wales
1991-93
Health inequalities post 1997
• 1997 Health Inequalities Decennial Supplement
• 1998 Acheson report:
Independent Inquiry into Inequalities in Health
• 1999 White paper:
Saving Lives: Our healthier nation
Inequality PSA Target
By 2010 to reduce the inequalities in
health outcomes by 10% as measured
by infant mortality and life expectancy
at birth.
Infant Mortality
Starting with children under one year, by
2010 to reduce by at least 10 per cent
the gap in mortality between the routine
and manual groups and the population
as a whole.
Life expectancy
Starting with Local Authorities, by 2010 to
reduce by at least 10% the gap in life
expectancy between the fifth of areas with
the “worst health and deprivation
indicators” and the population as a whole
(England).
Individual level measures
•
•
•
•
Ethnicity
Occupation
Social Class
National Statistics Socio-Economic
Classification
• Education
• Income
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
Occupation
• Long history of reporting
• Decennial Supplements
• Whitehall Study – 1967
Gradients in mortality by grade
• Whitehall II
Relationships - work, stress & health
The Registrar General’s
Social Classes
I Professional
II Intermediate
III-NM Skilled non-manual
III-M Skilled manual
IVPartly skilled manual
V Unskilled manual
VI Armed forces
lawyer, doctor
teacher, manager
typist, clerk
plumber, electrician
bus driver
cleaner, labourer
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
UK National Statistics Socio-Economic
Classification (NS-SEC)
1) Higher managerial and professional occupations
2) Lower managerial and professional occupations
3) Intermediate occupations
4) Small employers and own account workers
5) Lower supervisory and technical occupations
6) Semi-routine occupations
7) Routine occupations
8) Never worked and long-term unemployed
Infant Mortality by NS-SEC
1997-99
2005-07
Deaths per 1,000 live births
All*
Routine and Manual
Ratio
*All within marriage/joint registration
5.6
6.3
1.13
4.7
5.4
1.16
Occupation based measures limitations
• Information often not captured:
Women
Those not in the workforce
(including those not of working age)
• What is someone’s occupation?
• Changes over time
• Population availability
Education
• Captures those not in workforce
• Socio-economic position in early life
• Determinant of employment
• Knowledge, receptiveness to health education
• Meaning changes over time
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
conditions
1.12
1.00
Self-rated
health less
than ‘good’
1.41
0.98
0.95
0.85
0.71
0.81
0.62
0.64
Source: Blane et al 1996, Health and Social Organisation.
Income
• Direct measure of material circumstance
• Doesn’t take into account assets (wealth)
• Not measured in the census
Response rates
Liable to fluctuate
• Model-based estimates for small areas
Area based measures
•
•
•
•
Carstairs
Townsend
Jarman
Index of Multiple Deprivation
• National Statistics Area Classification
• P2 People and Places
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)
Maps Descriptive of London Poverty
Charles Booth's Inquiry into Life and Labour in London (1886-1903)
Two very different areas of London
Whitechape
l
http://booth.lse.ac.uk/static/a/4.html#i
Mayfair & Fitzrovia
London Deprivation - 1890s and 1990s
Copyright ©2000 BMJ Publishing Group Ltd.
Dorling, D. et al. BMJ 2000;321:1547-1551
Providence Place, Islington
c1900
Copyright ©2000 BMJ Publishing Group Ltd.
2000
Townsend index of material deprivation
•
•
•
Unemployment 16-64
Households with no car
Overcrowding > 1 person per room
•
Households not owner occupied
Carstairs deprivation index
• Male unemployment
• Households with no car
• Overcrowding > 1 person per room
• Low Social Class
Jarman scores
• Not designed as a measure of material
deprivation
• Designed to highlight areas of greatest
need for primary care
• Used subsequently as more general
measure of deprivation
Index of Multiple Deprivation
• Not dependent on census
• Seven domains
•
•
•
•
England
Counties
Local authorities
Lower Layer Super Output Areas
Ecological fallacy
• People within an area share the same
environmental characteristics (William S
Robinson)
• All deprived people are not living in
deprived areas
• All people living in deprived areas are not
deprived
IMD 2007 - Domains
Living environment
Crime
Housing & services
Education, skills, training
Health & disability
Income
Employment
0
5
10
15
Per cent
20
25
IMD 2007 – England & London
100
80
1
60
2
3
4
40
5
20
0
England
IMD2007 - London
IMD 2007 - Income
100
80
1
60
2
3
4
40
5
20
0
England
IMD2007 - London
Income
IMD 2007 - Housing
100
80
1
60
2
3
4
40
5
20
0
England
IMD2007 - London
Income
Housing
IMD 2007 - Environment
100
80
1
60
2
3
4
40
5
20
0
England
IMD2007 London
Income
Housing
Environment
IMD 2007 - Education
100
80
1
60
2
3
4
40
5
20
0
England
IMD2007 London
Income
Housing
Environment
Education
D
IM
on
do
n
H
ou
si
ng
In
co
m
e
-L
H
ea
lth
io
n
Ed
uc
at
En
vi
ro
nm
en
t
20
07
En
gl
an
d
IMD 2007 - Health
100
80
60
1
2
3
40
4
5
20
0
Health Domain
•
•
•
•
Year of potential life lost
Comparative illness and disability ratio
Emergency admissions to hospital
Adults suffering from mood or anxiety
disorders
Deprivation scores
• Measures of deprivation, not affluence
• Relative measures
• Deprivation a stronger proxy for health risk
in men than women
• Effects of deprivation attenuated at older
ages
• Different effects in different areas
Lung cancer mortality
Source: DS No 16 Geographic Variations in Health
Breast cancer incidence
Source: DS No 16 Geographic Variations in Health
Breast cancer mortality
Source: DS No 16 Geographic Variations in Health
Which indicator?
• Carstairs and Townsend - car ownership
• May tend to overestimate disadvantage in
London?
• Healthier people concentrated in capital?
• IMD – Health domain
• Outcomes and scores often correlated
Geodeomographic classifications
• Classify areas by socio-demographic characteristics
• National Statistics Area Classification
• Combinations of census and commercial data to identify
groups with similar lifestyles
• Examples include ACORN, Mosaic, P2 People & Places
Prevalence of hospital admission for mental health
conditions North West residents 1998-2002
P2 People and Places
SW16 3QL - Multicultural Key Worker
•
•
•
•
•
Ethnically very mixed
Severe overcrowding common
High unemployment
Little political interest - tabloid newspapers
People tend to smoke and take little exercise
• Shopping predominantly at Aldi or Lidl
Poor people or Poor Places
Individual vs Area Measures
Differences in health between areas:
Result of characteristics of population?
Or an independent area effect?
Individual characteristics often summarised
– groups may not be homogenous
Mortality rates by social class
males aged 20-64, 1991-1993
North West
1600
1200
800
400
0
I
II
IIIN
IIIM
IV
V
Age-standardised rate
Age-standardised rate
North East
1600
1200
800
400
0
I
II
IIIN
Social Class
Age-standardised rate
Age-standardised rate
1200
800
400
0
IIIN
V
South East
1600
II
IV
Social Class
East
I
IIIM
IIIM
IV
1600
1200
800
400
0
V
Social Class
Source: DS No 16 Geographic Variations in Health
I
II
IIIN
IIIM
Social Class
IV
V
Explanatory Mechanisms
•
•
•
•
•
•
•
Selection
Culture / lifestyle
Poverty
Psychosocial factors – Stress and Status
Healthcare
Environment
Social capital
Learning Objectives
• What are health inequalities?
• History of examining health inequalities
• Measures of socio-economic position and
deprivation
– Individual level
– Area level
• Explanatory mechanisms