Transcript South West Annual Public Health Scientific Conference

Association of Public Health Observatories
Day 1 Session 4
Health inequalities
Delivered by Alison Hill
Non-PHO contributors (from
University of Bristol):
Mary Shaw
Bruna Galobardes
Mildred Blaxter
© Association of Public Health Observatories
© Association of Public Health Observatories
Learning Objectives
By the end of this session, participants should be able to:

Identify different kinds of health inequalities and
understand their importance for health

Recognise the central importance of socio-economic
inequalities and deprivation

Understand different ways of measuring socio-economic
factors, both at individual and group (area) level

Interpret information on deprivation and health
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Overview:

What are health inequalities?

How can we measure socio-economic
deprivation?
- individual level
- group (area) level
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What do we mean by ‘health
inequalities’?
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What do we mean by ‘health
inequalities’?
Differences between groups of people in terms of
their health, including:
• determinants of health (eg smoking, obesity)
• experience of health and disease (including
incidence and prevalence of diagnosed disease AND
self-reported health / well-being)
• access to health care (eg GP consultations, hospital
admissions, treatment)
• health outcomes (survival, mortality etc)
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“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
“Tackling health inequalities is a top priority for
this Government, and it is focused on narrowing
the health gap between disadvantaged groups,
communities and the rest of the country.”
- Department of Health, 2007
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What kinds of health inequality are
there?
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What kinds of health inequality are
there?

Age

Sex

Geography

Ethnicity

Disability

Socio-economic
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Inequalities in England
All-age, all-cause mortality rate per 100,000 males: trend 1998 to 2007 for England, Spearhead LSPs, best
and worst regions, England forecast rates to 2010/11 (with 95% confidence intervals) and England PSA
target rate
1100
England
North West
900
800
South East
660
700
Spearhead LSPs
600
England forecast
rate
500
400
England forecast
rate 95% lower CI
300
England forecast
rate 95% upper CI
200
100
England PSA Target
Rate
Year
2010/11
2009/10
2008/09
2007
2006
2005
2004
2003
2002
2001
2000
1999
0
1998
All-age, all-cause mortlity rate per 100,00 males
1000
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Key concepts and measurements in health
inequality (and some evidence)
PART 1: Individual level socio-economic
position (SEP)
PART 2: Ecological/Area level: deprivation
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Part 1: 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.
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Occupation-based indicators
things to bear in mind

Relative position of different occupations
changes over time

Differences between ethnic groups & gender in
relative position of different occupations

Limited to those in paid employment

Possibility of reverse causality – downward
mobility with ill-health
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Some historical evidence
comparing occupations…
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)
Edwin Chadwick
Labourers and
artisans
38
25
19
16
17
15
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Common occupation-based
indicators

Registrar General’s Social Classes
– (prestige/status)

The new UK NS-SEC
– (employment relations)
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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
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Respiratory
Genitourinary
Circulatory
Digestive
Cancers
Accidents
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Evidence from the Acheson Report, 1998
Death rates per 100,000 by occupational social class, men aged 20-64, 1991-93
All causes
Lung cancer
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
IIINM
IIIM
IV
V
Stroke
235
136
54
34
156
45
50
40
30
92
20
14
13
I
II
19
24
25
IIIM
IV
10
0
I
II
IIINM
IIIM
IV
V
Source: Independent Inquiry into Inequalities in Health, 1998
Death rates
IIINM
V
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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
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National Statistics Socio-economic
Classification – analytic classes
1 Higher managerial and
professional occupations
2 Lower managerial and
professional occupations
Directors and chief executives of major organisations; civil
engineers; medical practitioners; IT strategy and planning
professionals;
Teachers quantity surveyors; public service administrative
professionals; social workers; nurses; IT technicians
3 Intermediate
occupations
medical and dental technicians Civil Service administrative
officers and local government clerical officers; counter clerks;
school and company secretaries;
4 Small employers and
own account workers
5 Lower supervisory and
technical occupations
6 Semi-routine
occupations
7 Routine occupations;
Hairdressing proprietors; shopkeepers; self-employed taxi
drivers;
Bakers; plumbers; electricians and motor mechanics employed
by others; gardeners;
Pest control officers; clothing cutters; traffic wardens; farm
workers; veterinary nurses; shelf fillers
Hairdressing employees; van, bus and coach drivers labourers;
hotel porters; bar staff; cleaners and domestics; road sweepers;
car park attendants
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Self-reported health of women aged 16-74 by NSSEC, %, England and Wales, 2001 (Census, ONS)
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Trends in infant mortality by socio-economic group
England and Wales 1994-2006, three-year rolling average
note that records before 2000 have been “re-coded” into NS SEC 90 for compatibility
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OTHER MEASURES OF SOCIOECONOMIC
STATUS
Education
Employment status
Income
Housing
Any others?
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Think longitudinal: life course
Childhood
Parent’s education
Parent’s
occupation
Household income
Household
conditions
Young adulthood
Education
Active professional life
First employment
Income
Household
conditions
Assets transfer
occurring when
starting a family
Retirement
Occupation 1st,...,last,
longest
Housewife
Household income
Wealth, deprivation
Household
conditions
Unemployment:
yes/no, number of
episodes
Income: changes over
time
Assets transfer
across generations
occurring at death
Wealth, deprivation:
changes over time
Household conditions:
changes over time
Partner’s SEP
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Socio-economic position (summary)
There is no single best indicator of SEP
What is your aim/research question?
Is the measure equally relevant to all
subgroups?
Is there a cohort effect to consider?
‘Off the shelf’ – take note of what you are using
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Group 1: Maggie
Maggie is 15. She has a 6 month-old son Darren.
Maggie got pregnant accidentally, having
unprotected sex after an evening binge drinking
with mates at the local club. She did not tell her
mum until it was too late for an abortion and,
anyway, she quite wanted the baby although her
boyfriend Tom disappeared off the scene pretty
quickly once she told him she was pregnant.
Maggie skipped school once she knew she was
having a baby and never went back. She fell out
with her mum so she is living in a damp bedsit
with Darren and living off benefits. She is waiting
for the council to find her a flat.
Meanwhile, she shares a kitchen with others in
the house. She is obese and eats lots of fast
food because it is easier than cooking.
She feels pretty low a lot of the time and does
not really know where life is taking her. Darren
has been in hospital several times with
gastroenteritis and also chest problems.
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Group 2: Gary
Gary is 25 years old and is currently
unemployed and homeless. He is on
probation following arrest for shoplifting.
He has a drugs habit and is also clinically
depressed and feels he is useless. He
grew up in a violent household, often
witnessing his dad hitting his mum, and
spent some time in care. His mother has
now left his father to go back home
abroad.
He left school with one GCSE and has
never had a job. Last year he was in
prison, not for the first time, for
shoplifting—a short sentence which meant
he lost his flat when his girlfriend moved
away.
He sleeps rough when he does not have
the money to get into the night shelter and
finds it difficult to keep the appointments
made for him with his care worker.
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Group 3: Lucy
Lucy is 78. She lives in a small rural community
and has managed on her own until recently, when
she had a minor stroke, and walks with the aid of a
stick. She is determined to carry on living in her
own home, but needs a home help to get on top of
the household chores.
Her neighbours are very good to her, but they go to
work during the day. They do help her to get to
church on Sundays and she gets visits from other
churchgoers during the week.
She really enjoys the lunch club which meets twice
a week in the neighbouring village and relies on the
local voluntary group to come and collect her. Her
GP surgery is also in the next village so if her
friends are busy she has to rely on a taxi to pick her
up for her appointments as there is no bus through
the village any more.
The village shop closed 2 years ago because many
of the people in Lucy’s village are only there at
weekends, so getting fresh fruit and vegetables can
be a bit of a problem.
Lucy owns her house—which is now too big for her.
One of her main anxieties is that the roof is falling
into disrepair—and she does not use the central
heating because of the cost.
Last year she slipped on the ice and broke her wrist
so she tends to stay in during the winter, which can
be a bit depressing.
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Group 4: Sanjay
Sanjay is in his early 50s. His parents
came to Britain in the 1950s and set up a
local convenience store in South London.
He was born in London.
He left school at 16 and helped in the
shop until his parents retired.
Sanjay now manages the shop and also
runs a small taxi business.
He is overweight and a heavy smoker. He
was recently diagnosed as a type 2
diabetic.
He is having chest pain on climbing stairs.
His GP has just referred him to the local
hospital and he is on the waiting list for a
CABG. The GP has advised Sanjay to
stop smoking but he is finding it difficult.
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Case studies: Maggie, Gary, Lucy, Sanjay

List the social and economic circumstances that could be
creating adverse life experiences for these people?

What are the implications for measurement of inequalities
in what you have listed?
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PART 1: Individual
measures of socio-economic position, such as social
class based on occupation, are important for describing
the extent of inequalities in health. They may also be
used in targets and for tracking trends over time.
PART 2: Area-based (ecological)
indicators of deprivation may be used in the absence of
individual level data, or in their own right, and can also
tell us about areas per se (and by implication about the
individuals within those areas).
They are also used for making decisions about the allocation of
resources to those areas
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Beware the ecological fallacy
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
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Sometimes we express the same
measure in a different way
e.g. Unemployment
Employment status is an individual indicator
Unemployment rates are an area-level
indicator
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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)
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Measures of area level deprivation
There are a number of deprivation measures
available
These are based mainly on Census 2001 data
• Townsend Index of material deprivation
• Carstairs deprivation index
• Jarman UPA score
This is mainly administrative data
• Index of Multiple Deprivation
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Indices of Deprivation
Third release (2007) from Department of
Communities and Local Government
• A summary measure at Super Output Area
(SOA) level (and others) calculated from
• 7 domains in total
• two supplementary Indices
•Income Deprivation Affecting Children Index (IDACI)
• Income Deprivation Affecting Older People (IDAOPI)
•www.communities.gov.uk/communities/neighbourhoodrenewal/deprivation/de
privation07
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IMD domains
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Using IMD

Make sure you understand the constituents of each
domain

Use the domain most closely associated with the aspect
of deprivation you are considering
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Geodeomographics

“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

People and Places is available through Observatories

APHO technical briefing 5: Geodemographic
Segmentation – in print
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Geodemographics has a long and honourable history
Maps Descriptive of London Poverty
Charles Booth's Inquiry into Life and Labour in London (1886-1903)
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Two very different areas of London
Whitechapel
http://booth.lse.ac.uk/static/a/4.html#i
Fitzrovia
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Common geodemographic tools
Supplier
Tool
Smallest
geographical construction
level
variables
CACI
ACORN
postcode
Census + survey subscribe
CACI
Health Acorn
Output area
Postcode/
Household
Census + survey subscribe
subscribe/
free academic
Census + survey use
OA
Census
free
SOA
Census
free
Experian
Beacon
Dodsworth
Mosaic UK
Output Area
Classification
2001 area
Classification
People and
Places, P2
Axicom
Personix Geo
ONS
cost
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OA
Census + survey free NHS
postcode
Census + survey subscribe
Tree
Structure of People and Places
A
Mature Oaks
B
Country Orchards
C
Blossoming Families
D
Rooted Households
E
Qualified Metropolitans
F
Senior Neighbourhoods
G
Suburban Stability
H
New Starters
I
Multicultural Centres
J
Urban Producers
Branch
H22
Student In the Community
H25
Working Singles
H26
Student Life
Leaf
K Weathered Communities
L
Disadvantaged Households
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M Urban Challenge
U Unclassified
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Prevalence of hospital admission for mental health
conditions
North West residents 1998-2002
Increasing deprivation
NW average
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What are the limitations of geodemographic
tools?

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
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Which measure to use?
•What does it measure?
•Spatial level and ecological fallacy
•How recent/frequent?
•Components – single or multiple components?
•Applicable to subgroups?
•suitable for time trends?
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Health inequalities:
explanatory mechanisms

Material factors
– Environment

Lifestyle factors
– Behaviour

Psychosocial factors
– Stressors
– Coping capacity
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The targets for tackling health
inequalities incorporates these
individual and aggregate levels:
National (PSA) target for 2010
To reduce the gap in infant mortality across
social groups, and raise life expectancy in the
most disadvantaged areas faster than
elsewhere
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What you should know a little more
about:

What are health inequalities?

Examples of past and current ways of
measuring deprivation
– Individual level
– Area level

links between deprivation and health
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