© Association of Public Health Observatories Health inequalities Delivered by Alison Hill Association of Public Health Observatories © Association of Public.

© Association of Public Health Observatories

Health inequalitiesDelivered by Alison Hill

Association of Public Health Observatories


Day 1 Session 4

Non-PHO contributors (from University of Bristol):Mary Shaw Bruna GalobardesMildred Blaxter


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


Overview:

What are health inequalities?

How can we measure socio-economic deprivation?

- individual level

- group (area) level


What do we mean by ‘health inequalities’?


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)


“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


What kinds of health inequality are there?


What kinds of health inequality are there?

Age

Sex

Geography

Ethnicity

Disability

Socio-economic


Inequalities in England

660

0

100

200

300

400

500

600

700

800

900

1000

1100

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

/09

2009

/10

2010

/11

All-a

ge, a

ll-ca

use

mor

tlity

rate

per

100

,00

mal

es

Year

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

England

North West

South East

Spearhead LSPs

England forecast rate

England forecast rate 95% lower CI

England forecast rate 95% upper CI

England PSA Target Rate




Key concepts and measurements in health inequality (and some evidence)

PART 1: Individual level socio-economic position (SEP)

PART 2: Ecological/Area level: deprivation


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.


Occupation-based indicatorsthings 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


Some historical evidence comparing occupations…

Age at death among different social orders, by district District Gentry and

professional Farmers and tradesman

Labourers and artisans

Rutland 52 41 38 Bath 55 37 25 Leeds 44 27 19 Bethnal Green 45 26 16 Manchester 38 20 17 Liverpool 35 22 15 Source: Chadwick (1842) cited in Macintyre (1999)

Edwin Chadwick


Common occupation-based indicators

Registrar General’s Social Classes

– (prestige/status)

The new UK NS-SEC

– (employment relations)


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


Accidents

Cancers

DigestiveRespiratory

Genitourinary

Circulatory


Evidence from the Acheson Report, 1998

All causes

280 300426 493 492

806

0

200

400

600

800

1000

I II IIINM IIIM IV V

Lung cancer

17 24 3454 52

82

020406080

100


Coronary Heart Disease

81 92136

159 156

235

050

100150200250


Stroke

14 1319

24 25

45

0

10

20

30

40

50


Source: Independent Inquiry into Inequalities in Health, 1998

Death rates per 100,000 by occupational social class, men aged 20-64, 1991-93

Death rates


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


National Statistics Socio-economic Classification – analytic classes

1 Higher managerial and professional

occupations

Directors and chief executives of major organisations; civil engineers; medical practitioners; IT strategy and

planning professionals; 2 Lower managerial

and professional occupations

Teachers quantity surveyors; public service administrative professionals; social workers; nurses; IT

technicians3 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

Hairdressing proprietors; shopkeepers; self-employed taxi drivers;

5 Lower supervisory and technical occupations

Bakers; plumbers; electricians and motor mechanics employed by others; gardeners;

6 Semi-routine occupations

Pest control officers; clothing cutters; traffic wardens; farm workers; veterinary nurses; shelf fillers

7 Routine occupations;

Hairdressing employees; van, bus and coach drivers labourers; hotel porters; bar staff; cleaners and domestics; road sweepers; car park attendants


Self-reported health of women aged 16-74 by NS-SEC, %, England and Wales, 2001 (Census, ONS)


Trends in infant mortality by socio-economic groupEngland and Wales 1994-2006, three-year rolling average

note that records before 2000 have been “re-coded” into NS SEC 90 for compatibility


OTHER MEASURES OF SOCIOECONOMIC STATUS

Education

Employment status

Income

Housing

Any others?


Think longitudinal: life course


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


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.


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.


Group 3: LucyLucy 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.


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.


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?


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


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


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


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)


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


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/deprivation07


IMD domains


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


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


Geodemographics has a long and honourable history

Maps Descriptive of London Poverty Charles Booth's Inquiry into Life and Labour in London (1886-1903)


Two very different areas of London

http://booth.lse.ac.uk/static/a/4.html#i

Whitechapel

Fitzrovia


Common geodemographic tools

Supplier Tool

Smallest geographical level

construction variables cost

CACI ACORN postcode Census + survey subscribe

CACI Health Acorn Output area Census + survey subscribe

Experian Mosaic UKPostcode/Household Census + survey

subscribe/free academic use

ONSOutput Area Classification OA Census free2001 area Classification SOA Census free

Beacon Dodsworth

People and Places, P2 OA Census + survey free NHS

Axicom Personix Geo postcode Census + survey subscribe


Structure of People and PlacesTree

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

K Weathered Communities

L Disadvantaged Households

M Urban Challenge

U Unclassified

H22 Student In the Community

H25 Working Singles

H26 Student Life

Branch

Leaf



Prevalence of hospital admission for mental health

conditions North West residents 1998-2002

Increasing deprivation

NW average


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


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?


Health inequalities: explanatory mechanisms Material factors

– Environment

Lifestyle factors

– Behaviour

Psychosocial factors

– Stressors

– Coping capacity


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


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

© Association of Public Health Observatories Health inequalities Delivered by Alison Hill Association of Public Health Observatories © Association of Public.

Documents

health care

health gap

determinants of health

department of health

tackling health inequalities

kinds of health inequality

obesity experience of

deprivation slide