scotpho public health intelligence training course 2011 “ health inequalities”
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ScotPHO public health intelligence training course 2011 “ health inequalities”. Rory J. Mitchell (NHS Health Scotland, ScotPHO). Overview of health inequalities session. What are health inequalities and why are they important? The scale of health inequalities in Scotland History & policy - PowerPoint PPT PresentationTRANSCRIPT
ScotPHO public health intelligence training course 2011
“health inequalities”
Rory J. Mitchell (NHS Health Scotland, ScotPHO)
Overview of health inequalities session
What are health inequalities and why are they important?
The scale of health inequalities in Scotland History & policy Measuring socio-economic position Measuring health inequalities
{ Practical exercise } Understanding health inequalities Tackling health inequalities
Health inequalities defined
health inequalities are differences in health between population groups age sex ethnicity sexual orientation socio-economic group (geography)
a broad view of health encompasses wellbeing and wider determinants
Defining population groups– 1
social class occupation education income benefits & tax credits
area v individual-based measures
Defining population groups – 1
National Statistics – Socio-economic Classification (NS-SEC)1 Higher managerial and professional occupations2 Lower managerial and professional occupations3 Intermediate occupations4 Small employers and own account workers5 Lower supervisory and technical occupations6 Semi-routine occupations7 Routine occupations8 Never worked and long-term unemployed
Defining population groups – 2
Scottish Index of Multiple Deprivation (SIMD)
identifies small area concentrations of multiple deprivation across all of Scotland in a fair way.
combines 38 indicators across 7 domains, namely: income, employment, health, education, skills and training, housing, geographic access and crime.
the overall index is a weighted sum of the seven domain scores.
this creates the overall SIMD score for each data zone, which is ranked to create the overall SIMD rank.
Scottish Index of Multiple Deprivation (SIMD)
Health inequalities in Scotland
Leyland et al., Inequalities in Mortality in Scotland 1992-2002; MRC SPHSU Occasional Paper #18
Male age specific mortality rates by NS-SEC. Scotland 2000-02
Health inequalities in ScotlandInter CHP
Deaths from alcohol conditions (5-year average 2005-2009)
0
10
20
30
40
50
60
70
80
90
100
Ag
e/s
ex
sta
nd
ard
ise
d r
ate
pe
r 1
00
,00
0 p
op
ula
tio
n
Community Health Partnership
Health inequalities in ScotlandThe percentage of P1 children in Scotland with no obvious
dental decay experience, by deprivation decile, 2008
Why do health inequalities matter? A moral imperative:
“Reducing health inequalities is a matter of fairness and social justice” – The Marmot Review, 2010
A political imperative:“Reducing inequalities in health is critical to
achieving the Scottish Government's aim of making Scotland a better, healthier place for everyone, no matter where they live. “ – Scottish Government
An economic imperative?
A strategy for improving population health?
Policy background Socio-economic differences in health recognised since 19th
century
Key documents…… Black Report (UK), 1980 Acheson Report (England & Wales), 1998 WHO Commission on Social Determinants of Health
(International), 2008 Marmot Review (England), 2010 Report of ministerial task force on health inequalities
(Scotland), 2008
Current policy drivers in Scotland “Equally Well” And… “Achieving our potential”, “Early years framework”, etc
measuring health inequalities
Measuring inequalities 1 – Range
absolute & relative inequality
e.g. mortality rate in most deprived = 1120 mortality rate in least deprived = 500
Measuring inequalities 1 – Range illustration
All-cause age & sex standardised mortality rates(European Standard Population)
0
200
400
600
800
1,000
1,200
1 2 3 4 5 6 7 8 9 10
Decile of SIMD
absolute inequality = 1120 - 500 = 620(i.e. difference in rate between most and least deprived group is 620)
Measuring inequalities 1 – Range illustration
All-cause age & sex standardised mortality rates(European Standard Population)
0
200
400
600
800
1,000
1,200
1 2 3 4 5 6 7 8 9 10
Decile of SIMD
relative inequality = 1120 / 500 = 2.2[mortality rate is 2.2 times greater in most deprived group]
Practical exercise: health inequalities trend scenarios
Group work: 5 groups, 5 minutes
Whole group discussion, 10 minutes
Practical exercise: questions for consideration.....
What is the change over time in rate of hospital admissions for (i) the most deprived group and (ii) the least deprived group?
What is the effect on absolute inequality?
What is the effect on relative inequality?
Is the scenario desirable?
Is the scenario realistic?
[How does it compare with other scenarios?]
Scenario 1…..Hospital admissions for heart attack aged <75 in Scotland,
2008 values with hypothetical projection to 2018 (Scenario 1 )
96
86
33
43
0
10
20
30
40
50
60
70
80
90
100
110
120
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Year
Eu
rop
ean
ag
e-st
and
ard
ised
m
ort
alit
y ra
te p
er 1
00,0
00
Most deprived
Least deprived
Absolute Inequality: no change Relative Inequality: + 0.37
Scenario 2Hospital admissions for heart attack aged <75 in Scotland,
2008 values with hypothetical projection to 2018 (Scenario 2 )
96
86
23
43
0
10
20
30
40
50
60
70
80
90
100
110
120
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Year
Eu
rop
ean
ag
e-st
and
ard
ised
m
ort
alit
y ra
te p
er 1
00,0
00
Most deprived
Least deprived
Absolute Inequality: + 10 Relative Inequality: + 1.51
Scenario 3Hospital admissions for heart attack aged <75 in Scotland,
2008 values with hypothetical projection to 2018 (Scenario 3 )
96
76
33
43
0
10
20
30
40
50
60
70
80
90
100
110
120
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Year
Eu
rop
ean
ag
e-st
and
ard
ised
m
ort
alit
y ra
te p
er 1
00,0
00
Most deprived
Least deprived
Absolute Inequality: - 10 Relative Inequality: + 0.07
Scenario 4Hospital admissions for heart attack aged <75 in Scotland,
2008 values with hypothetical projection to 2018 (Scenario 5 )
96
86
4343
0
10
20
30
40
50
60
70
80
90
100
110
120
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Year
Eu
rop
ean
ag
e-st
and
ard
ised
m
ort
alit
y ra
te p
er 1
00,0
00
Most deprived
Least deprived
Absolute Inequality: - 10 Relative Inequality: - 0.23
(Scenario 4)
Scenario 5Hospital admissions for heart attack aged <75 in Scotland,
2008 values with hypothetical projection to 2018 (Scenario 4 )
96
66
33
43
0
10
20
30
40
50
60
70
80
90
100
110
120
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Year
Eu
rop
ean
ag
e-st
and
ard
ised
m
ort
alit
y ra
te p
er 1
00,0
00
Most deprived
Least deprived
Absolute Inequality: - 20 Relative Inequality: - 0.23
(Scenario 5)
Measuring inequalities
– Slope Index of Inequality (SII)
Example from: Long term monitoring of health inequalities, Scottish Government 2010
SII = 238
Measuring inequalities – Relative Index of Inequality (RII)
RII = SII / population mean
= 238 /158
= 1.51
Measuring inequalities
– Relative Index of Inequality (RII)
Measuring inequalities
– population attributable risk (PAR)
PAR = proportion of cases attributable to SES
Illustrates the reduction in number of cases if all groups had the same rate as the least deprived group
For formula see “measuring socio-economic inequalities in health: a practical guide” – ScotPHO, 2007 [available from www.scotpho.org ]
Measuring inequalities
– population attributable risk (PAR)
All-cause age & sex standardised mortality rates(European Standard Population)
0
200
400
600
800
1,000
1,200
1 2 3 4 5 6 7 8 9 10
Decile of SIMD
Measuring inequalities – Concentration curve & index
Concentration Curve
0%
20%
40%
60%
80%
100%
0% 20% 40% 60% 80% 100%
Cumulative % of pop ranked by Deprivation
Cu
mu
lativ
e %
of d
ea
th
most deprived
least deprived
The Concentration Index (C) is defined as twice the area between the concentration curve & the diagonal
Choosing the most appropriate measures of inequality
In most situations, it is useful to present both an absolute and relative measure of inequality.
An absolute measure will:
give a context in which to assess the relative measure give an impression of the overall burden on population health
A relative measure will: take account of the size of the population of different groups take full advantage of the information across the whole population Allow comparison of measures over time or between different areas
Choice of measure to present will depend on the technical understanding of the audience
It may also be useful to present additional contextual data for background information, e.g. population rates and numbers, to show the underlying scale of the problem
understanding health inequalities
Determinants of health (inequalities)
How does socio-economic status affect health?
Income Differential
access to social resources, e.g. education work
Individual factors self esteem control stress
Community / cultural factors
Health behaviour & risk factors
Social cohesion
Social status
UPSTREAM DOWNSTREAM
Health Care
Health Outcomes
Socio-economic status over the life-course
early years young adulthood retirementworking life
Parent’s education
Parent’s occupation
Household income
House conditions
Retired income
Housing
Wealth
Education Employment
Occupation
Income
Housing
Unemployment
Community & cultural context
Asset transfer to next generation
How do health inequalities persist?
Theory of fundamental causes
“Our enormous capacity to control disease and death combined with social and economic inequality creates health disparities……it does so because…the benefits of this new found capacity are not distributed equally throughout the population, but are instead harnessed more securely by individuals and groups who are less likely to be exposed to discrimination and who have more knowledge, money, power, prestige and beneficial social connections.”
Bruce Link
tackling health inequalities
Strategies and challenges - 1
Targeting people in poverty using an area-based approach
Source: McLoone, 2001
Strategies and challenges – 2
Deprived groups less likely to take advantages of health care opportunities and respond to health improvement strategies
Resource requirements can be large, and are balanced against overall health improvement and other competing demands
Timescales can be measured in years, decades or generations (and a week is a long time in politics)
Strategies and challenges – 3 There is limited evidence for what actually works
Approaches that are most likely to work include:
Structural changes in the environment Legislative and regulatory controls Fiscal policies Income support Reducing price barriers Improving accessibility of services Prioritising disadvantaged groups Offering intensive support Starting young (MacIntyre, 2007)
Is equal health in unequal societies achievable……?
Resources and tools Measuring socio-economic inequalities in health: a practical
guide, ScotPHO 2007: http://www.scotpho.org.uk/home/Publications/scotphoreports/pub_measuringinequalities.asp Includes an interactive excel tool that illustrates
measurement of health inequalities:
The Scottish government Long-term monitoring of health inequalities report (2009): http://www.scotland.gov.uk/Publications/2009/09/25112211/0 Includes the most up-to-date government recommendations
for measuring and reporting inequalities in Scotland.
Association of Public Health Observatories (APHO) technical briefing on measuring health inequalities – due for publication April/May 2011. See ScotPHO website: http://www.scotpho.org.uk/home/resources/methodology/method_intro.asp
References
McIntyre S. Inequalities in health in Scotland: what are they and what can we do about them? MRC Social & Public Health Sciences Unit. Occasional Paper No. 17, 2007.
Wilkinson R., Pickett K. The Spirit Level - Why More Equal Societies Almost Always Do Better. Allen Lane, 2009
Black D., Morris J., Smith C., Townsend P. Inequalities in health: report of a Research Working Group. London: Department of Health and Social Security, 1980
Acheson D., 1998. Independent Inquiry into Inequalities in Health Report. The Stationery Office, London.
McLoone P. Targeting deprived areas within small areas in Scotland: population study. BMJ 2001, 323, 347-375.
Equally Well, Scottish Government 2008 Leyland et al., Inequalities in Mortality in Scotland 1992-2002;
MRC SPHSU Occasional Paper #18 McCartney G. Illustrating Glasgow’s health inequalities. JECH
2010 ScotPHO Profiles 2010
