Successful Ageing Influence of socio-economic factors, gender and health service provision

Shah Ebrahim

London School of Hygiene & Tropical Medicine

CADENZA Symposium 2008

Outline

• Socio-economic development and life expectancy

• Social class, survival and disability

• Gender, survival and disability

• Life-course influences on disability

• Health services

Successful ageing requires survival

Socio-economic position

Gender

Survival Health services

Socio-economic development and ageing

• Life expectancy: comparisons between countries by income levels

Life expectancy and GDP

Lynch et al. BMJ 2000;320:1200

Preston’s curves: explanations for better health

Preston, S. H Int. J. Epidemiol. 2007 36:484-490; doi:10.1093/ije/dym075

1900’s

Preston’s conclusion

• Improvements in survival are not all explained by economic growth

• Nutrition and education have had only a small role.

• Global diffusion of medical and health technologies: – innovations in hygiene and sanitation – maternal and child services – specific vaccines and drugs for treatment

of bacterial infections

Paradoxes of Costa Rica, Cuba, Sri

Lanka: high life

expectancy but low GDP

Marmot M, Clinical Medicine, 2006

Social class (an English view)

I’m middle class. I look

up to him but I look down

on him

I’m upper class. I

look down on both of

them I know my

place

John Cleese Ronnie Barker Ronnie Corbett

Social class and life expectancy:age 65

63886132 5950

55125037 4891

3000

3500

4000

45005000

5500

6000

6500

7000

I II IIInm IIIm IV V

Social class

Day

s of

life

exp

ecta

ncy

1972-6 1997-9

Locomotor disability and social class: British Regional Heart Study men

0

1

2

3

4

5

I II IIInm IIIm IV V

Odd

s ra

tio

12.3% 19.2% 21.5% 28.5% 33.7% 40.1%

Source: Ebrahim et al, Int J Epidemiology (2000)

Social class and disability: possible explanations

Social class Disability

Chronic diseases: Arthritis, CVD

Risk factors: inactivity, smoking, BMI etc

Locomotor disability and social class: British Regional Heart Study men

0

1

2

3

4

5

I II IIInm IIIm IV V

Odd

s ra

tio

Excluding men with CVD, arthritis and respiratory disease

Adjusted for smoking, BMI, activity and alcohol

12.3% 19.2% 21.5% 28.5% 33.7% 40.1%

Source: Ebrahim et al, Int J Epidemiology (2000)

Material and psycho-social models of causation

Poverty

MATERIAL CONDITIONS

Inadequate diet

Smoking

Poor housing

Reduced survival

PSYCHO-SOCIAL CONDITIONS

Lack of control

Increased stress

Low social capital

Lack of health & social services

A metaphor: air travel: differences in a neo-material and psychosocial

theory

First class Cattle class

Lynch & Davey Smith BMJ 2000;320;1200-1204

Material vs. psychosocial explanations

Compare air travellers in first and economy class. Travellers in economy have worse health because they sat in a cramped space and couldn't sleep not because they could see the bigger seats in first class

Lynch & Davey Smith. BMJ 2000;320:1200

Implications for intervention

• psychosocial interpretation: health inequalities would be reduced by abolishing first class, or mass psychotherapy to alter perceptions of relative disadvantage. • neo material viewpoint: health inequalities can be reduced by upgrading conditions in economy class

Lynch & Davey Smith BMJ 2000;320;1200-1204

Social inequalities and survival

• Growing wider

• Not fully explained by smoking, diet, exercise

• Potentially avoidable

Gender, survival and disability

Life expectancy at age 65

Office of National Statistics, UK

Percentage of life expectancy spent able to get outdoors, 1991

40

45

50

55

60

65

70

75

80

85

90

Per

cent

age

75-79 85+ 75-79 85+

8.6 4.8 11.2 6.1

Source: Bone et al Health Expectancy, 1995

Men Women

Distribution of walking time

8

8.5

9

9.5

10

10.5

11

11.5

12

1 (64, 66) 2 (66,69) 3 (69,72) 4 (72,75) 5 (75,82)

Age quintiles (range)

2% increase per single year increase in age, p<0.001)

Time to walk 6m.

Adult social class, 2002/3

7

7.5

8

8.5

9

9.5

10

10.5

11

I&II III IV&V

Time to walk 6m.

Adult occupational social class, 2002/3

4.9% increase in walking time per category increase in social class, p=0.02

Household income, 1937/9 and walking speed in 2002/3

7

7.5

8

8.5

9

9.5

10

10.5

>HK$120 HK$90-120 HK$60-89 <HK$60

Time to walk 6m.

Weekly household income, 1937/9

3.2% reduction in walking time per category increase in income, p=0.04

high

low

You need to walk at 0.8 m/s to cross a Hong Kong road

The youngest participants (aged 64-66) only walked at 0.7 m/s!

Guardian 9 September 2004

Inner-Age? Pharmanex? Isolagen?

Health services for older people

• Complex interventions - combinations of interdisciplinary teamwork for health and social problems

• Do they work?

MRC trial of multidimensional assessment and management

• 40,000 older people randomized to different care: death and institutional care

• Comparisons of geriatric service vs. primary care service

• Comparison of targeted service vs. universal service

• After 10 years work – geriatric service slightly worse than primary care and universal no better than targeted service

Components of complex interventions

• Assessment• Primary prevention

Physical activity Environment, home safetySelf care, immunisationSocial network

• Secondary preventionTreatment of chronic conditions

• Tertiary preventionMedication review, rehabilitation

Meta-analysis of 45 trials

0.87 (95% CI 0.79, 0.94)

Relative risk of not living in own home

Favours intervention

Favours control

Beswick A et al, Lancet 2007

Health care and social support

• Effective services– evidence base patchy in LMICs

• Affordability– privatisation of long-term care

• Accessibility– waiting lists, local treatment

• Appropriateness– growing private anti-ageing sector

Dixon, T. et al. BMJ 2004;328:1288

Number of admissions to hospitals in the three years before death, England,

1999-2000.

Projections of long-term care costs£

bil

lio

ns

£11.1

£14.7

£19.9

£28.0

2.6 3.54.9

74.5

5.5

7.2

10.1

4

5.7

7.8

10.9

0

5

10

15

20

25

30

1995 2010 2021 2031

PrivateexpenditureSocial services

NHS care

1.6% 1.5% 1.6% 1.8%GDP

With Respect to Old Age, Cm 4129, 1999

Summary

• Socio-economic factors play a major role in determining survival and disability

• Women do better than men in terms of survival but not in terms of disability

• Health services do improve survival and reduce institutionalisation

• But too much health service use is a problem for many