world research and innovation congress - brussels – 5 th june 2013

Development of European deprivation indices for public health policy

to tackle social inequalities in health

Carole Pornet

World Research and Innovation Congress - Brussels – 5th June 2013

Socioeconomic status is established as a main determinant for

health and tackling social inequities is a priority for numerous

international and national agencies for health.

How tackling social inequalities in health?

Socioeconomic status is established as a main determinant for

health and tackling social inequities is a priority for numerous

international and national agencies for health.

To be efficient, such policy needs to be based on a well-documented

knowledge of kind and magnitude of social inequalities

and on underlying mechanisms.

How tackling social inequalities in health?

Studying and tackling social disparities in health implies the ability:

to measure them accurately

to compare them between different areas or countries to follow trends over time (HCSP, 2009).

What is the initial value of ecological indices?

Information required to assess the socioeconomic status is in

routine not available at individual level.

To overcome this lack, socioeconomic characteristic

measureaments at residence area are regularly used

to approximate individual socioeconomic status: ecological

indices. Addresses or zip codes are required to connect clinical data

to ecological indices (geocoding).

What is the initial value of ecological indices?

Information required to assess the socioeconomic status is in

routine not available at individual level.

Unlike indicators at individual level: availability

for all individuals

To overcome this lack, socioeconomic characteristic

measureaments at residence area are regularly used to

approximate individual socioeconomic status: ecological indices. Addresses or zip codes are required to connect clinical data to

ecological indices (geocoding).

What is the added value of composite ecological indices?

Compared to basic indicators at geographical level, composite

ecological indices represent: a more comprehensive approach to deprivation, a more homogeneous distribution in a whole territory (Gentil C.,

GRELL 2011).

Measure of deprivation of living residence area « proxy » of individual deprivation background taken into account (positive and negative

externalities)

A wide variety of ecological deprivation indices in Europe…

Measurement of social inequalities greatly varies in Europe from one

country to another, even from one area to another within a country for

3 main reasons:

1. Determinants of social inequalities depend on the context.

2. The great majority of ecological indices are

opportunistic, i.e. created for a given area or country,

and for a given health topic.

3. Most of the ecological indices are deprivation indices

developed from census data, used as a ‘proxy’ of

individual deprivation measure but without referring to

individual deprivation experience.

The concept of relative deprivation

The poor are “the persons whose resources (material, cultural and

social) are so limited as to exclude them from the minimum acceptable

way of life in the Member State to which they belong” (Council of the

European Union, 1985).

outcome elements: “the exclusion from the minimum

acceptable way of life”, which covers material, cultural and

social aspects

input elements: “...due to a lack of resources”.


“Poverty can be defined objectively and applied consistently only in terms of the concept of relative deprivation. […] Individuals, families and groups in the population can be said to be in poverty when they lack the resources to obtain the type of diet, participate in the activities and have the living conditions and amenities which are customary, or at least widely encouraged or approved, in the societies to which they belong. Their resources are so seriously below those commanded by the average individual or family that they are, in effect, excluded from ordinary living patterns, customs or activities.” (Townsend, 1979)

Relative deprivation

depends on context

is defined by a threshold: below the average of the society.


The Townsend approach is built on the importance of participation in the society to which the person belongs, i.e. relative deprivation occurs when people “cannot obtain, at all or sufficiently, the conditions of life – that is, the diets, amenities, standards and services – which allow them to play the roles, participate in the relationships and follow the customary behaviour which is expected of them by virtue of their membership of society” (Townsend, 1987, 1993).

In Peter Townsend’s theory of relative deprivation: poverty can be defined as a lack of sufficient resources and “deprivation” is an outcome of poverty.

Deprivation: outcome of poverty

The concept of deprivation covers the various conditions, independent of income, experienced by people who are poor (Townsend, 1987).

Poverty: Income poverty = household whose total equivalised income is

< 60% median national equivalised household income*

Subjective poverty = « Ability to make ends meet »1. With great difficulty 2. With difficulty3. With some difficulty4. Fairly easily5. Easily6. Very easily

*as defined by EUROSTATThe equivalent scale is the so-called “OECD-modified equivalence scale” which assigns a value of:- 1 to the household head,- 0.5 to each additional

adult member - 0.3 to each child.


Poverty: Income poverty = household whose total equivalised income

is < 60% median national equivalised household income In France, in 2006: “Poor” households = 14.2%

Subjective poverty = « Ability to make ends meet »1. With great difficulty 2. With difficulty3. With some difficulty4. Fairly easily5. Easily6. Very easily

= 16%


Poverty: Income poverty = household whose total equivalised income

is < 60% median national equivalised household income In Portugal, in 2006: “Poor” households:

20.7%

Subjective poverty = « Ability to make ends meet »1. With great difficulty = 15.7%2. With difficulty3. With some difficulty4. Fairly easily5. Easily6. Very easily

Current difficulties in analyses of social inequalities in health

No gold standard of deprivation Multiplicity of deprivation indices

Current difficulties in analyses of social inequalities in health

No gold standard of deprivation Multiplicity of deprivation indices

Comparison of kind and magnitude of social inequalities

in health and a-fortiori comparison of underlying mechanisms

between different areas or countries in Europe are thus

prevented.

How overcoming the lack of comparability and appropriateness?

The first step of a consistent European public health policy aimed for

tackling social inequalities consists in creating a ‘homogenous’

reliable, relevant and accurate tool for measuring social deprivation.

How overcoming the lack of comparability and appropriateness?

The first step of a consistent European public health policy aimed for

tackling social inequalities consists in creating a ‘homogenous’

reliable, relevant and accurate tool for measuring social deprivation.

Using deprivation indices based on:- a shared mode of construction- a shared concept of relative deprivation- the same database (same questionnaire)

could overcome the lack of comparability and appropriateness

Objectives and principles of construction

Built from data available in census Best reflects the different dimensions of social deprivation,

including the perceived poverty Replicable in (European) space and over the time

Replicable in (European) space Indices would not be composed of the same elements in different

European countries BUT will be built according the same principles in all countries

Replicable over the time Indices will be continually updated according evolutions of

modalities and national census data, BUT always according the same principles


Census Population


First step: Construction of an individual deprivation indicator

Individual deprivation indicator used as gold standard

Census Population

From a European survey specifically designed to study deprivation: the EU-SILC* survey


EU-SILC*

Europeanindividualsurveyof deprivation


*European Union-Statistics on Income Living Conditions

First step: Construction of an individual deprivation indicator

EU-27:AustriaBelgium

CyprusCzech RepublicDenmarkEstoniaFinlandFranceGermanyGreeceHungaryIrelandItalyLatviaLithuaniaLuxembourg

NetherlandsPolandPortugal

SlovakiaSloveniaSpainSwedenUnited Kingdom

Romania

Malta

Bulgaria

EU-SILC

+ Iceland

+ Norway

The EU-SILC 2006

22

26 COUNTRIES

Developed by Eurostat (the Statistical Office of the European Union)

Standardised questionnaire involving annual interviewing of a representative panel of households and individuals:

• 60 500 households • ≈130 000 individuals aged ≥16 yrs

Designed to study deprivation and covers a wide range of domains:

• income (including various social benefits), • health, • education, • housing, • perceived poverty,• demographics, • employment characteristics.

EU-SILCThe EU-SILC survey

23


EU-SILC*


First step: Construction of an individual indicator




EU-SILC*


First step: Construction of an individual indicator



Individual deprivation indicator is composed of “enforced lacks”, i.e. lacks due to insufficient resources and thus problems of affordability, rather than lacks resulting from choices or lifestyle preferences (Mack and Lansley, 1985).

Fundamental needs: goods/services for which < 50% of households did not possess/realize because they could not afford (but would like to have, i.e. a lack is an “enforced lack” and does not simply reflect a choice, but a renonciation) and their lack reflects deprivation.

1.1 Selection of fundamental needs

EU-SILC

European IndividualSurvey of Deprivation

1st step: construction of an individual deprivation indicator

1st step: construction of an individual deprivation indicatorEU-SILC

Individual deprivation

indicator

1.1 Selection of fundamental needs

Fundamental needs: goods/services for which < 50% of households did not possess/realize because they could not afford (but would like to have, i.e. a lack is an “enforced lack” and does not simply reflect a choice, but a renonciation) and their lack reflects deprivation.

In France, in 2006

Financial incapacity to possess/realize

Fundamental need

Swimming-pool 95% No

Meat or fish 7% Yes

28

EU-SILC

Census


indicator

EDI

Current steps: « …. in space»Construction of 5 European deprivation indices

May 2012 : Steps 1 and 2 of construction of 5 EDI:- France- Italy- Portugal- Spain- UK

29

EU-SILC


indicator

Fundamental needs for people France Italy Portugal Spain UK

Meat or fish or vegetarian equivalent x x x x x

One week annual holidays x x x x

Unexpected financial expenses* x x x x x

Keep home adequately warm x x x x x

Phone (including mobile phone) x x x x x

TV x x x x x

Computer x x x

Washing machine x x x x x

Car x x x x x

1.1 Identification of people’s fundamental needs


*of amount = poverty threshold per one consumption unit independently of the size and structure of the household for a country, e.g.: in France €800

30

EU-SILC


indicator

In France (N=10,036)* Income poverty OR (95% CI)

Subjective poverty OR (95% CI)

Use your own means to cover a necessary yet unplanned expense of €800 1.4 (1.27-1.53) 2.6 (2.35-2.87)

One week annual holiday away from home 1.67 (1.51-1.83) 2.1 (1.91-2.3)

Have a computer 1.0 (0.89-1.12) 1.54 (1.38-1.72)

Eat a meal containing some meat or some fish or the vegetarian equivalent once every two days

1.21 (1.08-1.37) 1.78 (1.58-2.01)

Keep home adequately warm 1.19 (1.06-1.34) 1.28 (1.12-1.47)

Have a car 1.47 (1.28-1.68) 1.11 (0.94-1.31)

Have a washing machine 1.77 (1.39-2.26) 1.09 (0.84-1.4)

Have a phone (including mobile) 1.02 (0.77-1.35) 1.42 (1.04-1.94)

Have a colour TV 0.94 (0.59-1.5) 1.01 (0.68-1.5)

*Data weighted on non-response and adjusted on sample design of the French EU-SILC survey 2006 . In bold, selected fundamental needs because they were associated with income poverty and with subjective poverty . in italic: p>0.05.

1.2 Selection of fundamental needs associated with both income poverty and subjective poverty by multivariate logistic regression



31

EU-SILC


indicator

Fundamental needs France Italie Portugal Espagne UK

Meat or fish or vegetarian equivalent x x x

One week annual Holidays x x x x

Unexpected financial expenses x x x x x

Keep home adequately warm x x x

Phone (including mobile phone) x

TV

Computer x x

Washing machine

Car x x x

1.2 Selection of fundamental needs associated with both income poverty and subjective poverty

32

EU-SILC


indicator In France, for income poverty and subjective poverty, best fit =

model 2

In France: households are defined as deprived if they cannot afford at least 2 fundamental needs among the 4 retained, as

not deprived in all other cases.

0 1 2 3 40

200

400

600

800

1000

1200

1400

1600

Univariate logistic regression model chi² values, EU-SILC 2006 in France N=9,930

Objective poverty

Subjective poverty

Minimal number of fundamental needs lacking through financial incapacity

Logi

stic r

egre

ssio

n m

odel

chi²

valu

es

1.3 Definition of an individual deprivation indicator

Legend of axis models:1: 'poor‘= lack of at least 1 item among the 4 vs no item lacking 2: ‘poor'= lack of at least 2 items among the 4 vs lack at max 1 item 3: 'poor'= lack of at least 3 items among the 4 vs lack at max 2 items 4: 'poor'= lack all the 4 items


33

EU-SILC


indicatorFundamental needs for people France Portugal Spain UK


One week annual holidays x x x xUnexpected financial expenses x x x x xKeep home adequately warm x x x

Phone (including mobile phone) xComputer x xWashing machine

Car x x xTV

Minimal number of lacking fundamental needs

2 2 2 2 2



34

EU-SILC


indicatorFundamental needs for people France Portugal Spain UK


One week annual holidays x x x xUnexpected financial expenses x x x x xKeep home adequately warm x x x

Phone (including mobile phone) xComputer x xWashing machine

Car x x xTV

Minimal number of fundamental needs lacking

2 2 2 2 2

% of deprived households in 2006 25.1 23.2 22.6 26.9 19.8Unemployment rate in 2006 (OECD) 9.4% 6.8% 7.7% 8.1% 5.3%



pays 1

2 enforced lacks among:- Holidays- Unplanned expense- Meat, fish or vegetarian equivalent- Keeping house sufficiently warm


EU-SILC*



1st step: Construction of an individual indicator

pays 1

2 enforced lacks among:- Holidays- Unplanned expense- Car- Keeping house sufficiently warm


EU-SILC*




pays 1

2 enforced lacks among:- Holidays- Unplanned expense- Computer


EU-SILC*




pays 1

2 enforced lacks among:- Meat or fish or vegetarian equivalent- Unplanned expense- Car- Keeping house sufficiently warm- Phone (including mobile phone)


EU-SILC*





pays 1

2 enforced lacks among:- Holidays- Unplanned expense- Car- Keeping house sufficiently warm- Computer


EU-SILC*



Census Population


EU-SILC



2nd step: Research of common data in EU-SILC / Census

EU-SILC


Population census

Identical variables in both datasets




EU-SILC

EuropeanIndividualSurvey of Deprivation

Census Population

country 1

Identical variablesin both datasets




EU-SILC

EuropeanIndividualSurvey of Deprivation

Census Population

country 2Individual deprivation indicator used as gold standard

Identical variablesin both datasets




EU-SILC


Census Population

country 3




EU-SILC



Census Population


3rd step: Construction of the index used at aggregated level


EU-SILC

IRIS


indicator

EDI Census 1999

3rd step: Construction of the « French EDI »

3.1. Selection of those variables associated with the individual deprivation indicator by multivariate binary logistic regression*

In France ß 95% CI P-value

Overcrowding 0.11 0.02-0.20 0.0171

No access to a system of central or electric heating 0.34 0.25-0.43 <.0001

Non-owner 0.55 0.50-0.60 <.0001

Foreign nationality 0.23 0.13-0.32 <.0001

No access to a car 0.52 0.46-0.58 <.0001Single-parent household 0.41 0.33-0.48 <.0001Household with ≥6 persons 0.45 0.34-0.56 <.0001Low level of education 0.19 0.13-0.25 <.0001 Unemployment 0.47 0.38-0.55 <.0001 Unskilled worker-farm worker 0.37 0.27-0.46 <.0001

N =19 253 *Data weighted on non-response and adjusted on sample design of the French EU-SILC survey 2006.

EU-SILC

IRIS


indicator

EDI

Census 1999

3rd step: Construction of the « French EDI »

3.2. Weighting of selected variables which compose the aggregate deprivation index*

In France ß 95% CI P-value

Overcrowding 0.11 0.02-0.20 0.0171

No access to a system of central or electric heating 0.34 0.25-0.43 <.0001

Non-owner 0.55 0.50-0.60 <.0001

Foreign nationality 0.23 0.13-0.32 <.0001

No access to a car 0.52 0.46-0.58 <.0001Single-parent household 0.41 0.33-0.48 <.0001Household with ≥6 persons 0.45 0.34-0.56 <.0001Low level of education 0.19 0.13-0.25 <.0001 Unemployment 0.47 0.38-0.55 <.0001 Unskilled worker-farm worker 0.37 0.27-0.46 <.0001

N =19 253 *Data weighted on non-response and adjusted on sample design of the French EU-SILC survey 2006.

EU-SILC

European Union-Statistics on Income Living Conditions


CensusPopulation

Geographical deprivation index: the European

Deprivation IndexEDI


3rd step: Construction of the index used at aggregated level


12

3

49

EU-SILC

IRIS


indicator

EDI

0.1107 x % overcrowdingi + 0.3401 x % no access to a system of central or electric heatingi + 0.2285 x % foreign nationalityi + 0.5185 x % no access to a cari + 0.3682 x % unskilled worker-farm workeri + 0.4056 x % single-parent householdi + 0.4513 x % household with ≥6 personsi + 0.1906 x % low level of educationi + 0.4662 x % unemploymenti + 0.5508 x % non-owneri.

Census 1999

50

EU-SILC

Census


indicator

EDI

Mini Maxi Mean SD Quintile 1

Quintile 2

Quintile 3

Quintile 4

Quintile 5

-5.33 20.52 0 1.847

-5.332; -1.323

-1.323; -0.649

-0.649;-0.007

-0.007;0.948

0.948;20.520

Distribution of the EDI score in France (N = 49,989 IRIS) :

Census 1999

Geographical department of Calvados (n=829 IRISes)

51

EU-SILC

Census


indicator

EDI

Construction of the « French EDI »

Producer: Insee; diffusor: CMH

50 Km

Census 1999

Score of the EDI in France for each IRISi :Scorei = 0.13 x % overcrowdingi +

0.33 x % no exclusive use of bath or showeri + 0.16 x % foreign nationalityi + 0.29 x % no cari + 0.57 x % no business leaders-company managers/intermediate

occupationsi + 0.57 x % single-parent householdi + 0.46 x % households with ≥6 personsi + 0.14 x % low level of educationi + 0.56 x % unemployedi + 0.54 x % non-owneri.

Distribution of the score in France (N = 49,989 IRIS): Mini Maxi Mean SD Quintile 1

Quintile 2

Quintile 3

Quintile 4

Quintile 5

-8.72 25.40 0 2.07 -8.719; -1.465

-1.465; -0.717

-0.717;-0.006

-0.005;1.035

1.035;25.400

EU-SILC

Census


indicator

EDI Census 2007


Geographical department of Calvados (n=830 IRISes)

53

EU-SILC

Census


indicator

EDI


Producer: Insee; diffusor: CMH50 Km

Producer: Insee; diffusor: CMH

54

EU-SILC

LSOA


indicator

EDI

EDI score in UK for each LSOAi of census 2001*: 0.53 x % overcrowdingi + 0.43 x % no detached housei + 0.73 x % social rentedi + 0.42 x % no cari + 0.68 x % single-parent householdi + 0.23 x % no marriedi + 0.49 x % permanently disabled or/and unfit to worki + 0.16 x % no high education leveli + 0.19 x % elementary occupationsi .

Construction of the « UK EDI »Census 2001

N =15 756 *Data weighted on non-response and adjusted on sample design of the UK EU-SILC survey 2006.

55

EU-SILC

LSOA


indicator

EDI

Mini Maxi Mean SD Quintile 1

Quintile 2

Quintile 3

Quintile 4

Quintile 5

-5.66 11.36 0 2.99 -5.663; -2.665

-2.665; -1.392

-1.392;0.243

0.243;2.605

2.605;11.361

Distribution of the EDI score in UK for census 2001 (N = 34,378 LSOA) :

Census 2001

Construction of the « UK EDI »

56

EU-SILC


indicator

EDI

May 2013 : Steps 2-3 of EDI construction for:- Portugal- Spain- Italy

Current steps: « …. in space»End of construction of 3 other EDI

BelgiumCzech Republic

DenmarkFinlandFrance

GermanyItaly

LuxembourgPortugal

SpainSlovenia

SwitzerlandUK

OK

OK

OK

OK

OK O

KOK O

KOK

OK

OK

OK

OK

Future steps: « …. in space»Improvement and construction of 13 EDI

Multidisciplinary network of experts: - economists,- epidemiologists, - geographers, - physicians, - sociologists,- statisticians.


What is the Expected Impact?- to develop innovative methods to measure and monitor

social inequalities

- to provide a useful tool for policy makers and researchers

in Europe.

59

EU-SILC


indicator

EDI

Application for the open call for COST:

- March 2013: 2nd preliminary proposal

- June 5th: results?

- July 2013: full proposal

- December 2013: Results

Duration: 48 months


60

EU-SILC


indicator

EDI

Other funding sources are required:

Horizon 2020 (for 2014-2020)

Future steps: « …. in space»Construction of 29 EDI

61

EU-SILC

IRIS


indicator

EDI

Current and future steps: « …over the time » Continous updating of indices

Current applications

Cancer registries Pascale Grosclaude (Toulouse) Anne Marie Bouvier (Dijon) Karine Ligier (Lille) Julie Gentil (Dijon) Sandra Leguyader (Bordeaux) Simona Bara (Cherbourg) Olivier Ganry (Amiens)Florence Molinié (Nantes) Anne Valérie Guizard (Caen) Marc Colonna (Grenoble) Michel Robaszkiewicz (Brest) Brigitte Tretarre (Montpellier)

Implementation of a "national methodological platform"

Management structures of screeningChantal de Seze (Laon) Marie Christine Quertier (Saint-Lô) Hélène Delattre-Massy (Amiens) Jérôme Peng (Beauvais) Bernard Denis - Gastroenterologist Hôpital Pasteur- ADECA68 – (Colmar) Gérard Durand – ADECI35 – (Rennes)

Research teams labelled INSERM, CNRS Véronique Christophe (Lille)Claire Bonithon-Kopp (Dijon) Thierry Lang, Cyrille Delpierre (Toulouse)

Nadine Bossard (Lyon) Hospices civils de Lyon Franck Chauvin (HCSP), Sophie Rousseau (Villejuif-Institut Gustave Roussy) Rachel Bavdek - PRES-Lille Nord de France, IRENI (Dunkerque)Delobel Malika - Registre des Handicaps de l'Enfant de la Haute-Garonne RHE 31 INSERM U1027 (Toulouse)Marion Llaty - Institut de chimie des milieux et matériaux de Poitiers (IC2MP) - Unité Mixte de Recherche CNRS N°7285 (Poitiers)Nonna Mayer - Centre d'études européennes de Sciences Po-CNRS (programme de recherche POLINE - Politics of Inequalities) (Paris)Carine Bellera - Institut Bergonié – CRLC de Bordeaux et du Sud Ouest - INSERM CIC-EC 7 et CTD/INCA Bénedicte Jacquemin (CREAL-Centre for Research in Environmental Epidemiology, Barcelona)Nicole Le moual (Inserm CESP/UMRS 1018 , Paris)

EU-SILC

IRIS


indicator

EDI

Current and future steps: « …over the time » Continous updating of indices

Implementation of a “national methodological platform"

Cohorts :CANTO cohort - Patrick Arveux (Dijon) ARDCO cohort - Jean- Claude Pairon (Créteil) AGRICAN cohort – Pierre Lebailly (Caen)E3N cohort – Nicole Le Moual (Paris) CliniciansJean Claude Barbare (Amiens) Isabelle Ray-Coquard (Lyon)OthersHenri Clavaud (ARS PACA)

64

EU-SILC

Census


indicator

EDI

Thanks to

All co-authors: Cyrille Delpierre, Olivier Dejardin, Lydia Guittet,Ludivine Launay (+ programming), Pascale Grosclaude, Thierry Lang and Guy LaunoyFatima Maria de Pina, Marie-Jo Lucas (research of funding)Isabelle Salomez (organisation Workshop Portugal, logistics)Ana Miranda and Claudia Brito (organisation in Lisbon)Maria José Bento and Luis Antunes (organisation in Porto)Helena Cordeiro (INE, Portugues census questionnaire)Carme Borrell, Marc Mari Dell’Olmo (Spanish census questionnaire)Roberto Lillini, Nicola Caranci, Marina Vercelli (Italian census questionnaire)Bernard Rachet (UK census questionnaire)Alexandre Kych, Benoît Tudoux (CMH, French census data)Karien Reinig (EUROSTAT, all EU-SILC files)EPAAC (funding)And all participants at the Workshops 2012-2013

Current and future steps: « …. in space»Construction of 13 European indices

Carte de l’indice

Map of the French EDI in Normandy in 1999

Example of application

Data from the regional federation of cancer registries of Basse-Normandie

Relative survival of patients diagnoosed with cancer between 1997-2004 in Low-Normandy (all cancers – N=40,297) – J. Bryère, O. Dejardin, et al.

Carte des cas de cancer

Map of cancers incidence

Joséphine Bryère

Incidence rate for 100,000 inhabitants

Incidence of cancers and social deprivation.Geographical approach

Manche-Calvados1997-2006 (n = 47,699)


Quintiles of EDI: 1=the least deprived 5=the most deprived


Quintiles of EDI: 1=the least deprived 5=the most deprived

world research and innovation congress - brussels – 5 th june 2013

Documents

tackling social inequalities

social inequities

individual level

measure of deprivation

social disparities

public health policy

given health topic

given area