Inequalities, deprivation and health

Dr Mary Shaw

Scientific Director, SWPHIS

Reader in Medical Sociology, Department of Social Medicine, University of Bristol

With contributions from Bruna Galobardes, Helen Cooke, Mildred Blaxter

                                                  

Session Objectives1. What do we mean by health inequalities and

why are they important?

2. Present a range of indicators of socioeconomic position (SEP) at individual and area level

3. Show evidence past and present of health inequalities in the UK, using the indicators presented

What do we mean by ‘health inequalities’?

Generally: differences between groups of people in terms of their health outcomes

Specifically: health and illness are related to social and economic position

“The government’s strategy on health inequalities aims to narrow the gap in health outcomes across geographical areas, socio-economic groups, age groups and different black and minority ethnic groups, as well as between men and women and between the majority of the population and vulnerable groups with special needs”

(HM Treasury and Department of Health, 2002)

“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

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

PART 1: Individual level: socio-economic position

Education, occupation, social class, employment status, income, amenities, housing.

PART 2: Ecological/Area level: deprivation

Townsend, Carstairs, Jarman, Breadline Britain, Index of Multiple Deprivation

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.

[suggestion: useful to use instead of jumping between terms, and better than using one term when you have actually measured another]

EDUCATION: knowledge-related assets of an individual

Continuous variable: years of completed education

Categorical variable: educational achievements, such as completion of secondary education, attainment of qualification

Standardised death rates 1989-90 in the United States per 100,000 persons aged 25-64 of all races by years of education

Years of education Male Female 16 or more 318.9 194.4 13-15 501.5 280.7 12 602.1 292.5 9-11 739.8 318.3 0-8* 615.3 312.9

* contains very few US born people, may reflect a healthy migrant effect.

Source: Blane et al 1996, Health and Social Organisation.

Variations in rates of self-reported ill health among those aged 16 years or more by level of education, The Netherlands, 1981-85

Highest level of formal education completed

Chronic conditions

Self-rated health less than

‘good’ Primary school 1.12 1.41 Lower secondary school 1.00 0.98 Secondary education 0.95 0.81 Vocational college 0.85 0.62 University 0.71 0.64

Source: Blane et al 1996, Health and Social Organisation.

EDUCATION:

Captures early life SEP; Material resources of family of origin

Knowledge, cultural literacy, receptive to health education

Determinant of employment and indicator of material resources

Beware cohort change; meaning changes over time.

OCCUPATION: reflects an individuals social standing in society, status, privilege, intellect, parental background, income/living standards, educational background, working relations & conditions…

Current occupation

Longest held occupation

Occupation of head of household

Commonly excluded groups include: retired, people whose work is inside the home (mainly affecting women), the unemployed, students, and people working in unpaid, informal or illegal jobs.

Occupation-based indicators

• Marxist-based social class classifications (ownership of the means of production)

• Registrar General’s Social Classes (prestige/status)

• The new UK NS-SEC (employment relations)

• Working life characteristics, unemployment

Some historical evidence comparing occupations…

Table 1: Age at death among different social orders, by district

District Gentry andprofessional

Farmers andtradesman

Labourers andartisans

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

Edwin Chadwick

Number of deaths and proportional mortality ratios (PMR) for CJD and dementia among men aged 20-74 in selected occupational groups, England and Wales, 1979-96

1979-83 1984-87 1988-91 1992-96 CJD No PMR No PMR No PMR No PMR Farmers and farm workers 2 239 1 91 0 - 4 254 Butchers and abattoir workers 0 - 0 - 0 - 0 - Veterinarians

0 - 0 - 0 - 0 -

Dementia Farmers and farm workers 41 106 88 98 63 82 55 82 Butchers and abattoir workers 6 62 23 98 19 101 18 119 Veterinarians 0 - 0 - 3 359 1 132

Source: Aylin et al, 1999 BMJ, 318:10044-5.

SOCIAL CLASS: Strictly, refers to schema based on relations between class groups, e.g. bourgeoisie who own the means of production, and exploited proletatiat who sell their labour (Marx).

OCCUPATIONAL SOCIAL CLASS:

Mostly, occupations are grouped into occupational social classes, or socio-economic groups

Social Class based on Occupation (previous to 1990 known as The Registrar General’s Social Classes)

First devised 1911, social grades based on prestige or social standing; initial purpose – analysis of mortality and fertility data.

Used in official statistics and vital statistics, over long time period.

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

I II IIINM IIIM IV V

Coronary Heart Disease

81 92136

159 156

235

050

100150200250

I II IIINM IIIM IV V

Stroke

14 1319

24 25

45

0

10

20

30

40

50

I II IIINM IIIM IV V

Source: Independent Inquiry into Inequalities in Health, 1998

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

64.0

66.0

68.0

70.0

72.0

74.0

76.0

78.0

80.0

1972-76 1977-81 1982-86 1987-91 1992-96 1997-99

I

II

IIIN

IIIM

IV

V

Source: National Statistics, 2002

Average years of life expectancy by occupational social class, England and Wales, 1972-1999, Males

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

1. Higher managerial and professional employers 2. Lower managerial and professional 3. Intermediate employees 4. Small employers and own account workers 5. Lower supervisory, craft and related employees 6. Employees in semi-routine occupations 7. Employees in routine occupations

Never worked and long-term unemployed

UK National Statistics Socio-Economic Classification (NS-SEC)

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

Good health Fairly good health

Not good health

All 64.3 26.1 9.6

Higher managerial and professional occupations: Large employers and higher managerial occupations

79.1 17.1 3.8

Higher managerial and professional occupations: Higher professional occupations

81.0 15.6 3.4

Lower managerial and professional occupations 75.6 19.7 4.7

Intermediate occupations 73.3 21.8 4.9

Small employers and own account workers 69.6 24.1 6.3

Lower supervisory and technical occupations 66.1 26.4 7.5

Semi-routine occupations 66.1 27.0 6.9

Routine occupations 61.1 30.1 8.8

Never worked 49.3 31.8 18.9

Lon-term unemployed

55.5 35.0 9.5

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

note that records before 2000 have been “backcoded” into NS SEC 90 for compatibility

EMPLOYMENT STATUS: Economic activity / whether someone is employed/unemployed.

Strong link to income

Work-related benefits

Social isolation and loss of self-esteem; status, purpose and structure to day; respect of others; physical and mental activity; use of skills

Previous spells of unemployment

Excellent/good

Fair/poor

0 94 6 1 92 8 2+ 84 16 n 4,090 336

Work insecurity and self-reported general health at age 23 (NCDS)

Source: Blane et al 1996, Health and Social Organisation.

Occupation-based indicators (cont.)

• 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

INCOME: the most direct measure of material resources (different from accumulated WEALTH)

Can fluctuate dramatically

Individual, household, equivalised

Respondents reticent to divulge

NOT measured in the census!

Income

• Most direct measure of material circumstances• Doesn’t take into account assets (wealth)• In some countries there may be reluctance to

answer questions on income• Adjust for number of dependent people in household• SEP indicator that can change most on a short-time

basis: does the indicator capture this characteristic?

…some more

historical evidence

Source: Merlo et al, 2003 International Journal of Equity in Health

AMENITIES: often used as an indicator of income and wealth / living standards

Car access / ownership

Sole use of bathroom/toilet

Telephone, fridge etc

HOUSING: mainly but not only material

Housing tenure – own or rent

Housing conditions – damp, cold etc

Overcrowding

‘Ontological security’

Homelessness

SMRs, by social class, access to cars and housing tenure at the 1971 Census, women and men, all causes, England and

Wales, 1971-92 Age at death 45-64 Women Men Non manual social class Car Owner occupied 70* 72* Privately rented 82* 83* Local authority 93 96* No car Owner occupied 91 99 Privately rented 105 129* Local authority 125* 120* Manual social class Car Owner occupied 85* 82* Privately rented 100 93 Local authority 101 104 No car Owner occupied 99 101 Privately rented 128* 132* Local authority 131* 126* * statistically significant at the 95% level. England and Wales = 100. Source:

adapted from Smith and Harding (1997)

Socio-economic position

There is no single best indicator of SEP

What is your research question / aim?

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.

Think longitudinal: life course

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 are used in the absence of individual level data, in their own right, and can also tell us about areas per se (as well as the individuals within those areas).

They are also used for making decisions about the allocation of resources to those areas.

Linking individuals and areas…

E.g. Unemployment

Employment status is an individual indicators

Unemployment rates are area-level indicators

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).

Aggregated indicators based on census measures

Townsend Deprivation Index

Measures multiple deprivation for areas using 4 variables from the 1991 census:

% unemployment of those 16-64

% households with no car

% households not owner occupied

% overcrowding (> 1 person per room).

The Townsend Score is a summation of the standardised scores (z scores) for each variable (scores greater than zero indicate greater levels of material deprivation). This score was considered the best indicator of material deprivation available from the 2001 census.

It has been widely used in the health field.

0

50

100

150

200

250

300

-10.0 -7.5 -5.0 -2.5 0.0 2.5 5.0 7.5 10.0 12.5 15.0

Townsend's Index of Deprivation

Sta

nd

ard

ise

d I

lln

es

s R

ati

o (

<7

5)

Rural Wards

Deprived City Wards

Deprived Industrial Wards

Other Wards

Ward level variations of Townsend’s Index of Deprivation against the Standardised Illness Ratio (N = 8,481)

Source: Asthana et al 2002 see www.swpho.org.uk

Carstairs deprivation index

A measure of material deprivation for Scotland – based on census data. Very similar to the Townsend score but replaces the non-owner occupation variable with one concerning social class.

Jarman or UPA – underprivileged area score

Measures ‘social deprivation’, and was originally designed as a measure of GP workload (used for GP payments). Has subsequently been used as a more general measure of deprivation.

Ranks places. Based on census data…

1. Unemployment - unemployed residents aged 16+ as a proportion of all economically active residents aged 16+.

2. Overcrowding - persons in households with 1 and more persons per room as a proportion of all residents in households.

3. Lone pensioners - lone pensioner households as a proportion of all residents in households.

4. Single parents - lone 'parents' as a proportion of all residents in households.

5. Born in New Commonwealth - residents born in the New Commonwealth as a proportion of all residents.

6. Children aged under 5 - children aged 0-4 years of age as a proportion of all residents .

7. Low social class - persons in households with economically active head of household in socio-economic group 11 (unskilled manual workers) as a proportion of all persons in households.

8. One year migrants - residents with a different address one year before the Census as a proportion of all residents.

Area based deprivation indices used in UK

Variable Jarman Carstairs Townsend

Unemployed Yes Yes Yes

No car No Yes Yes

Overcrowding Yes Yes Yes

Social Classes IV and V No Yes No

Housing tenure No No Yes

Unskilled Yes No No

Lone pensioner Yes No No

Children under 5 years old Yes No No

Lone parent Yes No No

Geographical mobility Yes No No

Ethnic minority group Yes No No

from Eames et al, BMJ 1993

Breadline Britain (Poverty & Social Exclusion Survey)

A measure of ‘consensual’ or ‘perceived’ poverty - what people themselves understand and experience as the minimum acceptable standard of living in contemporary Britain. This minimum covers not only the basic essentials for survival, such as food and shelter, but also factors which enable people to participate in their social roles in society. The survey thus measured what possessions and activities the public perceived as necessities of life.

The perception of necessities and per cent of population

having each item: the 1990 Breadline Britain survey Standard-of-living items in rank order % claiming item as

necessity (1,831) % of population having

item A damp-free home 98 94 Heating to warm living areas of the home if it’s cold

97 96

An inside toilet (not shared with another household)

97 98

Bath, not shared with another household 95 97 Beds for everyone in the household 95 97 A decent state of decoration in the home 92 81 Fridge 92 98 Warm waterproof coat 91 91 Three meals a day for children 90 74 Two meals a day (for adults) 90 94 Insurance of contents of dwelling 88 83 Daily fresh fruit and vegetables 88 88 Toys for children e.g. dolls or models 84 75 Bedrooms for every child over 10 of different sexes

82 65

Carpets in living rooms and bedrooms 78 96 Meat/fish (or vegetarian equivalent) every other day

77 90

Two pairs all-weather shoes 74 90 more………….

74 91

Source: Gordon and Pantazis (1997)

The relationship between poverty and health at the ecological level

• All the previous measures of deprivation were wholly or partly based on the Census

• What are the problems associated with this approach?

• “Progress” was to base deprivation measures on administrative data, which could be more easily updated

• What are the problems associated with this approach?

Indices of Deprivation

Third release (2007) from Department of Communities and Local Government

A summary measure at Super Output Area (SOA) level calculated from

7 domains in total

two supplementary Indices

Income Deprivation Affecting Children

Income Deprivation Affecting Older Peoplewww.communities.gov.uk/communities/neighbourhoodrenewal/

deprivation/deprivation07

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

• Geodemographic (GD) classification systems can be used to segment populations and thereby identify target groups

• Use a combination of Census and commercial data to identify groups with similar lifestyles, eg where they shop, what papers they read

• Examples include ACORN, Mosaic, P2 People & Places, National Statistics 2001 Area Classification

• People and Places is available through Observatories

• Report of using geographic tools for social marketing http://www.erpho.org.uk/Download/Public/16892/1/Synthesis_6_Socialmarketing.pdf

People & Places geodemographic classification sorted by the IMD 2004, showing the proportion of areas in each IMD quintile

Prevalence of hospital admission for mental health conditions North West residents 1998-

2002

Which measure to use?

•Consider the theoretical basis

• Spatial level and ecological fallacy

• How recent/frequent?

• Components – single or multiple components?

• Universal coverage?

• Applicable to subgroups?

• Impact of cut-off points?

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.

Session Objectives Revisited1. What do we mean by health inequalities and

why are they important?

2. Present a range of indicators of socioeconomic position (SEP) at individual and area level

3. Show evidence past and present of health inequalities in the UK, using the indicators presented