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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
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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
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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
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“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)
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“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
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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
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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]
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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
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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.
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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.
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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.
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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.
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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
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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
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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.
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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
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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.
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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
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Accidents
Cancers
DigestiveRespiratory
Genitourinary
Circulatory
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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
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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
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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
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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)
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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
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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
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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
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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.
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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
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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!
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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?
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…some more
historical evidence
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Source: Merlo et al, 2003 International Journal of Equity in Health
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AMENITIES: often used as an indicator of income and wealth / living standards
Car access / ownership
Sole use of bathroom/toilet
Telephone, fridge etc
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HOUSING: mainly but not only material
Housing tenure – own or rent
Housing conditions – damp, cold etc
Overcrowding
‘Ontological security’
Homelessness
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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)
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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.
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Think longitudinal: life course
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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.
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Linking individuals and areas…
E.g. Unemployment
Employment status is an individual indicators
Unemployment rates are area-level indicators
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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
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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).
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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.
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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
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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.
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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…
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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.
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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
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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.
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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)
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The relationship between poverty and health at the ecological level
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• All the previous measures of deprivation were wholly or partly based on the Census
• What are the problems associated with this approach?
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• “Progress” was to base deprivation measures on administrative data, which could be more easily updated
• What are the problems associated with this approach?
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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
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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
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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
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People & Places geodemographic classification sorted by the IMD 2004, showing the proportion of areas in each IMD quintile
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Prevalence of hospital admission for mental health conditions North West residents 1998-
2002
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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?
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Health inequalities: explanatory mechanisms
• Material factors– Environment
• Lifestyle factors– Behaviour
• Psychosocial factors– Stressors– Coping capacity
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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.
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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