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 : ; doi: /ije/dym ’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

Locomotor disability and social class: British Regional Heart Study men 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 classDisability Chronic diseases: Arthritis, CVD Risk factors: inactivity, smoking, BMI etc

Locomotor disability and social class: British Regional Heart Study men 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 classCattle class Lynch & Davey Smith BMJ 2000;320;

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. neo­material viewpoint: health inequalities can be reduced by upgrading conditions in economy class Lynch & Davey Smith BMJ 2000;320;

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, Source: Bone et al Health Expectancy, 1995 MenWomen

Distribution of walking time 2% increase per single year increase in age, p<0.001) Time to walk 6m.

Adult social class, 2002/3 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 Time to walk 6m. Weekly household income, 1937/9 3.2% reduction in walking time per category increase in income, p=0.04 highlow

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 safety Self care, immunisation Social network Secondary prevention Treatment of chronic conditions Tertiary prevention Medication 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,

Projections of long-term care costs £ billions £11.1 £14.7 £19.9 £ % 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