1. Inequalities, deprivation and health Allan Baker

2. Acknowledgements This presentation has been adapted from the original presentation provided by the following contributors: –Helen Cooke –Mary Shaw –Bruna Galobardes –Mildred Blaxter

3. Learning Objectives What are health inequalities? History of examining health inequalities Measures of socio-economic position and deprivation –Individual level –Area level Explanatory mechanisms

4. What are health inequalities? Differences in health experience or outcome between population groups

5. Types of health inequality Social-economic environment e.g. jobs, housing, education, transport Lifestyles/health behaviour e.g. diets, smoking, social networks Access to effective health/social care e.g. services that result in health benefits Health outcomes e.g. increase/reduce mortality, ill health, disability GENDERGEOGRAPHYDISABILITYAGEETHNICITY SOCIAL CLASS

6. Travelling east from Westminster, each tube stop represents nearly one year of life expectancy lost –Data revised to 2002-06 Westminster Waterloo Southwark London Bridge Bermondsey Canada Water Canary Wharf North Greenwich Canning Town London UndergroundJubilee Line Differences in Life Expectancy within a small area in London River Thames 1 Source: Analysis by London Health Observatory using Office for National Statistics data revised for 2002-06. Diagram produced by Department of Health Male Life Expectancy 72.8 (CI 71.1-74.6) Female Life Expectancy 81.4 (CI 79.3-83.6) Male Life Expectancy 78.6 (CI 76.0-81.2) Female Life Expectancy 84.6 (CI 82.5-86.7)

7. Life expectancy at birth 1841 Males Females England 40 42 Surrey 44 46 London 35 38 Liverpool 25 27

8. Some historical evidence comparing occupations… Edwin Chadwick

9. The widening health gap Death ratios by social class Social class Professional Unskilled Average for working age men Year 1930-321959-631991-93 Log scale 160 100 50 25 1.2 times greater 2.9 times greater England & Wales

11. Health inequalities post 1997 1997 Health Inequalities Decennial Supplement 1998 Acheson report: Independent Inquiry into Inequalities in Health 1999 White paper: Saving Lives: Our healthier nation

12. Inequality PSA Target By 2010 to reduce the inequalities in health outcomes by 10% as measured by infant mortality and life expectancy at birth.

13. Infant Mortality Starting with children under one year, by 2010 to reduce by at least 10 per cent the gap in mortality between the routine and manual groups and the population as a whole.

14. Life expectancy Starting with Local Authorities, by 2010 to reduce by at least 10% the gap in life expectancy between the fifth of areas with the “worst health and deprivation indicators” and the population as a whole (England).

15. Individual level measures Ethnicity Occupation Social Class National Statistics Socio-Economic Classification Education Income

16. Health status Standardised ‘not good’ health ratios, London 2001 Source: 2001 Census

17. Occupation Long history of reporting Decennial Supplements Whitehall Study – 1967 Gradients in mortality by grade Whitehall II Relationships - work, stress & health

18. The Registrar General’s Social Classes IProfessional lawyer, doctor IIIntermediate teacher, manager III-NM Skilled non-manual typist, clerk III-MSkilled manual plumber, electrician IVPartly skilled manual bus driver VUnskilled manual cleaner, labourer VI Armed forces

19. Evidence from the Acheson Report, 1998 Source: Independent Inquiry into Inequalities in Health, 1998 Death rates by occupational social class, men aged 20-64, 1991-93 Death rates per 100,000

20. UK National Statistics Socio-Economic Classification (NS-SEC) 1)Higher managerial and professional occupations 2)Lower managerial and professional occupations 3)Intermediate occupations 4)Small employers and own account workers 5)Lower supervisory and technical occupations 6)Semi-routine occupations 7)Routine occupations 8)Never worked and long-term unemployed

21. Infant Mortality by NS-SEC 1997-99 2005-07 Deaths per 1,000 live births All* 5.6 4.7 Routine and Manual 6.3 5.4 Ratio 1.13 1.16 *All within marriage/joint registration

22. Occupation based measures - limitations Information often not captured: Women Those not in the workforce (including those not of working age) What is someone’s occupation? Changes over time Population availability

23. Education Captures those not in workforce Socio-economic position in early life Determinant of employment Knowledge, receptiveness to health education Meaning changes over time

24. Variations in rates of self-reported ill health among those aged 16 years or more by level of education, The Netherlands, 1981-85 Source: Blane et al 1996, Health and Social Organisation.

25. Income Direct measure of material circumstance Doesn’t take into account assets (wealth) Not measured in the census Response rates Liable to fluctuate Model-based estimates for small areas

26. Area based measures Carstairs Townsend Jarman Index of Multiple Deprivation National Statistics Area Classification P 2 People and Places

27. 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)

28. Maps Descriptive of London Poverty Charles Booth's Inquiry into Life and Labour in London (1886-1903)

29. Two very different areas of London http://booth.lse.ac.uk/static/a/4.html#i Whitechape l Mayfair & Fitzrovia

30. Copyright ©2000 BMJ Publishing Group Ltd. Dorling, D. et al. BMJ 2000;321:1547-1551 London Deprivation - 1890s and 1990s

31. Providence Place, Islington c1900 2000 Copyright ©2000 BMJ Publishing Group Ltd.

32. Townsend index of material deprivation Unemployment 16-64 Households with no car Overcrowding > 1 person per room Households not owner occupied

33. Carstairs deprivation index Male unemployment Households with no car Overcrowding > 1 person per room Low Social Class

34. Jarman scores Not designed as a measure of material deprivation Designed to highlight areas of greatest need for primary care Used subsequently as more general measure of deprivation

35. Index of Multiple Deprivation Not dependent on census Seven domains England Counties Local authorities Lower Layer Super Output Areas

36. Ecological fallacy People within an area share the same environmental characteristics (William S Robinson) All deprived people are not living in deprived areas All people living in deprived areas are not deprived

37. IMD 2007 - Domains

38. IMD 2007 – England & London

39. IMD 2007 - Income

40. IMD 2007 - Housing

41. IMD 2007 - Environment

42. IMD 2007 - Education

43. IMD 2007 - Health

44. Health Domain Year of potential life lost Comparative illness and disability ratio Emergency admissions to hospital Adults suffering from mood or anxiety disorders

45. Deprivation scores Measures of deprivation, not affluence Relative measures Deprivation a stronger proxy for health risk in men than women Effects of deprivation attenuated at older ages Different effects in different areas

46. Lung cancer mortality Source: DS No 16 Geographic Variations in Health

47. Breast cancer incidence Source: DS No 16 Geographic Variations in Health

48. Breast cancer mortality Source: DS No 16 Geographic Variations in Health

49. Which indicator? Carstairs and Townsend - car ownership May tend to overestimate disadvantage in London? Healthier people concentrated in capital? IMD – Health domain Outcomes and scores often correlated

50. Geodeomographic classifications Classify areas by socio-demographic characteristics National Statistics Area Classification Combinations of census and commercial data to identify groups with similar lifestyles Examples include ACORN, Mosaic, P 2 People & Places

52. Prevalence of hospital admission for mental health conditions North West residents 1998-2002

53. P 2 People and Places SW16 3QL - Multicultural Key Worker Ethnically very mixed Severe overcrowding common High unemployment Little political interest - tabloid newspapers People tend to smoke and take little exercise Shopping predominantly at Aldi or Lidl

54. Poor people or Poor Places Individual vs Area Measures Differences in health between areas: Result of characteristics of population? Or an independent area effect? Individual characteristics often summarised – groups may not be homogenous

55. Mortality rates by social class males aged 20-64, 1991-1993 Source: DS No 16 Geographic Variations in Health

56. Explanatory Mechanisms Selection Culture / lifestyle Poverty Psychosocial factors – Stress and Status Healthcare Environment Social capital

57. Learning Objectives What are health inequalities? History of examining health inequalities Measures of socio-economic position and deprivation –Individual level –Area level Explanatory mechanisms