1. ScotPHO public health intelligence training course 2011 “health inequalities” Rory J. Mitchell (NHS Health Scotland, ScotPHO)

2. Overview of health inequalities session  What are health inequalities and why are they important?  The scale of health inequalities in Scotland  History & policy  Measuring socio-economic position  Measuring health inequalities { Practical exercise }  Understanding health inequalities  Tackling health inequalities

3. Health inequalities defined  health inequalities are differences in health between population groups age sex ethnicity sexual orientation socio-economic group (geography)  a broad view of health encompasses wellbeing and wider determinants

4. Defining population groups– 1  social class  occupation  education  income  benefits & tax credits  area v individual-based measures

5. Defining population groups – 1 National Statistics – Socio-economic Classification (NS-SEC) 1Higher 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

6. Defining population groups – 2 Scottish Index of Multiple Deprivation (SIMD)  identifies small area concentrations of multiple deprivation across all of Scotland in a fair way.  combines 38 indicators across 7 domains, namely: income, employment, health, education, skills and training, housing, geographic access and crime.  the overall index is a weighted sum of the seven domain scores.  this creates the overall SIMD score for each data zone, which is ranked to create the overall SIMD rank.

7. Scottish Index of Multiple Deprivation (SIMD)

8. Health inequalities in Scotland Leyland et al., Inequalities in Mortality in Scotland 1992-2002; MRC SPHSU Occasional Paper #18 Male age specific mortality rates by NS-SEC. Scotland 2000-02

9. Health inequalities in Scotland Community Health Partnership

10. Health inequalities in Scotland The percentage of P1 children in Scotland with no obvious dental decay experience, by deprivation decile, 2008

11. Why do health inequalities matter?  A moral imperative: “Reducing health inequalities is a matter of fairness and social justice” – The Marmot Review, 2010  A political imperative: “Reducing inequalities in health is critical to achieving the Scottish Government's aim of making Scotland a better, healthier place for everyone, no matter where they live. “ – Scottish Government  An economic imperative?  A strategy for improving population health?

12. Policy background  Socio-economic differences in health recognised since 19 th century  Key documents……  Black Report (UK), 1980  Acheson Report (England & Wales), 1998  WHO Commission on Social Determinants of Health (International), 2008  Marmot Review (England), 2010  Report of ministerial task force on health inequalities (Scotland), 2008  Current policy drivers in Scotland  “Equally Well”  And… “Achieving our potential”, “Early years framework”, etc

13. measuring health inequalities

14. Measuring inequalities 1 – Range  absolute & relative inequality  e.g. mortality rate in most deprived = 1120 mortality rate in least deprived = 500

15. Measuring inequalities 1 – Range illustration  absolute inequality = 1120 - 500 = 620 (i.e. difference in rate between most and least deprived group is 620)

16. Measuring inequalities 1 – Range illustration  relative inequality = 1120 / 500 = 2.2 [mortality rate is 2.2 times greater in most deprived group]

18. Practical exercise: health inequalities trend scenarios  Group work: 5 groups, 5 minutes  Whole group discussion, 10 minutes

19. Practical exercise: questions for consideration.....  What is the change over time in rate of hospital admissions for (i) the most deprived group and (ii) the least deprived group?  What is the effect on absolute inequality?  What is the effect on relative inequality?  Is the scenario desirable?  Is the scenario realistic?  [How does it compare with other scenarios?]

20. Scenario 1….. Absolute Inequality: no change Relative Inequality: + 0.37

21. Scenario 2 Absolute Inequality: + 10 Relative Inequality: + 1.51

22. Scenario 3 Absolute Inequality: - 10 Relative Inequality: + 0.07

23. Scenario 4 Absolute Inequality: - 10 Relative Inequality: - 0.23 (Scenario 4)

24. Scenario 5 Absolute Inequality: - 20 Relative Inequality: - 0.23 (Scenario 5)

26. Measuring inequalities – Slope Index of Inequality (SII) Example from: Long term monitoring of health inequalities, Scottish Government 2010 SII = 238

27. Measuring inequalities – Relative Index of Inequality (RII) RII = SII / population mean = 238 /158 = 1.51

28. Measuring inequalities – Relative Index of Inequality (RII)

29. Measuring inequalities – population attributable risk (PAR)  PAR = proportion of cases attributable to SES  Illustrates the reduction in number of cases if all groups had the same rate as the least deprived group  For formula see “measuring socio-economic inequalities in health: a practical guide” – ScotPHO, 2007 [available from www.scotpho.org ]www.scotpho.org

30. Measuring inequalities – population attributable risk (PAR)

31. Measuring inequalities – Concentration curve & index  The Concentration Index (C) is defined as twice the area between the concentration curve & the diagonal

32. Choosing the most appropriate measures of inequality  In most situations, it is useful to present both an absolute and relative measure of inequality.  An absolute measure will: give a context in which to assess the relative measure give an impression of the overall burden on population health  A relative measure will: take account of the size of the population of different groups take full advantage of the information across the whole population Allow comparison of measures over time or between different areas  Choice of measure to present will depend on the technical understanding of the audience  It may also be useful to present additional contextual data for background information, e.g. population rates and numbers, to show the underlying scale of the problem

33. understanding health inequalities

34. Determinants of health (inequalities)

35. How does socio-economic status affect health? Income  Differential access to social resources, e.g. education work  Individual factors self esteem control stress  Community / cultural factors Health behaviour & risk factors Social cohesion Social status UPSTREAMDOWNSTREAM Health Care Health Outcomes

36. Socio-economic status over the life-course early yearsyoung adulthoodretirementworking life Parent’s education Parent’s occupation Household income House conditions Retired income Housing Wealth EducationEmployment Occupation Income Housing Unemployment Community & cultural context Asset transfer to next generation

37. How do health inequalities persist? Theory of fundamental causes “Our enormous capacity to control disease and death combined with social and economic inequality creates health disparities… …it does so because…the benefits of this new found capacity are not distributed equally throughout the population, but are instead harnessed more securely by individuals and groups who are less likely to be exposed to discrimination and who have more knowledge, money, power, prestige and beneficial social connections.” Bruce Link

38. tackling health inequalities

39. Strategies and challenges - 1 Targeting people in poverty using an area-based approach Source: McLoone, 2001

40. Strategies and challenges – 2  Deprived groups less likely to take advantages of health care opportunities and respond to health improvement strategies  Resource requirements can be large, and are balanced against overall health improvement and other competing demands  Timescales can be measured in years, decades or generations (and a week is a long time in politics)

41. Strategies and challenges – 3  There is limited evidence for what actually works  Approaches that are most likely to work include: Structural changes in the environment Legislative and regulatory controls Fiscal policies Income support Reducing price barriers Improving accessibility of services Prioritising disadvantaged groups Offering intensive support Starting young(MacIntyre, 2007)  Is equal health in unequal societies achievable……?

42. Resources and tools  Measuring socio-economic inequalities in health: a practical guide, ScotPHO 2007: http://www.scotpho.org.uk/home/Publications/scotphoreports/ pub_measuringinequalities.asp http://www.scotpho.org.uk/home/Publications/scotphoreports/ pub_measuringinequalities.asp Includes an interactive excel tool that illustrates measurement of health inequalities:  The Scottish government Long-term monitoring of health inequalities report (2009): http://www.scotland.gov.uk/Publications/2009/09/25112211/0 http://www.scotland.gov.uk/Publications/2009/09/25112211/0 Includes the most up-to-date government recommendations for measuring and reporting inequalities in Scotland.  Association of Public Health Observatories (APHO) technical briefing on measuring health inequalities – due for publication April/May 2011. See ScotPHO website: http://www.scotpho.org.uk/home/resources/methodology/meth od_intro.asp http://www.scotpho.org.uk/home/resources/methodology/meth od_intro.asp

43. References  McIntyre S. Inequalities in health in Scotland: what are they and what can we do about them? MRC Social & Public Health Sciences Unit. Occasional Paper No. 17, 2007.  Wilkinson R., Pickett K. The Spirit Level - Why More Equal Societies Almost Always Do Better. Allen Lane, 2009  Black D., Morris J., Smith C., Townsend P. Inequalities in health: report of a Research Working Group. London: Department of Health and Social Security, 1980  Acheson D., 1998. Independent Inquiry into Inequalities in Health Report. The Stationery Office, London.  McLoone P. Targeting deprived areas within small areas in Scotland: population study. BMJ 2001, 323, 347-375.  Equally Well, Scottish Government 2008  Leyland et al., Inequalities in Mortality in Scotland 1992- 2002; MRC SPHSU Occasional Paper #18  McCartney G. Illustrating Glasgow’s health inequalities. JECH 2010  ScotPHO Profiles 2010

44. rory.mitchell@nhs.net