1. Inequalities, Deprivation and Health

2. Learning Objectives By the end of this session, participants should be able to: Identify different kinds of health inequalities and understand their importance for health Recognise the central importance of socio-economic inequalities and deprivation Know about different ways to measure health inequalities 2

3. Definition of Health Inequality 3 Unfair or unjust differences in health determinants or outcomes within or between defined populations http://www.who.int/social_determinants/en/

4. What is Health Equity… 4 “Fair” distribution of health/health care resources or opportunities according to population need Allocating relatively more resources where there is relatively more need Equal quality of care for all

5. Background and Policy context 1971-1997 5 the inverse care law 1971 The availability of good medical care tends to vary inversely with the need for it in the population served.

6. Background and Policy context 1971-1997 6 the inverse care law 1971 the Black report 1980 showed the marked differences in health outcomes between the occupational classes and stressed the importance of inequalities in material conditions

7. Background and Policy context 1971-1997 7 the inverse care law 1971 the Black report 1980 The Health Divide 1987 Acheson Report 1988 Variations in Health 1995 Health Inequalities Decennial Supplement 1997

8. Background and Policy context 1971-1997 8 the inverse care law 1971 the Black report 1980 The Health Divide 1987 Acheson Report 1988 Variations in Health 1995 Health Inequalities Decennial Supplement 1997 All of these reports reinforce the same conclusion- poor people die younger and are less healthy

9. Keynotes 1-3 from Fair Society, Healthy Lives (Marmot review) 2010 1.Reducing health inequalities is a matter of fairness and social justice. In England, the many people who are currently dying prematurely each year as a result of health inequalities would otherwise have enjoyed, in total, between 1.3 and 2.5 million extra years of life. 2.There is a social gradient in health – the lower a person’s social position, the worse his or her health. Action should focus on reducing the gradient in health. 3.Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health. 9

10. From the Marmot review:

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14. Explanatory Mechanisms Department of Public Health (1991) Health Inequalities in the City of Toronto, City of Toronto Canada

15. The Role of Public Health in tackling health inequalities

16. Action taken to reduce health inequalities will benefit society in many ways. It will have economic benefits in reducing losses from illness associated with health inequalities. Each year in England these account for: productivity losses of £31-33B reduced tax revenue and higher welfare payments of £20-32B increased treatment costs well in excess of £5B 16 Cost of doing nothing

17. PART 1: Individual level: socio-economic position Ethnicity, occupation, employment status, social class, education, income PART 2: Ecological/Area level: deprivation Index of Multiple Deprivation, Geodemographic classifications 17 Key concepts and measurements in health inequality

18. Ethnicity Migrants or second, third.. Generation? Difficulties with language Different cultural/religious mores Discrimination/prejudice Differences in lifestyle factors compared to native population Genetic factors associated with disease risk factors Is it ethnicity or deprivation? 18

19. Ethnicity and Health Status 19 Standardised ‘not good’ health ratios, London 2001 Source: Source: 2001 Census, Analysis by LHO

20. Ethnicity and obesity in Year 6 children 20 Source: HSCIC, NCMP Dataset 2013/14, England Deprivation can often be a confounding factor

21. Source: DfES Ethnicity and educational development % achieving a good level of development at age 5, England 2013

22. Occupation/Employment Status 22 Social class usually affects health, rather than the other way around Occasions when poor health affects social position We can ask people about their current occupation, the one they have spent most of their working life doing, or the occupation of the head of household The relative position of an occupation can change over time Teachers were once held in a higher position of prestige and respect than they have been in recent years Subtle differences for different ethnic groups, and differences for men and women

23. Social Class 23 It is explicitly based on differences between employment conditions and relations

24. Smoking prevalence and Social Class, GB 2011-2012 24 Sources: General Lifestyle Survey and Opinions and Lifestyle Survey, Office for National Statistics

25. Education 25 Education: knowledge-related assets of an individual Continuous variable: years of completed education Categorical variable: educational achievements, such as completion of secondary education, degree Captures those not in workforce Socio-economic position in early life, material resources of family or origin Determinant of employment and indicator of future material resources Knowledge, literacy, receptiveness to health education

26. Education, chronic ill health and self reported health 26 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. poor diet? poor home environment? social environment?

27. Income and Mortality 27 Source: Merlo et al, 2003 International Journal for Equity in Health

28. Other Individual Measures 28 Amenities Often used as an indicator of income and wealth / living standards Car access / ownership Sole use of bathroom/toilet Telephone, fridge etc Are these still important? Any others you can think of? Things to consider…

29. Ecological Measures People within an area share the same environmental characteristics (William S Robinson) Ecological Fallacy can occur when a researcher or analyst makes an inference about an individual based on aggregate data for a group All deprived people are not living in deprived areas All people living in deprived areas are not deprived Employment status is an individual indicator. Unemployment rates are area-level indicators. 29

30. 30 Ecological Measures - 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).

31. 31 Ecological Measures - 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). Townsend Based on census data Unemployment – Overcrowding – Non car ownership – Non home ownership -

32. 32 Ecological Measures - 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). Townsend Carstairs unweighted combination of four census variables: unemployment, overcrowding, car ownership and low social class (Social Class IV and V, based on old registrar general social classes) – based on census data

33. 33 Ecological Measures - 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). Townsend Carstairs Jarman Developed to predict GP workload They give an indication of social deprivation, based on the weight of eight variables:- Unemployment Overcrowding Lone pensioners Single parents Born in New Commonwealth Children aged under 5 Low social class One year migrants

34. 34 Ecological Measures - 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). Townsend Carstairs Jarman Index of Multiple Deprivation We mainly use IMD as it is not census based so it can be updated more frequently

35. 35 7 Domains of IMD 2010

36. Deprivation and Breast cancer 36 Age-specific incidence rate (ASIR) per 100,000 population by deprivation group Source: PHE – NCIN Cancer by Deprivation, 1996-2011

37. Deprivation and Cancer 37 Source: PHE – NCIN, Second All Breast Cancer Report Breast Cancer 5-year relative survival, 2002/03

38. Geodemographic Classifications Classify areas by socio-demographic characteristics ONS National Statistics Area Classification Using socio-economic and demographic data from each census, they aim to identify areas of the country with similar characteristics Combinations of census and commercial data to identify groups with similar lifestyles Examples include ACORN, Mosaic, P 2 People & Places 38

39. 39 2011 Area Classification for Output Areas: Supergroups Source: Office for National Statistics Contains Ordnance Survey data © Crown copyright and database right 2014

40. People to Places 40 Increasing deprivation NW average Prevalence of hospital admission for mental health conditions North West residents 1998-2002, HES

41. What you have learnt By the end of this session, participants should be able to: Identify different kinds of health inequalities and understand their importance for health Recognise the central importance of socio-economic inequalities and deprivation Know about different ways to measure health inequalities 41