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This presentation arises from the project HEALTH EQUITY – 2020 which has received funding from the European Union, in the framework of the Health Programme.

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Presentation on theme: "This presentation arises from the project HEALTH EQUITY – 2020 which has received funding from the European Union, in the framework of the Health Programme."— Presentation transcript:

1 This presentation arises from the project HEALTH EQUITY – 2020 which has received funding from the European Union, in the framework of the Health Programme. Health inequalities in Europe Frank J van Lenthe Mariëlle A Beenackers Johan P Mackenbach

2 WP 4: TRANSLATIONAL EVIDENCE AND POLICY Aim: develop tools for drawing up evidence-based regional action plans to reduce health inequalities: –a case-by-case needs assessment, taking into account current exposure to the determinants of health inequalities and to policies tackling these determinants, –selection of actions known or expected to be effective in addressing these entry-points, and –a case-by-case analysis of the potential impact of these actions on population health and economic performance.

3 TOOLKIT - PART 1 Case-by case needs assessment •Determine most important indicators to include •Challenges with availability &validity of regional data •Sensitivity for regional differences •User friendliness

4 TOOLKIT - PART 1 •Needs Assessment: stepped and structured approach –Description of inequalities •Indicators used •Measures of association –Explanations of inequalities in health –Interventions and policies

5 Advantages Easy to measure High response rates Applicable to women, non- employed & elderly More comparable across countries Defined early in life (less reverse causality) Disadvantages Variations by cohort & country Quality of education usually ignored Transitions in adulthood not taken into account INDICATORS USED - EDUCATION

6 MEASURING ASSOCIATION BETWEEN SOCIOECONOMIC POSITION AND HEALTH Summary measure Absolute or relative Reference point Social group size All social groups Relative difference (e.g. RR)RelativeBestNo Absolute difference (e.g. RD)AbsoluteBestNo Regression-based relative effectRelativeAverageNoYes Regression-based absolute effectAbsoluteAverageNoYes Population Attributable Risk %RelativeBestYes Population Attributable RiskAbsoluteBestYes Relative Index of InequalityRelativeAverageYes Slope Index of InequalityAbsoluteAverageYes Relative Concentration IndexRelativeAverageYes Absolute Concentration IndexAbsoluteAverageYes Index of DisparityRelativeBestNoYes Between Group VarianceAbsoluteAverageYes Based on Harper 2008

7 MEASUREMENT ISSUES VALUE JUDGEMENTS •Relative vs. absolute inequalities “Inequality as such should be avoided” •Best vs. average as reference point “We should strive for upward leveling” •Social group size accounted or not “Larger groups are more important” •Gradient vs. extreme groups “Middle class should not be neglected”

8 Relative Risk of dying comparing manual classes to non- manual classes, men in two periods Mackenbach 2003 MORTALITY BY EDUCATION IN WESTERN EUROPE (1)

9 Absolute difference in death rate between manual classes and non-manual classes, men in two periods MORTALITY BY EDUCATION IN WESTERN EUROPE (2) Mackenbach 2003

10 IS GROUP SIZE IMPORTANT? Rate of ischaemic heart disease None Primary School High SchoolCollege/ University Educational level rate

11 Rate of ischaemic heart disease None Primary School High SchoolCollege/ University Educational level rate IS GROUP SIZE IMPORTANT

12 RELATIVE INEQUALITIES BY EDUCATION Total mortality, men Mackenbach et al. 2008

13 RELATIVE INEQUALITIES BY EDUCATION Total mortality, women Mackenbach et al. 2008

14 ABSOLUTE INEQUALITIES BY EDUCATION Total and CVD mortality, men Mackenbach et al. 2008

15 ABSOLUTE INEQUALITIES BY EDUCATION Total and cancer mortality, men Mackenbach et al. 2008

16 ABSOLUTE INEQUALITIES BY EDUCATION Total and injury mortality, men Mackenbach et al. 2008

17 CAUSES OF DEATH: 3 DIFFERENT “REGIMES” •Northwest: large inequalities for cancer (m/w) and CVD (m/w) •South: small inequalities for cancer (w) and CVD (m/w) •East: huge inequalities for cancer (m), CVD (m/w), injury (m/w)

18 PATHWAYS OF HEALTH INEQUALITIES •Behavioural/cultural pathways –Smoking, physical inactivity, alcohol, diet •Psychosocial pathways –Work stress, lack of social support, negative life events •Material pathways –Financial resources –Living circumstances –Working circumstances –General environment –Health care

19 POSSIBLE INTEGRATION Material factors Socioeconomic status BehaviorHealth Psychosocial factors

20 EXPLANATION OF INEQUALITIES IN MORTALITY Van Oort et al. 2005

21 RELATIVE INEQUALITIES BY EDUCATION Smoking-related mortality Mackenbach et al. 2008

22 RELATIVE INEQUALITIES BY EDUCATION Alcohol-related mortality Mackenbach et al. 2008

23 RELATIVE INEQUALITIES BY EDUCATION Obesity Mackenbach et al. 2008

24 RELATIVE INEQUALITIES BY EDUCATION Mortality amenable to medical intervention Mackenbach et al. 2008

25 DETERMINANTS: 3 DIFFERENT “REGIMES” •Northwest: large inequalities for smoking (m/w), alcohol (m/w), obesity (m/w); small inequalities for health care (m/w) •South: small inequalities for smoking (m/w), alcohol (w), health care (m/w); large inequalities for obesity (m/w) •East: large inequalities for smoking (m), alcohol (m/w), health care (m/w); small inequalities for obesity

26 NATIONAL POLICIES •Britain: Independent Inquiry (1998) etc. •Netherlands: Albeda committee (2001) •Sweden: Public Health Commission (2002) •Norway: National Strategy (2006) •Finland: National Action Plan (2008)

27 EXAMPLE - NETHERLANDS - ALBEDA COMMITTEE •4 specific strategies –Reduction of inequalities in education, income and other socioeconomic factors –Reduction of the negative effects of health problems on socioeconomic position –Reduction of the negative effects of socioeconomic position on health –Improve access and quality of healthcare for lower socioeconomic groups •26 recommendations •11 quantitative targets for intermediate outcomes

28 LABOUR MARKET AND WORKING CONDITIONS •Universal approaches  Employment protection and labor market policies for chronically ill citizens – Sweden  Occupational health services with check-ups and preventive interventions – France •Targeted approaches  Reduction in retirement age for manual workers – Italy  Job rotation among dustmen – Netherlands Mackenbach & Bakker 2003

29 HEALTH-RELATED BEHAVIOURS •Universal approaches  Serve low-fat food products through mass catering in schools and workplaces – Finland •Targeted approaches  Stop-smoking support targeted to deprived areas – Britain Mackenbach & Bakker 2003

30 HEALTH CARE •Improving quality of care  Nurse practitioners to support GPs working in deprived areas – Netherlands •Working with other agencies  Community Strategies led by local government agencies, but integrating care across all local public sector services, including health - England Mackenbach & Bakker 2003

31 TERRITORIAL APPROACHES •Comprehensive health strategies for deprived areas  Municipal health policy towards Ciutat Vella, Barcelona – Spain Mackenbach & Bakker 2003

32 PACKAGE OF POLICIES SHOULD REFLECT DETERMINANTS •Check prevalence of determinants by socioeconomic group •Estimate theoretical potential for reduction of health inequalities •This will vary by time and place – strategies need to be tailored •In practice, potential will also depend on effectiveness of policies

33 POSSIBLE METHODS – EURO-GBD-SE Working with counterfactual scenarios •Scenario 1: complete elimination of inequalities: e.g. “What would happen to mortality when the whole population would smoke as much as the highest SES group?”  ideal scenario – to estimate inequalities •Scenario 2: partial elimination of inequalities: E.g. “What would happen to mortality when the lowest SES groups had a decrease in smoking as seen in evaluation studies of interventions?”  possible scenario – to estimate effects of a policy/intervention

34 Eikemo et al, preliminary EURO-GBD-SE report

35 TOOLKIT - PART 2 Health and economic impact assessment •Use and translate existing initiatives •Economic impact •Quantitative assessment (e.g. EURO-GBD-SE) –Determine most important indicators to include –Challenges with availability &validity of regional data –Sensitivity for regional differences –User friendliness

36 TOOLKIT - PART 3 Policy and intervention database •Make existing initiatives accessible •Screening existing databases •Grading evidence

37 MILESTONES •Milestone 1: –Workshop with other EU projects to share lessons learned (tomorrow) •Milestone 2: –Preliminary paper version of toolkit, ready for being tested in pilot regions (M15) •Milestone 3: –Toolkit presented at WP7 workshops as part of further testing (M30) •Milestone 4: –Final online version of toolkit (M36)

38 WORKPLAN Preparation for toolkit (M1-6) •Organize workshop to merge learning from recent and relevant projects •Review about potentially important interventions and policies •Inventory of available methods to assess inequalities •Inventory of methods to assess the effects of policies/interventions •Inventory of what data is needed and what data is available Development of toolkit (M4-15) •Develop methods to for the assessment of inequalities •Develop methods to analyse the main determinants of these inequalities •Develop methods to estimate the impact of policies/interventions on inequalities •Integrate findings into a toolkit Implementation of toolkit (M15-36) •Pre-test and further development of the toolkit •Capacity building


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