Inequalities, deprivation and health
Dr Mary Shaw
Scientific Director, SWPHIS
Reader in Medical Sociology, Department of
Social Medicine, University of Bristol
With contributions from Bruna Galobardes, Helen Cooke, Mildred Blaxter
Session Objectives
1. What do we mean by health inequalities and
why are they important?
2. Present a range of indicators of
socioeconomic position (SEP) at individual
and area level
3. Show evidence past and present of health
inequalities in the UK, using the indicators
presented
What do we mean by ‘health inequalities’?
Generally: differences between groups of people
in terms of their health outcomes
Specifically: health and illness are related to
social and economic position
“The government’s strategy on health
inequalities aims to narrow the gap in health
outcomes across geographical areas, socioeconomic groups, age groups and different
black and minority ethnic groups, as well as
between men and women and between the
majority of the population and vulnerable groups
with special needs”
(HM Treasury and Department of Health, 2002)
“Inequality in health is the worst
inequality of all. There is no more
serious inequality than knowing that
you’ll die sooner because you’re
badly off” Frank Dobson, 1997
Key concepts and measurements in health
inequality (and some evidence)
PART 1: Individual level: socio-economic position
Education, occupation, social class, employment
status, income, amenities, housing.
PART 2: Ecological/Area level: deprivation
Townsend, Carstairs, Jarman, Breadline Britain,
Index of Multiple Deprivation
Individual level: socio-economic position
Socio-economic position: an umbrella term
for the way that people are ordered into a
hierarchy based on their social and economic
circumstances. Encompasses a range of
concepts with different theoretical and
disciplinary origins.
[suggestion: useful to use instead of jumping
between terms, and better than using one
term when you have actually measured
another]
EDUCATION: knowledge-related assets of an
individual
Continuous variable: years of completed
education
Categorical variable: educational
achievements, such as completion of
secondary education, attainment of
qualification
Standardised death rates 1989-90 in the United
States per 100,000 persons aged 25-64 of all
races by years of education
Years of education
16 or more
13-15
12
9-11
0-8*
Male
318.9
501.5
602.1
739.8
615.3
Female
194.4
280.7
292.5
318.3
312.9
* contains very few US born people, may reflect a healthy migrant effect.
Source: Blane et al 1996, Health and Social Organisation.
Variations in rates of self-reported ill health
among those aged 16 years or more by level of
education, The Netherlands, 1981-85
Highest level of formal
education completed
Chronic
conditions
Primary school
Lower secondary school
Secondary education
Vocational college
University
1.12
1.00
0.95
0.85
0.71
Self-rated
health less than
‘good’
1.41
0.98
0.81
0.62
0.64
Source: Blane et al 1996, Health and Social Organisation.
EDUCATION:
 Captures early life SEP; Material resources
of family of origin
 Knowledge, cultural literacy, receptive to
health education
 Determinant of employment and indicator of
material resources
 Beware cohort change; meaning changes
over time.
OCCUPATION: reflects an individuals social
standing in society, status, privilege, intellect,
parental background, income/living standards,
educational background, working relations &
conditions…
Current occupation
Longest held occupation
Occupation of head of household
Commonly excluded groups include: retired,
people whose work is inside the home (mainly
affecting women), the unemployed, students, and
people working in unpaid, informal or illegal jobs.
Occupation-based indicators
• Marxist-based social class classifications
(ownership of the means of production)
• Registrar General’s Social Classes
(prestige/status)
• The new UK NS-SEC (employment relations)
• Working life characteristics, unemployment
Some historical evidence comparing
occupations…
Edwin Chadwick
Table 1: Age at death among different social orders, by district
District
Gentry and
Farmers and
professional
tradesman
Rutland
52
41
Bath
55
37
Leeds
44
27
Bethnal Green
45
26
Manchester
38
20
Liverpool
35
22
Source: Chadwick (1842) cited in Macintyre (1999)
Labourers and
artisans
38
25
19
16
17
15
Number of deaths and proportional mortality ratios (PMR)
for CJD and dementia among men aged 20-74 in selected
occupational groups, England and Wales, 1979-96
1979-83
1984-87
1988-91
1992-96
CJD
No
PMR
No
PMR
No
PMR
No
PMR
Farmers and farm workers
Butchers and abattoir workers
Veterinarians
2
0
0
239
-
1
0
0
91
-
0
0
0
-
4
0
0
254
-
41
6
0
106
62
-
88
23
0
98
98
-
63
19
3
82
101
359
55
18
1
82
119
132
Dementia
Farmers and farm workers
Butchers and abattoir workers
Veterinarians
Source: Aylin et al, 1999 BMJ, 318:10044-5.
SOCIAL CLASS: Strictly, refers to
schema based on relations between
class groups, e.g. bourgeoisie who
own the means of production, and
exploited proletatiat who sell their
labour (Marx).
OCCUPATIONAL SOCIAL CLASS:
Mostly, occupations are grouped into
occupational social classes, or socioeconomic groups
Social Class based on Occupation
(previous to 1990 known as The Registrar
General’s Social Classes)
First devised 1911, social grades based on
prestige or social standing; initial purpose –
analysis of mortality and fertility data.
Used in official statistics and vital statistics,
over long time period.
The Registrar General’s Social Classes
I
II
III-NM
Professional, e.g. lawyer, doctor,
accountant
Intermediate, e.g. teacher, nurse, manager
III-M
Skilled non-manual, e.g.typist, shop
assistant
Skilled manual, e.g. plumber, electrician
IV
Partly skilled manual, e.g. bus driver.
V
Unskilled manual e.g. cleaner, labourer
VI
Armed forces
Respiratory
Genitourinary
Circulatory
Digestive
Cancers
Accidents
Evidence from the Acheson Report, 1998
Death rates per 100,000, by occupational social class, men aged 20-64, 1991-93
Lung cancer
All causes
806
1000
800
600
400
280
300
I
II
426
493
492
200
0
IIINM
IIIM
IV
100
80
60
40
20
0
82
17
24
I
II
V
235
136
81
159
52
IIIM
IV
34
IIINM
V
Stroke
Coronary Heart Disease
250
200
150
100
50
0
54
45
50
40
156
30
92
20
14
13
I
II
19
24
25
IIIM
IV
10
0
I
II
IIINM
IIIM
IV
V
Source: Independent Inquiry into Inequalities in Health, 1998
IIINM
V
Average years of life expectancy by occupational social
class, England and Wales, 1972-1999, Males
80.0
78.0
76.0
I
74.0
II
IIIN
72.0
IIIM
IV
70.0
V
68.0
66.0
64.0
1972-76
1977-81
Source: National Statistics, 2002
1982-86
1987-91
1992-96
1997-99
UK National Statistics Socio-Economic
Classification (NS-SEC)
As of 2000 this has replaced the Registrar
General’s social classes for use in official
statistics and surveys.
It is explicitly based on differences
between employment conditions and relations
UK National Statistics Socio-Economic
Classification (NS-SEC)
1.
2.
3.
4.
5.
6.
7.
Higher managerial and professional employers
Lower managerial and professional
Intermediate employees
Small employers and own account workers
Lower supervisory, craft and related employees
Employees in semi-routine occupations
Employees in routine occupations
Never worked and long-term unemployed
Self-reported health of women aged 16-74 by NSSEC, %, England and Wales, 2001 (Census, ONS)
All
Good health Fairly good Not good
health
health
64.3
26.1
9.6
Higher managerial and professional occupations:
Large employers and higher managerial
occupations
Higher managerial and professional occupations:
Higher professional occupations
79.1
17.1
3.8
81.0
15.6
3.4
Lower managerial and professional occupations
75.6
19.7
4.7
Intermediate occupations
73.3
21.8
4.9
Small employers and own account workers
69.6
24.1
6.3
Lower supervisory and technical occupations
66.1
26.4
7.5
Semi-routine occupations
66.1
27.0
6.9
Routine occupations
61.1
30.1
8.8
49.3
31.8
18.9
55.5
35.0
9.5
Never worked
Lon-term unemployed
Trends in infant mortality by socio-economic group:
England and Wales 1994-2006, three-year rolling average,
England and Wales
note that records before 2000 have been “backcoded” into NS SEC 90 for
compatibility
EMPLOYMENT STATUS: Economic activity /
whether someone is employed/unemployed.
Strong link to income
Work-related benefits
Social isolation and loss of self-esteem;
status, purpose and structure to day; respect
of others; physical and mental activity; use of
skills
Work insecurity and self-reported
general health at age 23 (NCDS)
Previous
spells of
Excellent/good Fair/poor
unemployment
0
94
6
1
92
8
2+
84
16
n
4,090
336
Source: Blane et al 1996, Health and Social Organisation.
Occupation-based indicators (cont.)
•
•
•
•
Relative position of different occupations
changes over time
Differences between ethnic groups &
gender in relative position of different
occupations
Limited to those in paid employment
Possibility of reverse causality – downward
mobility with ill-health
INCOME: the most direct measure of material
resources (different from accumulated
WEALTH)
Can fluctuate dramatically
Individual, household, equivalised
Respondents reticent to divulge
NOT measured in the census!
Income
• Most direct measure of material circumstances
• Doesn’t take into account assets (wealth)
• In some countries there may be reluctance to
answer questions on income
• Adjust for number of dependent people in household
• SEP indicator that can change most on a short-time
basis: does the indicator capture this characteristic?
…some
more
historical
evidence
Source: Merlo et al, 2003 International Journal of Equity in Health
AMENITIES: often used as an indicator of
income and wealth / living standards
Car access / ownership
Sole use of bathroom/toilet
Telephone, fridge etc
HOUSING: mainly but not only material
Housing tenure – own or rent
Housing conditions – damp, cold etc
Overcrowding
‘Ontological security’
Homelessness
SMRs, by social class, access to cars and housing tenure at
the 1971 Census, women and men, all causes, England and
Wales, 1971-92
Age at death 45-64
Women
Men
Non manual social class
Car
Owner occupied
Privately rented
Local authority
No car
Owner occupied
Privately rented
Local authority
70*
82*
93
72*
83*
96*
91
105
125*
99
129*
120*
Manual social class
Car
Owner occupied
85*
82*
Privately rented
100
93
Local authority
101
104
No car
Owner occupied
99
101
Privately rented
128*
132*
Local authority
131*
126*
* statistically significant at the 95% level. England and Wales = 100. Source:
adapted from Smith and Harding (1997)
Socio-economic position
There is no single best indicator of SEP
What is your research question / aim?
Is the measure equally relevant to all
subgroups?
Is there a cohort effect to consider?
‘Off the shelf’ – take note of what you are
using.
Think longitudinal: life course
Childhood
Parent’s education
Parent’s
occupation
Household income
Household
conditions
Young adulthood
Education
Active professional life
First employment
Income
Household
conditions
Assets transfer
occurring when
starting a family
Occupation 1st,...,last,
longest
Housewife
Unemployment:
yes/no, number of
episodes
Income: changes over
time
Wealth, deprivation:
changes over time
Household conditions:
changes over time
Partner’s SEP
Retirement
Household income
Wealth, deprivation
Household
conditions
Assets transfer
across generations
occurring at death
PART 1: Individual measures of socioeconomic position, such as social class based
on occupation, are important for describing the
extent of inequalities in health. They may also be
used in targets and for tracking trends over time.
PART 2: Area-based (ecological) indicators of
deprivation are used in the absence of individual
level data, in their own right, and can also tell us
about areas per se (as well as the individuals
within those areas).
They are also used for making decisions about
the allocation of resources to those areas.
Linking individuals and areas…
E.g. Unemployment
Employment status is an individual
indicators
Unemployment rates are area-level
indicators
Area level: 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).
Aggregated indicators based on census
measures
Townsend Deprivation Index
Measures multiple deprivation for areas
using 4 variables from the 1991 census:
% unemployment of those 16-64
% households with no car
% households not owner occupied
% overcrowding (> 1 person per room).
The Townsend Score is a summation of the
standardised scores (z scores) for each
variable (scores greater than zero indicate
greater levels of material deprivation). This
score was considered the best indicator of
material deprivation available from the 2001
census.
It has been widely used in the health field.
Ward level variations of Townsend’s Index of Deprivation
against the Standardised Illness Ratio (N = 8,481)
300
Rural Wards
Deprived City Wards
Standardised Illness Ratio (<75)
250
Deprived Industrial Wards
Other Wards
200
150
100
50
0
-10.0
-7.5
-5.0
-2.5
0.0
2.5
5.0
Townsend's Index of Deprivation
Source: Asthana et al 2002 see www.swpho.org.uk
7.5
10.0
12.5
15.0
Carstairs deprivation index
A measure of material deprivation for
Scotland – based on census data. Very
similar to the Townsend score but replaces
the non-owner occupation variable with one
concerning social class.
Jarman or UPA – underprivileged area
score
Measures ‘social deprivation’, and was
originally designed as a measure of GP
workload (used for GP payments). Has
subsequently been used as a more general
measure of deprivation.
Ranks places. Based on census data…
1. Unemployment - unemployed residents aged 16+ as a proportion
of all economically active residents aged 16+.
2. Overcrowding - persons in households with 1 and more persons
per room as a proportion of all residents in households.
3. Lone pensioners - lone pensioner households as a proportion of
all residents in households.
4. Single parents - lone 'parents' as a proportion of all residents in
households.
5. Born in New Commonwealth - residents born in the New
Commonwealth as a proportion of all residents.
6. Children aged under 5 - children aged 0-4 years of age as a
proportion of all residents .
7. Low social class - persons in households with economically
active head of household in socio-economic group 11 (unskilled
manual workers) as a proportion of all persons in households.
8. One year migrants - residents with a different address one year
before the Census as a proportion of all residents.
Area based deprivation indices used in UK
Variable
Jarman Carstairs Townsend
Unemployed
Yes
Yes
Yes
No car
No
Yes
Yes
Overcrowding
Yes
Yes
Yes
Social Classes IV and V
No
Yes
No
Housing tenure
No
No
Yes
Unskilled
Yes
No
No
Lone pensioner
Yes
No
No
Children under 5 years old Yes
No
No
Lone parent
Yes
No
No
Geographical mobility
Yes
No
No
Ethnic minority group
Yes
No
No
from Eames et al, BMJ 1993
Breadline Britain (Poverty & Social
Exclusion Survey)
A measure of ‘consensual’ or ‘perceived’
poverty - what people themselves understand
and experience as the minimum acceptable
standard of living in contemporary Britain. This
minimum covers not only the basic essentials
for survival, such as food and shelter, but also
factors which enable people to participate in
their social roles in society. The survey thus
measured what possessions and activities the
public perceived as necessities of life.
The perception of necessities and per cent of population
having each item: the 1990 Breadline Britain survey
Standard-of-living items in rank order
A damp-free home
Heating to warm living areas of the home if it’s
cold
An inside toilet (not shared with another
household)
Bath, not shared with another household
Beds for everyone in the household
A decent state of decoration in the home
Fridge
Warm waterproof coat
Three meals a day for children
Two meals a day (for adults)
Insurance of contents of dwelling
Daily fresh fruit and vegetables
Toys for children e.g. dolls or models
Bedrooms for every child over 10 of different
sexes
Carpets in living rooms and bedrooms
Meat/fish (or vegetarian equivalent) every other
day
Two pairs all-weather shoes
more………….
Source: Gordon and Pantazis (1997)
% claiming item as
necessity (1,831)
98
97
% of population having
item
94
96
97
98
95
95
92
92
91
90
90
88
88
84
82
97
97
81
98
91
74
94
83
88
75
65
78
77
96
90
74
74
90
91
The relationship between poverty and
health at the ecological level
• All the previous measures of deprivation
were wholly or partly based on the Census
• What are the problems associated with
this approach?
• “Progress” was to base deprivation
measures on administrative data, which
could be more easily updated
• What are the problems associated with
this approach?
Indices of Deprivation
Third release (2007) from Department of
Communities and Local Government
A summary measure at Super Output
Area (SOA) level calculated from
7 domains in total
two supplementary Indices
Income Deprivation Affecting Children
Income Deprivation Affecting Older People
www.communities.gov.uk/communities/neighbourhoodrenewal/deprivation/de
privation07
Using IMD
• Make sure you understand the
constituents of each domain
• Use the domain most closely associated
with the aspect of deprivation you are
considering
Geodeomographics
•
Geodemographic (GD) classification systems can be used to segment
populations and thereby identify target groups
•
Use a combination of Census and commercial data to identify groups
with similar lifestyles, eg where they shop, what papers they read
•
Examples include ACORN, Mosaic, P2 People & Places, National Statistics
•
People and Places is available through Observatories
•
Report of using geographic tools for social marketing
http://www.erpho.org.uk/Download/Public/16892/1/Synthesis_6_Socialmarketing.pdf
2001 Area Classification
People & Places geodemographic classification sorted by the IMD 2004,
showing the proportion of areas in each IMD quintile
Prevalence of hospital admission for mental health
conditions North West residents 1998-2002
Which measure to use?
•Consider the theoretical basis
• Spatial level and ecological fallacy
• How recent/frequent?
• Components – single or multiple components?
• Universal coverage?
• Applicable to subgroups?
• Impact of cut-off points?
Health inequalities: explanatory
mechanisms
• Material factors
– Environment
• Lifestyle factors
– Behaviour
• Psychosocial factors
– Stressors
– Coping capacity
The targets for tackling health inequalities
incorporates these individual and
aggregate levels:
National (PSA) target for 2010
To reduce the gap in infant mortality across
social groups, and raise life expectancy in the
most disadvantaged areas faster than
elsewhere.
Session Objectives Revisited
1. What do we mean by health inequalities and
why are they important?
2. Present a range of indicators of
socioeconomic position (SEP) at individual
and area level
3. Show evidence past and present of health
inequalities in the UK, using the indicators
presented