Summary Measures of SES
Disparities in Health:
Implications for Policy
Elsie Pamuk & Kim Lochner
National Center for Health Statistics
Centers for Disease Control and Prevention
For inherently ordered domains,
the primary focus is usually on the
domain itself,
not on the component groups …..
because the groups are defined
by the amount of the underlying
domain
Whenever the focus is on the
domain,
it is appropriate to combine
information from the component
groups and create a summary
measure of disparity.
Common characteristics of
summary measures of health
disparities related to SES



Use information from all of the
component groups
Preserve the inherent ordering of the
groups
Incorporate the relative size of the
groups
Regression-based
measures
Concentration Index
CONCENTRATION INDEX:
Age-adjusted deaths for U.S. men by education, 1990-2000
1
0.9
0.8
0.7
Cumulative
proportion of ageadjusted deaths
C = -.11
0.6
0.5
0.4
0.3
0.2
0.1
<HS
HS/GED
Some
college
College
Degree +
0
0
0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
1
Cumulative proportion of men aged 25+ by level of education
Data Source


NHIS/NDI linked mortality file
Population characteristics
- sex, age, education, income obtained from NHIS surveys conducted
from 1990-2000

Survey records matched to death
records in the U.S. vital statistics
(through 2002)
Educational Inequality Indices in cause-specific mortality:
U.S. Men, aged 25+, NHIS/NDI, 1990-2000
SII
RII (mean)
RII (ratio)
C
-320
-.67
2.02
-.10
Stroke
-59
-.71
2.09
-.11
Other cardiovascular
-18
-.53
1.72
-.08
Lung cancer
-130
-1.14
3.63
-.18
Colon cancer
-27
-.74
2.19
-.12
Prostate cancer
-10
-.23
1.26
-.04
Other cancer
-73
-.39
1.48
-.06
Pneumonia / Influenza
-17
-1.10
3.45
-.17
HIV
-33
-.79
2.31
-.12
Lower respiratory disease
-81
-1.13
3.62
-.18
Liver disease
-20
-1.08
3.35
-.17
Diabetes
-41
-1.02
3.06
-.16
Nephritis / Nephrosis
-12
-.60
1.86
-.09
Homicide
-15
-2.15
-27.74
-.33
Suicide
-17
-.75
2.21
-.12
Unintentional injury
-66
-1.20
4.02
-.19
All other causes
-99
-.50
1.66
-.08
Heart disease
Educational Inequality Indices in cause-specific mortality:
U.S. Men, aged 25+, NHIS/NDI, 1990-2000
SII
RII (mean)
RII (ratio)
C
Prostate cancer
-10
-.23
1.26
-.04
Other cancer
-73
-.39
1.48
-.06
All other causes
-99
-.50
1.66
-.08
Other cardiovascular
-18
-.53
1.72
-.08
Nephritis / Nephrosis
-12
-.60
1.86
-.09
-320
-.67
2.02
-.10
Stroke
-59
-.71
2.09
-.11
Colon cancer
-27
-.74
2.19
-.12
Suicide
-17
-.75
2.21
-.12
HIV
-33
-.79
2.31
-.12
Diabetes
-41
-1.02
3.06
-.16
Liver disease
-20
-1.08
3.35
-.17
Pneumonia / Influenza
-17
-1.10
3.45
-.17
Lower respiratory disease
-81
-1.13
3.62
-.18
-130
-1.14
3.63
-.18
Unintentional injury
-66
-1.20
4.02
-.19
Homicide
-15
-2.15
-27.74
-.33
Heart disease
Lung cancer
os
t
at
e
Al
l o can
ce
th
er
r
Al
Al
ca
lo
lo
nc
th
th
er
e
er
ca r
ca
us
rd
Ne
es
io
ph
rit vas
cu
is
/N
ep lar
He
hr
o
ar
t D sis
is
ea
se
Al
lC
au
se
S
Co
tro
lo
ke
n
ca
Pn
nc
eu
er
m
on Sui
c
ia
/In i de
flu
en
za
Di
ab
Li
et
ve
Lo
r d es
we
is
rr
ea
es
se
pi
ra
to
H
ry
di IV
se
as
Un Lu n
e
g
in
ca
te
nt
nc
io
n a er
li
n
Ho jury
m
ic
id
e
Pr
Absolute value of index
Relative Inequality Indices:
RII (mean), RII (ratio) and C
30
25
20
15
RII (mean)
RII (ratio )
C
10
5
0
Conversion between C and RII
C = 2 cov(x,y)/m
SII = cov(x,y)/var(x)
and,
RII = SII/m = [cov(x,y)/var(x)]/m
so,
C = 2 var(x)(RII)
Pr
os
Al ta te
lo
c
t h an
Al
e r ce
l o Al
r
c
th l o
e r t h anc
c er
e
Ne ard c a r
ph i o us
rit v as es
is
/N cul
He e p ar
ar hro
tD
s
is is
e
Al a s
lC e
au
s
Co S e
t
lo ro
Pn
k
n
ca e
eu
n
m
on S cer
ia uic
/In
f lu ide
en
z
D
Lo
Li i a a
ve be
w
er
r d te
re
is s
sp
ea
ira
se
to
ry H
di I V
Un
s
L
i n un e a
se
te
nt g c
io an
na ce
li r
n
Ho jur
m y
ic
id
e
Absolute value of RI
2.00
1.50
RII (mean)
C
1.00
0.00
0.25
0.20
0.15
0.10
0.50
0.05
0.00
Absolute value of C
Relative Index of Inequality (RII mean)
and the Concentration Index (C)
0.35
0.30
os
t
Al a te
lo
ca
Al
t
n
h
l o All
er ce
th o t ca r
er he n
Ne ca r c ce r
ph rdi a u
ri t ova se s
is
/N scu
la
He ep
ar hro r
tD s
is is
e
Al as
lC e
au
Co S se
lo tro
Pn
k
n
ca e
eu
nc
m
on Su er
i a ic
/In id
fl u e
en
D
Lo
Li ia za
ve be
w
er
r d te
re
is s
ea
sp
se
ira
to
ry H
Un L dis IV
ea
in un
te g
s
nt ca e
io
na nce
li r
n
Ho jur
y
m
ic
id
e
Pr
Relative educational inequality in cause-specific
mortality:
U.S. Men, NHIS/NDI 1990-2000
2.0
1.5
RII
(mean)
1.0
0.5
0.0
re
a
st
c
an
RII
(mean)
c
Su er
ic
A
id
ll
ot S t e
A he rok
ll
o t r ca e
he n
c
U
C r ca er
A nin olo u
ll
ot ten n c ses
he t i
a
r c o n n ce
ar al i r
di nj
ov ur
as y
cu
A
Pn
la
l
eu Lu l Ca r
m ng us
on c
e
ia an
/In c
Lo
Li flu er
ve
en
w
er
r
z
re He dis a
sp ar
ea
t
i
r
D s
N
ep ato ise e
hr ry as
d
iti
s/ i se e
Ne a
p h se
ro
s
D
ia is
b
H ete
om s
ic
id
e
H
IV
B
Relative educational inequality in cause-specific
mortality:
U.S. Women, NHIS/NDI, 1990-2000
2.0
1.5
1.0
0.5
0.0
nt
e
nt
io
na
li
nj
ur
y
2.0
HI
V
S
Lu ui
ng cid
ca e
Li
Lo
ve
n
w
r d cer
er
is
re
ea
sp
se
ira
S
to
ry tro
d i ke
se
a
Ho se
Pn
m
C
ic
eu o l
id
m on
on
ca e
Br
ia
n
/In ce
ea
st
flu r
or
en
z
Pr A
o s ll C a
ta
te aus
Al
ca e
lo
nc
th
er
Al
er
lo
th Hea cau
s
er
r
ca t D es
r d is e
i
a
Al ova se
lo
s
t h cu l
ar
er
c
Ne
an
ph
c
rit Dia er
is
/N bet
ep es
hr
os
is
Un
i
Relative educational inequality in cause-specific
mortality:
Men compared with Women
2.5
Women
Men
RII
(mean)
1.5
1.0
0.5
0.0
rd
HI
V
is
ot
he ea
r c se
Pn
au
eu
se
m
s
on Dia
b
ia
et
e
Pr /In
os flu s
e
ta
Al
te nza
lo
ca
Lo th He
n
a
e
w
er r c rt D cer
is
re ard
ea
sp
io
ira va se
t o sc
u
ry
di lar
se
a
Al se
Al
l
lo
th Cau
er
s
Ne
Co ca e
nc
ph
l
e
rit on
ca r
Un is
in /Ne nce
te
ph
r
nt
io ros
na
is
li
nj
ur
y
Lu Str
ng ok
ca e
nc
e
Su r
i
Ho cid
m e
ic
id
e
Al
l
RII
(mean)
Li
ve
Relative inequality in cause-specific male mortality:
Education compared to Income
2.5
2.0
Education
Income
1.5
1.0
0.5
0.0
Slope Indices of Inequality for cause-specific mortality:
U.S. Men, aged 25+, NHIS/NDI, 1990-2000
SII
Heart disease
-320
Stroke
-59
Other cardiovascular
-18
Lung cancer
-130
Colon cancer
-27
Prostate cancer
-10
Other cancer
-73
Pneumonia / Influenza
-17
HIV
-33
Lower respiratory disease
-81
Liver disease
-20
Diabetes
-41
Nephritis / Nephrosis
-12
Homicide
-15
Suicide
-17
Unintentional injury
-66
All other causesBut
-99
Slope Indices of Inequality for cause-specific mortality:
U.S. Men, aged 25+, NHIS/NDI, 1990-2000
co
Heart disease
SII
-320
Stroke
-59
Other cardiovascular
-18
Lung cancer
-130
Colon cancer
-27
Prostate cancer
-10
Other cancer
-73
Pneumonia / Influenza
-17
HIV
-33
Lower respiratory disease
-81
Liver disease
-20
Diabetes
-41
Nephritis / Nephrosis
-12
Homicide
-15
Suicide
-17
Unintentional injury
-66
All other causes
-99
Sum = -1037
Percent contribution of mortality inequality
for specific causes to total inequality:
U.S. men ages 25+, NHIS/NDI, 1990-2000
100%
90%
80%
13.0
3.2
5.1
9.4
70%
All other causes
Pneumonia &
Influenza
Diabetes & N/N
10.6
60%
External causes
50%
20.4
Other cancer
40%
30%
20%
10%
0%
38.2
Lung cancer &
Lower Resp
Cardiovascular
Decomposition of total RII into
contributions of relative inequality
for specific causes
RII
Prop *
RII
% of
RII for
all
causes
.404
-.67
-.271
38.2
186.1
.127
-1.14
-.144
20.4
268.7
.183
-.41
-.075
10.6
External causes
84.5
.058
-1.16
-.067
9.4
Diabetes & N/N
61.1
.042
-.87
-.036
5.1
Pneumonia /
Influenza
42.1
.029
-.79
-.023
3.2
231.7
.158
-.58
-.092
13.0
Age-adj
DR
Prop of
AC DR
Cardiovascular
disease
592.6
Lung cancer & LRD
Other cancer
All other causes
Percent contribution of mortality inequality for specific causes
to total inequality:
Education compared with Income
100%
13.0
80%
3.2
5.1
9.4
17.4
3.5
5.2
7.1
10.6
60%
20.4
10.6
17.3
40%
20%
All other causes
Pneumonia &
Influenza
Diabetes & N/N
External causes
Other cancer
38.2
38.8
Education
Income
0%
Lung cancer &
Lower Resp
Cardiovascular
Percent contribution of mortality inequality for specific causes
to total income-related inequality:
Men compared with Women
100%
80%
17.4
17.6
3.5
5.2
3.0
7.1
11.4
4.1
60%
10.6
17.3
Pneumonia &
Influenza
Diabetes & N/N
10.7
11.4
40%
20%
All other causes
External causes
Other cancer
38.8
41.8
Men
Women
0%
Lung cancer &
Lower Resp
Cardiovascular
Uses of summary measures:

Comparisons of relative
inequality indexes
• Enhance etiological understanding
of SES patterns
• Point to areas for future research

Decomposition of summary
measures
• Targeting of resources for maximal
reduction of inequality