Title
Sub-title
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  1/39
MEASURING SOCIAL INEQUALITIES
IN HEALTH:
GOING BEYOND DESCRIPTION TO
SUPPORT INTERVENTION
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  2/39
RESEARCH OBJECTIVES

Design a strategy for surveillance of
social inequalities in health in
Québec

Propose a set of indicators to
measure social inequalities in health
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  3/39
SPECIFIC OBJECTIVES
• Define a conceptual framework
• Identify the attributes of an SIH surveillance strategy
(work of the WHO Commission on Social Determinants of
Health)
• Identify relevant indicators
• Produce indicator scoreboard prototypes
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  4/39
Conceptual framework
Three approaches
• Structural
• Lifecourse
• Access to resources (economic,
geographic, regulations, ...)
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  5/39
1) Structural approach
• Point out the fundamental causes of
SIH, which translates inequalities
(income, wealth, education, profession)
into health disparities, regardless of
proximal cause of disease
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  6/39
1) Structural approach – Mackenbach model
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  7/39
Lifecourse approach
– Health is determined by a combination of life
circumstances
– SIS take root in the conditions during the first years
of life, when health gaps widen
– Far-reaching effects impeding their chances of
avoiding SIH determinants (e.g. low birth weight,
chronic stress in early childhood, workplace
accidents early on in work life)
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  8/39
Les ISS au quotidien
Les plus riches
Les plus pauvres
Naissance
Maturité scolaire
Décrochage
scolaire
Insersion
professionnelle
Niveau de
revenu
Milieu de vie
État de santé
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  9/39
Espérance de
vie
3) Access to resource approach
– Living environments—neighbourhood, region—offer
resources favourable or unfavourable to health
(air quality, food safety, active transportation, parks,
tobacco products sold to minors, video lottery
terminals)
– Economic regulations also govern access to
resources.
– Measure the level of access to resources
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  10/39
SIH surveillance – Seven health areas
1)Mental health
2)Occupational health
3)Child development
4) Ethnicity
5) Infectious diseases
6)Access to primary care services
7) Chronic diseases, lifestyle habits
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  11/39
Seven research teams
1)Mental health: Louise Fournier (INSPQ)
2)Occupational health: Michel Rossignol (DSP)
3)Child development: Sylvana Côté (UdeM)
4)Ethnicity Alex Battaglini (CSSS)
5)Infectious diseases: Richard Massé (ÉSP)
6)Access to primary care services: J-F Lévesque
(INSPQ)
7) Chronic diseases, lifestyle habits: Lise Gauvin
(UdeM)
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  12/39
Research teams (con't)
• Socioeconomic inequalities: Jean-Michel
Cousineau
• Ethics: Michèle Stanton-Jean
• Steering committee
– Marie-France Raynault
–
–
–
–
Richard Massé
Jérôme Martinez
Lise Gauvin
Dominique Côté
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  13/39
CHOICE OF INDICATORS
Each team identified indicators that could measure SIH
in its area and produced a report that included
• what's important to know about SIH in relation
to the theme
• an annotated selection of the 10 best indicators
• the operationalization of the conceptual
framework with these indicators
• an argument in favour of three key indicators
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  14/39
CHOICE OF INDICATORS
• The teams also filled out sheets for each of
the 10 selected indicators in their areas
• Sample sheets:
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  15/39
Indicator:
Having a family physician, by income quintiles or material
and social deprivation
Population/Subpopulation
concerned
The population is stratified by income quintiles or material
and social deprivation
Definition of the
indicator or
calculation used
HCU_Q01AA Do you have a family doctor?
1) Yes
2 No
DK, R
HCU_Q01AB Why don't you have a family doctor?
INTERVIEWER: Choose all answers that are appropriate.
1 There are none in the region
2 None in the region are taking new patients
3 Haven't tried to get one
4 Had one who left or retired
5 Other – Specify
DK, R
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  16/39
Reasons for choosing Indicators related to the notion of care and services
this indicator
coverage. This indicator is linked wit the notion of
having a regular source of care, which is known to
facilitate access to care and obtaining appropriate care.
Limits of the
indicator
Data sources,
if they already exist:
-geographical scale
-frequency of data
collection
-data limitations
Indicator originating from survey data and therefore
often based on small sample sizes that limit the
possibility of conducting quintile analyses or small
geographical unit analyses.
Indicator can be biased depending on a person's
understanding of the notion of family doctor.
Multiple survey questionnaires. Data compiled
cyclically in the Canadian Community Health Survey.
Available in Canada for provinces and for denselypopulated regions.
Data compiled every two years.
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  17/39
How is the indicator The number of physicians available and the possibility of
consistent with
having a family doctor are linked to government policies
"Mackenbach's
and choices.
structural
approach"* (if it is)?
How is the indicator Nil
consistent with the
"lifecourse
approach"* (if it is)?
How is the indicator Overlaps the notion of healthcare coverage, and reasons
consistent with the
for not having a family doctor are linked to geographical
"resource
availability of services.
regulations
approach"* (if it is)?
References
Statistics Canada
Levesque, Pineault et al. 2007
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  18/39
Choice of indicators
• The steering committee then examined the key
indicators proposed, to ensure balance and
completeness.
• Same exercise for socioeconomic indicators,
starting from the ones used by the DSP to
monitor the state of health of Montrealers
(census, SLID and Emploi et Solidarité sociale
Québec)
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  19/39
Selected indicators
1. Mental health
1) Psychological distress
2) Access to psychotherapy
3) Stigmatization due to mental health
problems
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  20/39
1) Psychological distress – rationale
•
•
•
Important aspect of mental health; gives a good idea
of a population's state of mental health and of the
impacts of economic, political and social swings.
The rate of distress in Québec is high (especially
among women, young people and low-income
individuals).
A number of interventions are possible to reduce the
gaps between different groups (see CIHI's latest
report)
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  21/39
1) Psychological distress
•
Definition or calculation used: Proportion of the
population aged 15 and over showing high levels on
the psychological distress scale (Kessler)
•
Already compiled – Source: Canadian Community
Health Survey (Stats Can)
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  22/39
2) Access to psychotherapy – rationale:
• Due to a lack of a sufficient number of professionals in
the public network, many people cannot benefit from
affordable services when difficult situations arise.
• Individuals who cannot pay for privately delivered
services are affected the most.
• The consequences of not treating psychological issues
can be disastrous.
• This indicator reflects broad inequality and must lead to
the mobilization of many stakeholders.
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  23/39
2) Access to psychotherapy
• Definition or calculation used: Proportion of the
population aged 15 and over who benefit from
psychotherapy for depression.
• Indicator to build: The Canadian Community
Health Survey (Stats Can) provides data consultations
with a professional, but does not indicate if a visit
resulted in a diagnosis of depression or if
psychotherapy ensued.
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  24/39
2. Occupational health
1) Absence from work > 90 days due to low
back pain and musculoskeletel disorders
2) Businesses"outside the standards" for
chemical contaminants
3) Incidence of carpal tunnel syndrome
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  25/39
3. Child development
1) School readiness
2) Level of development at age 2
3) Children 0 to 5 years old in low-income families
4) Availability of childcare services in facilities
5) Breastfeeding for the first six months
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  26/39
4. Infectious diseases
1) Children's vaccine coverage against
influenza, pneumococcus and some vaccinepreventable diseases
2) Living environments at increased risk for
infectious diseases:
a) Overcrowded housing
b) Weak social support
3) Populations vulnerable to ID
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  27/39
OTHER INDICATORS
5. Access to care
• Having a regular family physician
• Unmet health services needs
• Health services avoided because of costs
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  28/39
6. Chronic diseases and prevention
•
•
•
Smoking rate
Diabetes rate based on glycohemoglobin
Road injuries among pedestrians, cyclists and drivers
of motor vehicles
7. Ethnicity
•
•
•
•
•
Knowledge of languages spoken
Social disqualification
Immigration status
Duration residing
Ethnic origin
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  29/39
SOCIOECONOMIC INDICATORS
• Distribution of the population by income range
• Proportion of the population with low income using
the Market Basket Measure (MBM)*, before and
after taxes
• Proportion of families living below the low income
cutoff
• Average/median income of families, households and
individuals
• Proportion of the population receiving employment
insurance
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  30/39
SOCIOECONOMIC INDICATORS
• Employment rate (the unemployment rate is more
volatile)
• Proportion of the population by highest level of
education completed
• Proportion of private households by household type
• Proportion of the population using 30% to 50% of their
income for housing (affordability ratio)
• Number of people waiting for social housing
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  31/39
SOCIOECONOMIC INDICATORS
• Interquintile income ratios
– 5th quintile/3rd quintile
– 3rd quintile/1st quintile
– Interesting to track socioeconomic inequalities
(2nd and 4th quintiles more difficult to interpret)
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  32/39
COMPLEMENTARY INDICATORS
• Overall literacy
• Health literacy
• Food insecurity
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  33/39
Conceptual model of public good
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Principles of the Universal Declaration
on Bioethics and Human Rights
• Human dignity and human rights
• Benefit and harm
• Autonomy and individual responsibility
• Consent
• Persons without the capacity to consent (new)
• Respect for human vulnerability and personal integrity
•Privacy and confidentiality
• Equality, justice and equity
•Non-discrimination and non-stigmatization
• Respect for cultural diversity and pluralism
• Solidarity and cooperation
• Social responsibility and health (health has been added)
• Sharing of benefits
• Protecting future generations (new)
• Protection of the environment, the biosphere and biodiversity
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  35/39
Examples of articulating principles with the
nature of the indicators
Principles or values
Human dignity and human
rights
Respect and autonomy of
individuals
Benefit and harm
Indicators
Justice and equity
that allow everyone to be treated justly but also take
into account various clienteles' differences
Transparency
Understandable
Social responsibility
that allows to increase the state's and citizens' social
responsibility
Privacy and confidentiality
that respect private life
that do not stigmatize
that do not hamper the autonomy of others and enable
respect
whose beneficial effects for the population prevail
over harmful ones
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  36/39
Process – Ethical framework
• Each selected indicator has been examined in
terms of ethical principles and values targeted by
the surveillance strategy
• Ethical issues specific to each of them will be
detailed in the surveillance strategy
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  37/39
EXAMINATION OF INDICATORS WILL THEY
ENABLE US TO MOVE CLOSER TO THE
DECLARATION'S PRINCIPLES?
• Each indicator has been associated with a
principle, which will make it easier to respect
– For example, in occupational health, business who
do not meet the standards invoke social
responsibility;
– Absence of MSD > 90 days raises the question of
non-stigmatization toward those who are absent for
a long period of time as well as the issue of equity
(future employability undermined)
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  38/39
EXAMINATION OF INDICATORS DO THEY
RESPECT THESE ETHICAL PRINCIPLES...
1. Before data collection – in the way they were
designed?
2. During data collection?
3. Post data collection?
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  39/39
Next steps
•
•
•
•
•
•
Final formatting
Development of consultation questionnaire
Meetings with CSSS
Integration of comments
Final report to the Quebec Health Department
Conference and publications
Centre Léa-Roback  Marie-France Raynault  October 31th 2012  40/39