Social Inequalities in Health

PUBH 804
Dr. Daniel Fuller
August 20, 2014

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Overview
1.
2.
3.
4.
5.
6.
7.

Inequality and inequity

Explaining health inequalities
Measuring health inequalities
Quantifying difference
Poverty and Gradient
Action on Health Inequalities
Conclusions
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1. Inequality and inequity

Health inequality is the term used to designate

differences, variations, and disparities in the
health achievements of individuals and groups.
Health inequity refers to those inequalities in
health that are deemed to be unfair or
stemming from some form of injustice.

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Kawachi et al., 2002

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Neudorf et al., 2014

Inequities reflect values

What are societal values?

Fairness
Diversity
Inclusion
Democracy
Individual Independence
Sustainability
Health
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Inequality vs. Inequity

Person A, dies skydiving at age 40.

Person B, does not skydive, dies at age 80.

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Inequality vs. Inequity

Person A, has random genetic mutation, dies at

age 40.
Person B, does not have random genetic
mutation, dies at age 80.

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Saskatoon Health Region

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Neudorf et al., 2014

Inequality, inequity or both?

Groups of 2-3.
Take 5 minutes.
In the 3 scenarios discuss whether the difference
is an inequality, an inequity or both.

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2. Explaining Health Inequalities

2.1 Artefact
2.2 Selection
2.3 Behavioural
2.4 Structural
2.4.1 Material
2.4.2 Psychosocial

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2.1 Artefact

There is no real relationship between social

factors and health.
How we measure social factors will affect the
results we get.
Social
Factor

Health
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2.2 Selection

Ill health causes social differences between

groups.

Health

Social
Factor
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Artefact and Selection

These 2 explanations have been shown to be

false and are no longer considered valid
explanations for health inequalities.

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2.3 Behavioural

Health damaging behaviours (smoking, drinking,

etc) are differentially distributed across social
groups and explain the SES gradient.

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2.4 Structural

Social and physical environment (crime, housing)

are differentially distributed across social groups
and explain the SES gradient.

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2.4.1 Structural - Material

Material
Less access to tangible material conditions, food,
shelter, health care, home ownership, access to
internet, etc.

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2.4.2 Structural - Psychosocial

Psychosocial
Direct or indirect effects of stress stemming from
either being lower on the socioeconomic hierarchy,
or living under conditions of relative
socioeconomic disadvantage.
Allostatic Load

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2.4 Structural

Material and psychosocial explanations for

health inequalities are not mutually exclusive.

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How do you explain the gradient?

Groups of 2-3.
Take 5 minutes.
Write down as many explanations for the
gradient in diabetes in Saskatoon as possible.
Is the gradient unequal, inequitable, or both?

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Saskatoon Data - Diabetes

30

Diabetes Rate per 1000

25

20

15

10

0
Lowest Income

Highest Income

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Neudorf et al., 2014

3. Measuring Health Inequalities

3.1 Independent measures
Income
Ethnicity

3.2 Composite measures

Combination of multiple independent measures

3.3 Area level factors (Places)

Index of Deprivation
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3.1 Independent Measures

Income

Before Tax
After Tax
Individual
Household

Ethnicity
Education
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3.1 Independent Measures

Income (Canadian Community Health Survey)

What is your best estimate of the total income
received by all household members, from all
sources, before taxes and deductions, in the past
12 months?

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3.1 Independent Measures

Income (Behavioral Risk Factor Surveillance

System)
Is your annual household income from all sources:

Less than $10,000

Less than $15,000 ($10,000 to less than $15,000)
Less than $20,000 ($15,000 to less than $20,000)
Less than $25,000 ($20,000 to less than $25,000)
Etc
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3.2 Composite Measures

Deprivation Index
Individual Income
Education Level
Employment

Top 20% versus bottom 20%

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Pampalon et al., 2009

3.2 Composite Measures

Life Expectancy (age 25) and Deprivation

Canada

Men

Top 20%: 57.7 years (57.7+25=82.7 years)

Bottom 20%: 48.2 years (57.7+25=73.2 years)

Women

Top 20%: 64.1 years (64.1+25=89.1 years)

Bottom 20%: 56.5 years (64.1+25=81.6 years)

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Pampalon et al., 2009

3.3 Area Level Measures

Based on geographic areas

Neighbourhoods
Census Geographies

Dissemination Area

400-700 people in an area (similar to a neighbourhood)

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3.3 Area Level Measures

Pampalon Index of Deprivation

Combines 6 independent measures

Material Deprivation

Proportion of people without high school (15 years +)

Employment ratio (15 years +)
Average income (15 years +)

Social Deprivation

Proportion of people living alone (15 years +)

Proportion of people separated, divorced or widowed (15 years +)
Proportion of single-parent families (15 years +)
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Pampalon et al., 2009

Deprivation Index in Saskatoon

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4. Quantifying Difference
Social Group Differences
4.1 Rate Ratio
4.2 Rate Difference
4.3 Regression
Distribution of Health Status
4.4 Lorenz Curve and Gini Coefficient
4.5 Concentration Curve and Coefficient
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4.1 Rate Ratio

Income
Income < $20,000

Diabetes Rate per 1000 in 2009

25.2
15.8
13.2
4.6

Income > $100,000

2.5

Divide rate of lowest by rate of highest

25.2/2.5=10.1

10.1 times more diabetes in poorest compared

to richest
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4.2 Rate Difference

Income
Income < $20,000

Diabetes Rate per 1000 in 2009

25.2
15.8
13.2
4.6

Income > $100,000

2.5

Subtract rate of lowest by rate of highest

25.2-2.5=22.7

22.7 more cases per 1000 people in poorest

compared to richest
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4.3 Regression

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Wilson et al., 2009

Distribution of health status

4.4 Lorenz Curve and Gini Coefficient
4.5 Concentration Curve and Coefficient

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4.4 Lorenz Curve and Gini Coefficient

Gini Coefficent
Canada=32.6
USA=40.8
Japan=24.9

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https://en.wikipedia.org/wiki/Lorenz_curve

4.5 Concentration Curve and Coefficient

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4.5 Concentration Curve and Coefficient

Concentration Coefficient cut offs

Low inequality <= 0.06
Moderate inequality >0.06 to <=0.20
High inequality >0.20

Diabetes Concentration Coefficient

0.39

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Complimentary measures

Social group differences and distribution of

health status are complimentary measures.
The choice depends on the research questions,
hypothesis, and type of data available.

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Choose a measure and method

A health region asks you to examine differences

in diabetes rates between First Nations and NonFirst Nations populations.
Would you choose a) social group difference, or
b) distribution of health status?
Which method would you chose to quantify
differences?
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5. Poverty and Gradient

5.1 Poverty
a. Absolute
b. Relative

5.2 Gradient
5.3 Individual or population

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5.1 Poverty

Absolute poverty is defined as the inability to

meet basic human needs, such as food, shelter
and, avoidance of disease.
Relative poverty, by contrast, defines poverty in
terms of its relation to the standards that exist
elsewhere in society.

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Kawachi et al., 2002

Absolute Poverty

Market Basket Measure

A nutritious diet (2008 Health Canada)

Clothing and footwear
Shelter
Transportation

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http://www.statcan.gc.ca/pub/75f0002m/2013002/mbm-mpc-eng.htm

Relative Poverty

Low Income Cut Off (LICO)

A LICO is an income threshold below which a family
will likely devote a larger share of its income to the
necessities of food, shelter, and clothing than an
average family.

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http://www.statcan.gc.ca/pub/75f0002m/2012002/figure/fig1-eng.htm

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http://www.statcan.gc.ca/pub/75f0002m/2012002/figure/fig1-eng.htm

5.1 Socioeconomic Gradient

The socioeconomic gradient in health refers to

the worse health of those who are at a lower
level of socioeconomic position - whether
measured by income, occupational grade, or
educational attainment - even those who are
already in relatively high socioeconomic groups.

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Kawachi et al., 2002

5.2 Socioeconomic Gradient

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Marmot et al., 1978

5.2 Socioeconomic Gradient

30

Diabetes Rate per 1000

25

20

15

10

0
Lowest Income

Highest Income

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Neudorf et al., 2014

5.3 Individual or Population

Groups of 2-3.
Take 5 minutes.
Should we use relative or absolute measures to
compare low income or gradients between
countries?

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5.3 Individual or Population

Individual socioeconomic position versus

country average
United States

$32.2 per person per day

World Wide Extreme Poverty

$1.25 per person per day

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http://www.irp.wisc.edu/faqs/faq1.htm

5.3 Individual or Population

Proportion of the population in
households with an income less than
60% of the national median

Ireland
Malta
Germany
Cyprus
Poland
United Kingdom
Portugal
Italy
Spain
Estonia
Greece
Lithuania
Bulgaria
Romania

The UK has a slightly higher proportion of its population in relative low

income than the European Union average

Luxembourg

30%

Finland
Belgium

25%

Sweden

20%

France
Denmark

EU average

Austria
Hungary

15%

Slovenia

10%

Source: Eurostat; the data is for 2009 and is before deducting housing costs; updated Dec 2010

Slovakia
Netherlands

5%

0%
Czech Republic

Latvia

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http://www.poverty.org.uk/01/c.pdf

5.3 Individual or Population

Between individuals in same country
Absolute or Relative Measures

Between countries
Relative Measures
Quality of data differs
Measures differ between countries and over time
Reporting years differ
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6. Action on Health Inequalities

6.1 Millennium Development Goals
6.2 WHO Commission on the Social Determinants
of Health
6.3 Upstream

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6.1 Millennium Development Goals

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http://www.un.org/millenniumgoals/

6.1 Millennium Development Goals

http://www.youtube.com/watch?v=NBoaQtaQA
Os#t=90

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www.usask.ca
http://www.who.int/social_determinants/thecommission/finalreport/en/

6.2 Social Determinants of Health

Closing the Gap in a Generation (WHO)
1. Improve Daily Living Conditions
2. Tackle the Inequitable Distribution of Power,
Money, and Resources
3. Measure and Understand the Problem and Assess
the Impact of Action

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http://www.who.int/social_determinants/thecommission/finalreport/en/

6.3 Upstream
society, through evidence-based, people-

https://www.youtube.com/watch?v=qarQXqKb
mLg

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7. Conclusions
Inequity is value based
Explanations for inequalities matters
There are many complimentary ways to measure
and quantify health differences
Depend on research question, and hypothesis

Individual and population approaches will

influence measures and methods
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References
Kawachi, I., Subramanian, S. V., & Almeida-Filho, N. (2002). A glossary for health inequalities. Journal of Epidemiology &
Community Health, 56(9), 647 652.
Neudorf, C., Kryzanowski, J., Turner, H., Cushon, J., Fuller, D., Ugolini, C., et al. (2014). Advancing Health Equity in Health Care.
Saskatoon. Retrieved June 27, 2014, from
http://www.communityview.ca/pdfs/2014_shr_phase3_advancing_healthequity_healthcare_series.pdf
Winslow, C-E. (1948). Poverty and Disease. American Journal of Public Health, 38, 173-184.
Marmot, M. G., Rose, G., Shipley, M., & Hamilton, P. J. (1978). Employment grade and coronary heart disease in British civil
servants. Journal of Epidemiology & Community Health, 32(4), 244 249. doi:10.1136/jech.32.4.244
Marmot, M. G., & Davey Smith, G. (1989). Why are the Japanese living longer? British Medical Journal, 299, 1547 1551.
Pampalon, R., Hamel, D., Gamache, P., & Raymond, G. (2009). A deprivation index for health planning in Canada. Chronic Diseases
in Canada, 29(4), 178 191.
Pampalon, R., Hamel, D., & Gamache, P. (2009). A comparison of individual and area-based socio-economic data for monitoring
social inequalities in health. Health Reports, 20(3), 84 94.
Richard, W., & Michael, M. (2003). The Solid Facts: Social Determinants of Health (pp. 1 33). World Health Organization.
World Health Organization. (2008). Closing the gap in a generation (pp. 1 256). Geneva: Commission on the Social Determinants
of Health.
Regidor, E. (2004). Measures of health inequalities: part 1. Journal of Epidemiology & Community Health, 58(10), 858 861.
doi:10.1136/jech.2003.015347
Regidor, E. (2004). Measures of health inequalities: part 2. Journal of Epidemiology & Community Health, 58(11), 900 903.
doi:10.1136/jech.2004.023036

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