Health, wealth and air pollution

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Title Sub-title
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MEASURING SOCIAL INEQUALITIES IN HEALTH GOING
BEYOND DESCRIPTION TO SUPPORT INTERVENTION
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• 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

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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

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Conceptual framework

• Three approaches
• Structural
• Lifecourse
• Access to resources (economic, geographic,
  regulations, ...)

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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

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1) Structural approach Mackenbach model
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• 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)

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Les ISS au quotidien
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• 3) Access to resource approach
• Living environmentsneighbourhood, regionoffer
  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

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• SIH surveillance Seven health areas
• Mental health
• Occupational health
• Child development
• 4) Ethnicity
• 5) Infectious diseases
• Access to primary care services
• 7) Chronic diseases, lifestyle habits

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• Seven research teams
• Mental health Louise Fournier (INSPQ)
• Occupational health Michel Rossignol (DSP)
• Child development Sylvana Côté (UdeM)
• Ethnicity Alex Battaglini (CSSS)
• Infectious diseases Richard Massé (ÉSP)
• Access to primary care services J-F Lévesque
  (INSPQ)
• 7) Chronic diseases, lifestyle habits Lise
  Gauvin (UdeM)

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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

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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

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CHOICE OF INDICATORS

• The teams also filled out sheets for each of the
  10 selected indicators in their areas
• Sample sheets

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  Indicator   Having a family physician, by income quintiles or material and social deprivation
  Population/Sub-population 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  
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 Reasons for choosing this indicator  Indicators related to the notion of care and services 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  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.
 Data sources, if they already exist geographical scale frequency of data collection data limitations  Multiple survey questionnaires. Data compiled cyclically in the Canadian Community Health Survey.   Available in Canada for provinces and for densely-populated regions.   Data compiled every two years.
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  How is the indicator consistent with "Mackenbach's structural approach" (if it is)?   The number of physicians available and the possibility of having a family doctor are linked to government policies and choices.
  How is the indicator consistent with the "lifecourse approach" (if it is)?   Nil
  How is the indicator consistent with the "resource regulations approach" (if it is)?   Overlaps the notion of healthcare coverage, and reasons for not having a family doctor are linked to geographical availability of services.  
  References   Statistics Canada Levesque, Pineault et al. 2007  
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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)

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Selected indicators

• 1. Mental health
• Psychological distress
• Access to psychotherapy
• Stigmatization due to mental health problems  

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• 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)

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• 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)

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• 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.

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• 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.

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• 2. Occupational health
• Absence from work gt 90 days due to low back
  pain and musculoskeletel disorders
• Businesses"outside the standards" for chemical
  contaminants
• Incidence of carpal tunnel syndrome

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• 3. Child development
• School readiness
• Level of development at age 2
• Children 0 to 5 years old in low-income families
• Availability of childcare services in facilities
• Breastfeeding for the first six months

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• 4. Infectious diseases
• Children's vaccine coverage against influenza,
  pneumococcus and some vaccine-preventable
  diseases
• Living environments at increased risk for
  infectious diseases
• a) Overcrowded housing
• b) Weak social support
• 3) Populations vulnerable to ID

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• OTHER INDICATORS
• 5. Access to care
• Having a regular family physician
• Unmet health services needs
• Health services avoided because of costs

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• 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

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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

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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

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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)

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COMPLEMENTARY INDICATORS

• Overall literacy
• Health literacy
• Food insecurity

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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
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Examples of articulating principles with the
nature of the indicators
Principles or values Indicators
Human dignity and human rights that do not stigmatize
Respect and autonomy of individuals that do not hamper the autonomy of others and enable respect
Benefit and harm whose beneficial effects for the population prevail over harmful ones
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
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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

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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 gt 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)

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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?

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Next steps

• Final formatting
• Development of consultation questionnaire
• Meetings with CSSS
• Integration of comments
• Final report to the Quebec Health Department
• Conference and publications