health inequalities, sustainability and inclusion: an agenda for statistics giuseppe costa...

Health inequalities, sustainability and inclusion: an agenda for statistics

Giuseppe Costa Università di Torino

Do health inequalities (HIs) matter for a sustainable and inclusive development?

Challenges for statistics.

-About health inequalities- Facts- Mechanims- Solutions- Knowledge gaps

-Policy implications: the role of evidence -Challenges for statistics:

- Data, design, validity- The contribution of BES

Do health inequalities (HIs) matter for a sustainable and inclusive development?

Challenges for statistics.

-About health inequalities- Facts- Mechanims- Solutions- Knowledge gaps

-Policy implications: the role of evidence -Challenges for statistics:

- Data, design, validity- The contribution of BES

Income in the 2008 in Torino

Fonte: Studio Longitudinale

Torinese

Health expectancy at birth in Torino in the 2000’s

Income in the 2008 in Torino

Mortality by education among males in Italy 2000-2007

Marinacci et al, 2011

Self assessed health (prevalence of bad and very bad) by educationITALIAN MALES 25-84 YEARS

Elaborazione a cura del Servizio di Epidemiologia ASLTO3 su dati ISTAT, indagine multiscopo sulla salute 2013

FIRST DETERMINANT OF HEALTH VARIATION EVERY WHEN IT IS MEASURED

EVERY CONTEXT

ETHEROGENEITY IN SIZE

DUE TO POVERTY OF INDIVIDUAL RESOURCES (EDUCATION, CLASS, INCOME)

GRADIENT

HEALTH INEQUALITIES

ALWAYS IN FAVOUR OF THE MORE ADVANTAGED

Do health inequalities (HIs) matter for a sustainable and inclusive development?

Challenges for statistics.

-About health inequalities- Facts- Mechanims- Solutions- Knowledge gaps

-Policy implications: the role of evidence -Challenges for statistics:

- Data, design, validity- The contribution of BES

DEMAND

CONTROL

REWARD

SUPPORT

DEMAND

CONTROL

REWARD

SUPPORT

SOCIAL POSITION= LIFE CONTROL

RISK FACTORS

STRESS

D ’Errico et al., 2011 Elaborazioni su campione di occupati iscritti alla CGIL in Provincia di Torino

Job strain in male workforce in Torino

RISK FACTORS

LIFESTYLES

FONTE: PASSI 2010-2012 / Da: Costa G., Bassi M., Gensini G.F., Marra M., Nicelli A.L., Zengarini N.(2014) L ’equità nella salute in Italia. Secondo rapporto sulle disuguaglianze sociali in sanità. Fondazione Smith Kline e Franco Angeli, Milano.

Smokers in ItalyMales 2010-2012

Low education High education

SOCIAL POSITION= LIFE CONTROL

Low education High education

Overweight in ItalyFemales 2010-2012

RISK FACTORS

ENVIRONMENT

Fonte: FORASTIERE ET AL. 2011

Population (%) living close to a waste disposal by area deprivation of residence, Italy 2001

SOCIAL POSITION= LIFE CONTROL

RISK FACTORS

BARRIERS TO CARE

Elaborazioni su dati dello Studio Longitudinale Torinese – Servizio Sovrazonale di Epidemiologia ASL TO3

Acute coronary disease In Torino, 2009

Coronary revascularization In Torino, 2009

-

+

-

+

SOCIAL POSITION= LIFE CONTROL

RISK FACTORS

STRESS

LYFESTILES

ENVIRONMENT

BARRIERS TO CARE DISEASE

SOCIAL POSITION= LIFE CONTROL

Do health inequalities (HIs) matter for a sustainable and inclusive development?

Challenges for statistics.

-About health inequalities- Facts- Mechanims- Solutions- Knowledge gaps

-Policy implications: the role of evidence -Challenges for statistics:

- Data, design, validity- The contribution of BES

Fonte: Elaborazione Servizio di Epidemiologia ASLTO3 su dati ISTAT, indagine multiscopo sulla salute 2005 e 2013

UNEMPLOYMENT AND MENTAL HEALTH IN ITALY, 2013

Cases attributable to unemployment every year

388.545Economic interventions against

risk of poverty among unemployed

minus 80.185RISK FACTORSSTRESS

LIFESTYLESENVIRONMENT

BARRIERS TO CARE

SOCIAL POSITION= LIFE CONTROL

DISEASE minus 257.497

Back to unemploymnent rates pre-crisis

Pacelli et al. 2014

POPULATION COVERAGE IN BREAST CANCER SCREENING IN EMILIA ROMAGNA

1997-2000

% of cases diagnosed too late

% of survivors at 5 years after diagnosisi

2001-2003

RISK FACTORSSTRESS

LIFESTYLESENVIRONMENTBARRIERS TO

CARE

SOCIAL POSITION= LIFE CONTROL

DISEASE

Costa et al., elaborazioni su dati dello Studio Longitudinale Torinese – Servizio Sovrazonale di Epidemiologia ASL TO3

Differences in life expectancy at 65 anni by social class

- +

RISK FACTORSSTRESS

LIFESTYLESENVIRONMENT

BARRIERS TO CARE

SOCIAL POSITION= LIFE CONTROL

DISEASE

Do health inequalities (HIs) matter for a sustainable and inclusive development?

Challenges for statistics.

-About health inequalities- Facts- Mechanims- Solutions- Knowledge gaps

-Policy implications: the role of evidence -Challenges for statistics:

- Data, design, validity- The contribution of BES

Marra e Zengarini, 2012

Death “attributable to educational inequalities explained by educational inequalities in

measurable risk factors. Turin 2000’s

Priority setting among the male population in Turin

Diabetes

BMISocial support

Physical Activity

Activity status

Fruit&Veg

Occupational class

Smoking

0

10

20

30

40

0 50 100 150 200 250

Avoidable deaths by eliminating the impact of a specific risk factor among all the population

Avo

idab

le d

eath

s b

y el

imin

atin

g

soci

al i

neq

ual

itie

s in

th

e ex

po

sure

to

a

spec

ific

ris

k fa

cto

r

0

200

400

600

800

1000

1200

Lith

ua

nia

Est

on

ia

Po

lan

d

Tu

sca

ny

Fra

nce

Cze

ch R

Bru

sse

ls

Ba

rce

lon

a

Sco

tlan

d

Hu

ng

ary

Ne

the

rla

nd

s

No

rwa

y

Sw

itze

rla

nd

Tu

rin

Sw

ed

en

Au

stri

a

Ba

squ

e

Fin

lan

d

Ma

dri

d

De

nm

ark

En

gla

nd

/W

De

ath

s a

ttri

bu

tab

le t

o h

ea

lth

ine

qu

alit

ies

Explained Not explained

45,7%

Marra e Zengarini, 2012

Death “attributable to educational inequalities explained and not explained by educational

inequalities in measurable risk factors

Which the impact of CONTEXTUAL DETERMINANTS AND OTHER RISK FACTORS in the remaining 54%?

HPA-axis dysregulation

Inflammatoryprocesses

Neural function/structure

Epigenetic mechanisms

ENVIRONMENTAL EXPOSURES

BEHAVIORAL EXPOSURES

PSYCHOSOCIAL EXPOSURES

OUTER LAYER: DETERMINANTS

MIDDLE LAYER: RISK FACTORS

INNER LAYER: BIOLOGICAL PATHWAYS

HEALTHY AGEING

Life

-cou

rse

SES

Impact of individual deprivation on mortality*

Impact of area deprivation on mortality**

+ 70%

+ 5% + 7% + 14% + 1%

*low education **composite deprivation index

RESULTSNPE: Italy

Facts

Explanations

SolutionsResponsibilities

www.disuguaglianzedisalute.it

Do health inequalities (HIs) matter for a sustainable and inclusive development?

Challenges for statistics.

-About health inequalities- Facts- Mechanims- Solutions- Knowledge gaps

-Policy implications: the role of evidence -Challenges for statistics:

- Data, design, validity- The contribution of BES

The WHO Commission on Social Determinants of Health (CSDH) – Overarching recommendations

Improve the conditions in which people are born, grow, live, work, and age

Tackle the Inequitable Distribution of Power, Money, and Resources

Measure and Understand the Problem, Evaluate Action, Expand the Knowledge

Base, Develop the Work Force

Country clusters by level of

policy response

•Cluster 1: Relatively positive and active response to health inequalities.

– At least one national response to HIs or comprehensive regional HI policy responses.

•Cluster 2: Variable response to health inequalities.

– No explicit national policy on HIs, but at least one explicit regional response or a number of other policies with some focus on health inequalities.

•Cluster 3: Relatively undeveloped response to health inequalities.

– No focused national or regional responses to health inequalities, no explicit health inequality reduction targets (though there may be targeted actions on the social determinants of health).

INMP project’stakeholders

National Health System

Social and economic

workforce and representatives

Civil society

Media

Ministries (non health)

Global health

Migrants Cooperation

PRP

Monitoring

Colleges

Clinical

governance

Economy Labour

OOSS

EnterprisesVolunteers associations

Scientific

societies

Many community of practices arising… at least one health equity audit

exercise for each by the end of 2015

Do health inequalities (HIs) matter for a sustainable and inclusive development?

Challenges for statistics.

-About health inequalities- Facts- Mechanims- Solutions- Knowledge gaps

-Policy implications: the role of evidence -Challenges for statistics:

- Data, design, validity- The contribution of BES

Monitoring health and social determinants of health across the lifecourse

• Health and health care measurements by socioeconomic position, sex, geographical distribution

• Early years– An indicator of early child development at age 5• Youth• Proportion of young people not in education/ training or

employment • An adult poverty measure• A measure of social isolation and/or poverty at older ages

Marmot, Lancet 2013

Education Employment Material resources

Family support

Contextual

characteristics

Measuring SES in the 2011 census

Educational credentials

Employment status

Occupational position *

Marital status

Household typology

Housing tenure *

Deprivation index

* available only in the 2011 sample based census

Knoledge gaps in indicators: the precariousness

0

10

20

30

40

50

60

70

80

60-64 65-69 70-74 75-79 80-84 85-89 90+

%

2000 2005 2013

At least one type of functional limitation* by age

2.5 years post- ponement

*difficulty in movement, difficulty in communication (views, heard, word), limitation of ambulation, difficulties in the functions of everyday life

National Health Interview Survey, 2000-2005-2013 - Italy

Compression of functional limitation?

0

10

20

30

40

50

60

70

80

90

60-64 65-69 70-74 75-79 80-84 85-89 90+

%

adequates

not adequates

0

10

20

30

40

50

60

70

80

90

60-64 65-69 70-74 75-79 80-84 85-89 90+

%

adequates

not adequates

2000 2005

2013

At least one type of functional limitation by economic resources

0

10

20

30

40

50

60

70

80

90

60-64 65-69 70-74 75-79 80-84 85-89 90+

%

adequates

not adequates

National Health Interview Survey, 2000-2005-2013 - Italy

Larger for the more advantaged?

Mortality rate ratios (1971-2007) by education level for the cohort of men in Turin 50-59 at 1971, without frailty and with frailty (unobserved etherogeneity).

Zarulli et al, BMJopen 2013

Do health inequalities (HIs) matter for a sustainable and inclusive development?

Challenges for statistics.

-About health inequalities- Facts- Mechanims- Solutions- Knowledge gaps

-Policy implications: the role of evidence -Challenges for statistics:

- Data, design, validity- The contribution of BES

Confronto tra grandezza delle disuguaglianze di salute e politiche di contrasto

ES

IT

NL

Eng

SW

AT

DKBE

NO

FISc

LT

FR

EEHU

PL

CZ

0

2

4

6

8

10

12

14

16

18

20

15% 20% 25% 30% 35% 40% 45% 50% 55% 60%

Peso delle disuguaglianze sul totale della mortalità maschile

Live

llo d

i ava

nzam

ento

svi

lupp

o po

litich

e di

con

tras

to

Marra and Zengarini in Eikemo T et al, 2012http://www.euro-gbd-se.eu/fileadmin/euro-gbd-se/public-files/EURO-GBD-SE_Final_report.pdf

% of mortality explained by educational inequalities

Relative importance of the size of health inequalities matters?

Ad

van

cem

ent

in t

he

dev

elo

pm

ent

of

act

ion

s to

red

uce

hea

lth

in

equ

ali

ties

Multiple Factors, Competing Agendas and Diverse Interest Groups

Focus on the Co-Production of Results

Benefits for health

Benefits for other sectors

Benefits for societal goals

Equity & Health Equity as common measures of public policy performance

Benessere Equo e Sostenibile Wellbeing Equitable and Sustainable

Multidimensional aspects of quality of life, including health

Focus on distribution of wellbeing: including inequalities

Guarantee for next generations

Key domains for the Italian BES

The individual sphere

The context

Benessere Equo e Sostenibile Wellbeing Equitable and Sustainable

How to summarize the indicators of the health domain? Healthy ageing is the strongest component

Any avoidable inequality in the wellbeing and in its determinants (geographical, social, ethnic…)

Benessere Equo e Sostenibile Wellbeing Equitable and Sustainable

About mechanisms…

Environment (physical and social)

Education

Health care

Services

Landscape culture

Innovation

Economic growth

Politics

Labour

Istitutions

Health

Risk factors

Resources

Participation/cohesion

Inclusion

Austerity

Rationing Less welfare

Lower environmental impactLower pressure

Putting the BES indicators into the scene of the crisis

Athens, December 5, 2013

Do health inequalities (HIs) matter for a sustainable and inclusive development?

Challenges for statistics.

-About health inequalities- Facts- Mechanims- Solutions- Knowledge gaps

-Policy implications: the role of evidence -Challenges for statistics:

- Data, design, validity- The contribution of BES

Prevalence of stunting by family income and year of survey: Brazil

Victora et al 2011, Monteiro et al 2010

Under five mortality per 1000 live births by mother’s education: Peru 2000 and 2012

(U5M for the ten years preceding the survey) Source: measuredhs.com

Teheran, January 2006

• Meeting with ayatollah Khamenei

”Serious mental health problems as a result of the war with Iraq”

- War and conflict no 1 public health problem in EMRA region

-Opportunity to connect to the international Red cross/Red crescent movement

Priorities agreed by 65 Health and Well-being Boards – Local Government England

Kings Fund 2013

5 7 9

2328

49

0

10

20

30

40

50

60

Prevention Inequality Ageing Mentalhealth

Unhealthybehaviours

MarmotPrinciples

1985 2005

employeesRL – RL

1985 2005

Artigiani - Commercianti

1996 2006

Parasubordinati

self employed

precarious work

WHIP

1994 2007

Work injuries and occ. dis.

INAIL

2001 2008

Hospitalization

Health ministry

ISTAT 1999 2011Causes of death

Longitudinal studies: WHIP HEALTH, 8% sample of the Italian workforce