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
Income in the 2008
in Torino
Health expectancy
at birth in Torino
in the 2000’s
Fonte: Studio Longitudinale Torinese
Mortality by education among males in Italy 2000-2007
Marinacci et al, 2011
Self assessed health (prevalence of bad and very bad) by
education
ITALIAN MALES 25-84 YEARS
Elaborazione a cura del Servizio di Epidemiologia ASLTO3 su dati ISTAT, indagine multiscopo sulla salute 2013
HEALTH INEQUALITIES
FIRST DETERMINANT OF HEALTH VARIATION
EVERY WHEN IT IS MEASURED
EVERY CONTEXT
ETHEROGENEITY IN SIZE
DUE TO POVERTY OF INDIVIDUAL RESOURCES
(EDUCATION, CLASS, INCOME)
ALWAYS IN FAVOUR OF THE MORE ADVANTAGED
GRADIENT
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
Job strain in male workforce in Torino
RISK FACTORS
STRESS
SOCIAL POSITION
= LIFE CONTROL
D’Errico et al., 2011 Elaborazioni su campione di occupati iscritti alla CGIL in Provincia di Torino
Smokers in Italy
Males 2010-2012
Low education
Overweight in Italy
Females 2010-2012
Low education
High education
High education
RISK FACTORS
LIFESTYLES
SOCIAL POSITION
= LIFE CONTROL
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.
Population (%) living close to a waste
disposal by area deprivation of residence,
Italy 2001
RISK FACTORS
ENVIRONMENT
SOCIAL POSITION
= LIFE CONTROL
Fonte: FORASTIERE ET AL. 2011
Acute coronary disease
In Torino, 2009
Coronary revascularization
In Torino, 2009
-
-
+
+
RISK FACTORS
BARRIERS TO CARE
SOCIAL POSITION
= LIFE CONTROL
Elaborazioni su dati dello Studio Longitudinale Torinese – Servizio Sovrazonale di Epidemiologia ASL TO3
RISK FACTORS
STRESS
LYFESTILES
ENVIRONMENT
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
UNEMPLOYMENT AND MENTAL HEALTH IN ITALY, 2013
Cases attributable to unemployment every year
SOCIAL POSITION
= LIFE CONTROL
388.545
Economic interventions against risk of
poverty among unemployed
RISK FACTORS
STRESS
LIFESTYLES
ENVIRONMENT
BARRIERS TO CARE
minus 80.185
Back to unemploymnent rates pre-crisis
DISEASE
minus 257.497
Fonte: Elaborazione Servizio di Epidemiologia ASLTO3 su dati ISTAT, indagine multiscopo sulla salute 2005 e 2013
POPULATION COVERAGE IN BREAST CANCER
SCREENING IN EMILIA ROMAGNA
SOCIAL POSITION
= LIFE CONTROL
1997-2000
2001-2003
RISK FACTORS
STRESS
LIFESTYLES
ENVIRONMENT
BARRIERS TO
CARE
% of cases diagnosed
too late
% of survivors at 5
years after diagnosisi
DISEASE
Pacelli et al. 2014
Differences in life expectancy at 65 anni by social
class
SOCIAL POSITION
= LIFE CONTROL
-
+
RISK FACTORS
STRESS
LIFESTYLES
ENVIRONMENT
BARRIERS TO CARE
DISEASE
Costa et al., elaborazioni su dati dello Studio Longitudinale Torinese – Servizio Sovrazonale di Epidemiologia ASL TO3
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
Death “attributable to educational inequalities
explained by educational inequalities in measurable
risk factors. Turin 2000’s
Avoidable deaths by eliminating
social inequalities in the exposure to
a specific risk factor
Priority setting among the male population in Turin
40
Activity status
30
Occupational class
20
BMI
Social support
Smoking
10
Diabetes
Physical Activity
Fruit&Veg
0
0
50
100
150
200
250
Avoidable deaths by eliminating the impact of a specific risk factor among
all the population
Marra e Zengarini, 2012
Which the impact of CONTEXTUAL
DETERMINANTS AND OTHER RISK
FACTORS in the remaining 54%?
1200
1000
800
600
400
45,7%
Explained
England/W
Denmark
Madrid
Finland
Basque
Austria
Sweden
Turin
Switzerland
Norway
Netherlands
Hungary
Scotland
Barcelona
Brussels
Czech R
France
Poland
Estonia
0
Tuscany
200
Lithuania
Deaths attributable to health inequalities
Death “attributable to educational inequalities
explained and not explained by educational
inequalities in measurable risk factors
Not explained
Marra e Zengarini, 2012
Life-course SES
OUTER LAYER:
DETERMINANTS
MIDDLE LAYER:
RISK FACTORS
INNER LAYER:
BIOLOGICAL PATHWAYS
Epigenetic
mechanisms
ENVIRONMENTAL
EXPOSURES
PSYCHOSOCIAL
EXPOSURES
BEHAVIORAL
EXPOSURES
Inflammatory
processes
Neural
function/
structure
HPA-axis
dysregulation
HEALTHY
AGEING
+ 70%
Impact of individual deprivation on mortality*
+ 5%
+ 7%
+ 14%
Impact of area deprivation on mortality**
*low education **composite deprivation index
+ 1%
RESULTS
NPE: Italy
Interrupted time-series analysis for Italy (Turin) - graphs by education - age 30-79
100
Total
ISCED5-6 (High)
-3.2
80
P>|t|=0.027
P>|t|=0.940
60
-1.7
-6.0
40
-2.9
100
ISCED3-4 (Middle)
ISCED0-2 (Low)
-3.4
P>|t|=0.058
80
P>|t|=0.180
60
-1.8
-5.7
0
-2
01
6
20
06
20
01
-2
00
1
-2
00
6
19
96
19
91
-1
99
1
-1
99
6
19
86
19
81
-1
98
1
-1
98
6
Period
Note: in Turin breast cancer screening started in 1992
19
76
-1
97
0
19
71
20
06
-2
01
6
-2
00
1
20
01
-2
00
6
19
96
-1
99
1
19
91
19
86
-1
99
6
-1
98
1
19
81
-1
98
19
76
19
71
-1
97
6
40
-8.5
Facts
Explanations
Solutions
Responsibilities
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).
Many community of practices arising…
at least one health equity audit
exercise for each by the end of 2015
Migrants
Cooperation
Global
health
Civil society
Monitoring
governance
Economy
PRP
Colleges
Clinical
Media
National
Health
System
INMP project’
stakeholders
Scientific
societies
Social and economic
workforce and representatives
OOSS
Enterprises
Volunteers
associations
Labour
Ministries (non
health)
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
Measuring SES
in the 2011 census
Education
Educational
credentials
Employment
Employment
status
Occupational
position *
* available only in the 2011 sample based census
Family
support
Marital
status
Household
typology
Material
resources
Housing
tenure *
Contextual
characteri
stics
Deprivation
index
Knoledge gaps in indicators:
the precariousness
At least one type of functional limitation* by age
80
Compression of functional
limitation?
70
60
%
50
2.5 years postponement
40
30
20
10
0
60-64
65-69
70-74
2000
75-79
2005
80-84
85-89
90+
2013
*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
At least one type of functional limitation by economic resources
90
90
80
70
60
80
Larger for the more
2000
advantaged?
60
adequates
%
50
adequates
50
not adequates
%
not adequates
40
40
30
30
20
20
10
10
0
0
90+
60-64
65-69
70-74
75-79
80-84
85-89
90+
90
80
2013
70
60
adequates
50
%
60-64 65-69 70-74 75-79 80-84 85-89
2005
70
not adequates
40
30
20
10
0
60-64
65-69
70-74
75-79
80-84
85-89
90+
National Health Interview Survey, 2000-2005-2013 - Italy
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
Relative importance
of the size
health inequalities
matters?
Confronto tra grandezza
delleof
disuguaglianze
di salute
e politiche di contrasto
20
Eng
inequalities
health
reduce di
of actions to
politiche
contrasto
in the development
Advancement
Livello di avanzamento
sviluppo
18
NO
SW
Sc
ES
16
14
FI
BE
DK
NL
12
IT
10
HU
PL
FR
AT
8
EE
LT
CZ
6
4
2
0
15%
20%
25%
30%
35%
40%
45%
50%
55%
60%
delle disuguaglianze
sul totale della
maschile inequalities
%Peso
of mortality
explained
by mortalità
educational
Marra and Zengarini in Eikemo T et al, 2012
http://www.euro-gbd-se.eu/fileadmin/euro-gbd-se/public-files/EURO-GBD-SE_Final_report.pdf
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…
Putting the BES indicators into the scene
of the crisis
Economic growth
Politics
Istitutions
Resources
Participation/cohesion
Health
Inclusion
Risk factors
Labour
Education
Austerity
Rationing
Health care
Innovation
Landscape culture
Less welfare
Services
Lower pressure
Environment
(physical and social)
Lower environmental
impact
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
60
49
50
40
28
30
23
20
10
5
7
9
0
Prevention
Inequality
Ageing
Mental
health
Unhealthy
behaviours
Marmot
Principles
Kings Fund 2013
Longitudinal studies: WHIP HEALTH,
8% sample of the Italian workforce
RL – RL
W
H
I
P
employees
2005
1985
Artigiani - Commercianti
self employed
1985
2005
Parasubordinati
precarious work
2006
1996
Work injuries and occ. dis.
INAIL
1994
2007
Hospitalization
Health ministry
ISTAT
2001
1999
2008
Causes of death
2011