Best practice guidelines for monitoring socioeconomic inequalities in health status: lessons from Scotland

Context: In this article we present “best practice” guidelines for monitoring socioeconomic inequalities in health status in the general population, using routinely collected data. Methods: First, we constructed a set of critical appraisal criteria to assess the utility of routinely collected outcomes for monitoring socioeconomic inequalities in population health status, using epidemiological principles to measure health status and quantify health inequalities. We then selected as case studies three recent “cutting‐edge” reports on health inequalities from the Scottish government and assessed the extent to which each of the following outcomes met our critical appraisal criteria: natality (low birth weight rate, LBW), adult mortality (all‐cause, coronary heart disease [CHD], alcohol‐related, cancer, and healthy life expectancy at birth), cancer incidence, and mental health and well‐being. Findings: The critical appraisal criteria we derived were “completeness and accuracy of reporting”; “reversibility and sensitivity to intervention”; “avoidance of reverse causation”; and “statistical appropriateness.” Of these, the most commonly unmet criterion across the routinely collected outcomes was “reversibility and sensitivity to intervention.” The reasons were that most mortality events occur in later life and that the LBW rate has now become obsolete as a sole indicator of perinatal health. Other outcomes were also judged to fail other criteria, notably alcohol‐related mortality after midlife (“avoidance of reverse causation”); all cancer sites’ incidence and mortality (statistical appropriateness due largely to heterogeneity of SEP gradients across different cancer sites, as well as long latency); and mental health and well‐being (“uncertain reversibility and sensitivity to intervention”). Conclusions: We conclude that even state‐of‐the‐art data reports on health inequalities by SEP have only limited usefulness for most health and social policymakers because they focus on routinely collected outcomes that are not very sensitive to intervention. We argue that more “upstream” outcome measures are required, which occur earlier in the life course, can be changed within a half decade by feasible programs and policies of proven effectiveness, accurately reflect individuals’ future life‐course chances and health status, and are strongly patterned by SEP.     

Practitioner perspectives on tackling health inequalities: Findings from an evaluation of healthy living centres in Scotland

Little is known about how health practitioners tasked with tackling health inequalities account for their own programmes and actions. This paper attempts to address this gap by drawing on data collected in the course of an evaluation of the Healthy Living Centre (HLC) programme, which was designed to address the wider determinants of health, in particular social exclusion and socioeconomic disadvantage, through targeting services at the most deprived local communities. Six Scottish HLC case studies explored in depth how HLC practitioners conceptualised ‘health inequalities’ and applied the construct to legitimate their public health and health improvement work. Practitioners drew on multiple explanations of health inequalities, sought to apply holistic approaches to service provision, and developed activities that took account of classed practices intended to overcome class-related disempowerment and stigma. They discussed the challenges of positioning services to appeal to and reach target groups and the difficulties in assessing the impact of their work on reducing health inequalities. Responses to tackling inequalities were variable across time and between HLCs, resulting from uneven learning about target groups and their changing needs, an evolving policy agenda and consideration given to the longer-term sustainability of HLC sites. Although practitioners' work to address health inequalities was limited by the programme's focus on working with disadvantaged groups, findings illustrate how classed practices are linked to the challenges of attracting and successfully engaging with such groups. Practitioner accounts highlighted the importance of gaining acceptance to overcome barriers to engagement with disadvantaged communities, the time required to achieve a satisfactory level of engagement, the proximity of service providers to clients and the adaptability of services necessary to address evolving needs.     

Measuring ethnicity in New Zealand: developing tools for health outcomes analysis

Objective. This study examines the development of new tools for analysing links between ethnicity and health outcomes. In a New Zealand context, it focuses on (1) how ethnicity is increasingly articulated as a social construct, (2) how individuals belonging to more than one ethnic group have been recorded and reported in research, and (3) health research and policy implications of the growing proportion of New Zealanders who claim multi-ethnic affiliations.

Design. New Zealand provides a microcosm in which to consider ethnicity, indigeneity, migration and intermarriage, and their interacting effects on society, culture, identity and health outcomes. Against a backdrop of historical debates about the measurement of race, and then ethnicity, the paper explores recent changes in the recording and reporting of ethnicity in the five-yearly Census of Population and Dwellings, and in death registrations. These changes are then considered in relation to the study of ethnic health disparities and the development of policies to overcome them.

Results. In the 2001 Census, of those who responded to the ethnicity question, at a level 1 classification 7.9% gave more than one response. In relation to the indigenous people of New Zealand, of all those who recorded Māori as one or more of their ethnic groups, only 56% recorded Māori only. In the younger age groups, less than half the Māori ethnic group were Māori only. Single ethnic categories disguise considerable within-group diversity in outcomes.

Conclusion. While single ethnic group disparity studies have been useful in the past, we suggest that more sophisticated ways of conceptualising and analysing ethnicity data in relation to health disparities are now required in New Zealand. Based on the New Zealand experience, we also suggest that as international migration continues, and as intermarriage becomes more frequent in most countries, there will be pressure to move from single group race-based measures towards culturally-based complex ethnicity measures.     

Assessing public health policy approaches to level-up the gradient in health inequalities: the Gradient Evaluation Framework

Objectives

This paper seeks to introduce and analyse the development of the Gradient Evaluation Framework (GEF) to facilitate evaluation of policy actions for their current or future use in terms of their ‘gradient friendliness’. In particular, this means their potential to level-up the gradient in health inequalities by addressing the social determinants of health and thereby reducing decision-makers' chances of error when developing such policy actions.

Study design

A qualitative developmental study to produce a policy-based evaluation framework.

Methods

The scientific basis of GEF was developed using a comprehensive consensus-building process. This process followed an initial narrative review, based on realist review principles, which highlighted the need for production of a dedicated evaluation framework. The consensus-building process included expert workshops, a pretesting phase, and external peer review, together with support from the Gradient project Scientific Advisory Group and all Gradient project partners, including its Project Steering Committee.

Results

GEF is presented as a flexible policy tool resulting from a consensus-building process involving experts from 13 European countries. The theoretical foundations which underpin GEF are discussed, together with a range of practical challenges. The importance of systematic evaluation at each stage of the policy development and implementation cycle is highlighted, as well as the socio-political context in which policy actions are located.

Conclusions

GEF offers potentially a major contribution to the public health field in the form of a practical, policy-relevant and common frame of reference for the evaluation of public health interventions that aim to level-up the social gradient in health inequalities. Further research, including the need for practical field testing of GEF and the exploration of alternative presentational formats, is recommended.     

A rapid review of key strategies to improve the cognitive and social development of children in Scotland

Objectives

Inequalities in health and educational outcomes in Scotland show a strong and persistent socioeconomic status gradient. Our aims were to provide policy-makers with a synthesis of international research evidence that assesses the effectiveness of early childhood interventions aimed at equitably promoting cognitive and social development and suggest potential areas for action in Scotland.

Methods

A rapid review was conducted of review level studies of early childhood interventions with outcome measures relating to child cognitive-language or social-emotional development, subsequent academic and life achievement. Websites were searched and interviews were conducted to identify relevant interventions, policies and programmes delivered in Scotland.

Results

: Early childhood intervention programmes can reduce disadvantage due to social and environmental factors. Scottish health policy demonstrates a clear commitment to early childhood development but much work remains in terms of detail of policy implementation, identification of high risk children and families, and early childhood monitoring systems.

Conclusions

Programmes should provide a universal seamless continuum of care and support from pregnancy through to school entry with the intensity of support graded according to need. The current information systems in Scotland would be inadequate for monitoring the effects of early childhood interventions especially in relation to cognitive-language and social-emotional development.     

Quality of health care for ethnic/racial minority populations

This article reviews the composition and characteristics of the health professions, the demographics of the national population, and factors that influence access to health care and satisfaction with care for ethnic/racial minority populations in the United States. In addition, an overview of publicly funded US health insurance programs for the poor is provided along with a discussion of the impact that managed care is having on the American health care system. Finally, the paper summarizes conference discussions regarding the problems, strategies, and approaches that the UK and the US have experienced with respect to providing quality health care for ethnic/racial minority populations.     

Developing an evidence base for policies and interventions to address health inequalities: the analysis of "public health regimes"

Systematic reviews have become an important methodology in the United Kingdom by which research informs health policy, and their use now extends beyond evidence-based medicine to evidence-based public health and, particularly, health inequalities policies. This article reviews the limitations of systematic reviews as stand-alone tools for this purpose and suggests a complementary approach to make better use of the evidence. That is, systematic reviews and other sources of evidence should be incorporated into a wider analytical framework, the public health regime (defined here as the specific legislative, social, political, and economic structures that have an impact on both public health and the appropriateness and effectiveness of public health interventions adopted). At the national level this approach would facilitate analysis at all levels of the policy framework, countering the current focus on individual interventions. It could also differentiate at the international level between those policies and interventions that are effective in different contexts and are therefore potentially generalizable and those that depend on particular conditions for success.     

Placing intersectional inequalities in health

Research into geographical inequalities in health has focused almost exclusively on examining the effects of area-level deprivation and has been largely framed through a compositional-contextual lens, their inter-relationship and the influence of vertical macro-economic and political/policy drivers. However, in the broader health inequalities field, intersectionality has recently emerged as a critical theoretical and methodical approach which examines the concurrent and interacting influences on health of multiple axes of inequality (such as socio-economic status, gender, race/ethnicity and sexuality or gender-identity). Simultaneously, social geography has been explicitly using intersectionality to analyse how mutually constitutive forms of social oppression interact and interrelate with place. This paper exploits the analytical space opened up by this ‘intersectional turn’ by outlining the benefits for research into geographical inequalities in health that can be achieved by taking a more explicit approach to intersectional inequalities. It argues that: (1) geographical research into health inequalities should more explicitly and widely apply an intersectional lens; and relatedly that, in turn, (2) place needs to be considered as an aspect of intersectionality and integrated into the wider intersectional inequalities in health literature. The paper summarises the evolution of theories of place and health inequalities and outlines intersectional theory and the work to date that has been undertaken to integrate this perspective into our understanding of health inequalities. Drawing on the social geography literature into place and intersectionality, the paper explores how this perspective is being used to enhance our understanding of place effects more generally – and how place itself can be considered as an element of intersectional inequalities. Drawing these different bodies of work together, the paper concludes by considering the implications for theories of geographical inequalities in health.     

The UK public health system: change and constancy

The public health system in the UK has evolved from medical officer posts rooted in the era of sanitary reform to a modern service embedded within the National Health Service. The challenge for today's public health function is to retain a broad-based philosophy encompassing population programmes addressing health inequalities, whilst also delivering the personalized approach to supporting lifestyle change which is being demanded increasingly.     

Developing a new small-area measure of deprivation using 2001 and 2011 census data from Scotland

Material deprivation contributes to inequalities in health; areas of high deprivation have higher rates of ill-health. How deprivation is measured has a great impact on its explanatory power with respect to health. We compare previous deprivation measures used in Scotland and proposes a new deprivation measure using the 2001 and 2011 Scottish census data. We calculate the relative index of inequality (RII) for self-reported health and mortality. While across all age groups different deprivation measures provide similar results, the assessment of health inequalities among those aged 20–29 differs markedly according to the deprivation measure. In 2011 the RII for long-term health problem for men aged 20–24 was only 0.71 (95% CI 0.60–0.83) using the Carstairs score, but 1.10 (0.99–1.21) for the new score and 1.13 (1.03–1.24) for the income domain of Scottish Index of Multiple Deprivation (SIMD). The RII for mortality in that age group was 1.25 (0.89–1.58) for the Carstairs score, 1.69 (1.35–2.02) for the new measure and 1.76 (1.43–2.08) for SIMD. The results suggest that researchers and policy makers should consider the suitability of deprivation measures for different social groups.     

The buffering effects of ethnic density on experienced racism and health

Studies in the United Kingdom (UK) show a consistent inequality between the health of ethnic minorities and that of white people. This is exacerbated by the over-representation of ethnic minorities in deprived areas, which have been associated with poorer infant and child health, chronic disease, and high mortality rates. Ethnic density, defined as the proportion of ethnic minority residents in an area, is generally thought of in relation to the negative impacts of area effects on health. However, it can be considered in terms of social networks and supportive communities, possibly mitigating the detrimental impact of racism on the health of ethnic minority people. This study investigated the ethnic density effect and hypothesised that ethnic minority people who live in areas of high ethnic density would report decreased experienced racism and better health outcomes compared to their counterparts living in areas of low ethnic density. Multiple logistic regressions were conducted using data from the Fourth National Survey of Ethnic Minorities and the 1991 UK Census. Results showed a negative association between ethnic density and psychotic symptomatology, but no evidence of an association between ethnic density and general self-rated health. Findings confirm that the experience of racism is lower in places of higher ethnic density and indicate a tendency for a weaker association between racism and health as ethnic density increases.     

Examining the differential association between self-rated health and area deprivation among white British and ethnic minority people in England

Recent discourses in the area of neighbourhood effects on health have advocated for a relational perspective of space and place, focussing on the mutually reinforcing and reciprocal relationship between the environment and the individual. An example of such relationship is that of the interaction between area deprivation and individual ethnicity on reports of self-rated health, which we explored using cross-sectional data from the 2007 Citizenship Survey linked to the 2001 UK census. We aimed to examine whether the association between area deprivation and poor self-rated health differs for ethnic minority groups, as compared to white British people. Following from this, we also examined whether possible differential associations were mediated by ethnic density effects and perceptions of and satisfaction with neighbourhood characteristics. Results of random effects multilevel logistic regression models showed the detrimental association between area deprivation and self-rated health to be of greater magnitude and stronger for white British people than for ethnic minority people. This differential association was not mediated by ethnic density effects or perceptions of and satisfaction with neighbourhood characteristics.     

Deprivation (im)mobility and cause-specific premature mortality in Scotland

A common approach for measuring geographical inequalities in health has been to calculate deprivation scores for small areas and then to aggregate these into quintiles. Mortality rates may then be compared for the highest and lowest deprivation quintiles at two points in time and the change in the difference between the rates determines the extent to which inequalities have widened or narrowed. This 'period-specific' approach to measuring inequalities is problematic both because deprivation calculated at different points in time is not directly comparable, and because the boundaries of the areas used for such analyses often change during the study period. Using 10,058 small areas for Scotland whose boundaries do not change between 1981 and 2001 we examine the deprivation (im)mobility of areas, identifying those that are persistently well-off, stable or deprived and those that improved or worsened during the period. We focus particularly on the 638 persistently most deprived areas. We demonstrate, first and importantly, that premature mortality rates increased significantly over this twenty year period in these areas. Second, we examine which causes of death are mainly responsible for this increase; the risk of death from chronic liver disease, mental disorders due to alcohol, suicide and 'other' causes increased considerably. The geographical approach we describe here is novel and provides new insights into the relationship between deprivation and premature mortality. We suggest that these persistently most deprived Scottish areas deserve special attention and may be particularly appropriate sites for public health interventions related to these causes of premature death.     

'Doing' public health and 'making' public health practitioners: putting policy into practice in 'Starting Well'

Public health policy has arguably taken a new direction in the UK since 1997. This is typified by a review of the public health workforce. A key profession within this workforce is that of health visiting. Starting Well, a Scottish National Health Demonstration Project is one attempt to develop the public health role of health visitors. The project aimed to improve child health by providing intensive home visiting to families in Glasgow. This paper reports on a process study focused on whether Starting Well, an intervention exemplifying contemporary public health policy, could be operationalised through health visiting practice. Semi-structured interviews were conducted with a purposive sample of 44 staff responsible for developing and implementing the programme. Whilst greater contact with families allowed health visitors to develop their understanding of the life circumstances of their case-load families, the evaluation raised issues about the feasibility of systematically changing practice and demonstrated the difficulties of implementing an approach that relied as much on individual values and organisational context as formal guidelines and standardised tools. Furthermore, the ability of the systems and structures within which practitioners were operating to facilitate a broad public health approach was limited. The policy context for public health demands that increasing numbers of health workers are familiar with its principles and modus operandi. It remains, however, a contested area of work and its implementation requires change at a number of levels. This has implications for current policy assumptions about improving population health.     

Regional risk factors for health inequalities in Scotland and England and the “Scottish effect”

This paper uses data from the Scottish Health Survey 2003 and the comparable Health Survey for England 2003 to look at whether Scotland's poor health image and mortality profile is reflected in regional inequalities in prevalence of four risk factors for cardiovascular disease: fruit and vegetable consumption, smoking, obesity and diabetes. It also looks at the “Scottish effect” – how much of any difference between and within Scotland and England remains once socio-demographic factors have been taken in to account. The paper then uses regional analyses to determine the extent to which areas within England and Scotland contribute to their national health advantage and disadvantage. All 2003 strategic health authorities in England and Scottish health boards were compared with Greater Glasgow health board as the reference category.The results showed that significant geographic variation in the risk factors remained once individual economic status was taken into account, but the relationship was complex and varied in strength and direction depending upon risk factor involved and gender of respondent. A small number of areas had significantly lower odds of fruit and vegetable consumption of five portions or more a day in men, compared with Greater Glasgow. In contrast some areas had significantly higher odds of fruit and vegetable consumption for women compared with Greater Glasgow.There was greater geographic variation in the odds of smoking in women than in men. Respondents in the south west and southeast of England (areas which usually show health advantage) did not show significantly lower odds of smoking compared with Greater Glasgow once socio-economic variation, age and urban residence was taken into account. It was respondents from central England that had lower odds of smoking than might be expected. Obesity stood out as the single risk factor that had demonstrated a “Scottish effect” in women only.     

Revisiting the immigrant paradox in reproductive health: the roles of duration of residence and ethnicity

The immigrant paradox refers to the contrasting observations that immigrants usually experience similar or better health outcomes than the native-born population despite socioeconomic disadvantage and barriers to health care use. This paradox, however, has not been examined simultaneously in relation to varying degrees of exposure to the receiving society and across multiple outcomes and risk factors. To advance knowledge on these issues, we analysed data of the Maternity Experiences Survey, a nationally representative cross-sectional survey of 6421 Canadian women who delivered singleton infants in 2006-07. We compared the prevalence of adverse pregnancy outcomes and related risk factors according to women's ethnicity and time since migration to Canada. We calculated prevalences and prevalence ratios (PR) with 95% confidence intervals. Compared to Canadian-born women of European descent, recent immigrants were at lower risk of preterm delivery and morbidity during pregnancy despite having the highest prevalence of low income and low support during pregnancy among all groups, but the paradox was not observed among immigrants with a longer stay in Canada. In contrast, recent immigrants were at higher risk of postpartum depression. Immigrants of non-European origin also had higher prevalence of postpartum depression, irrespective of their length of residence in Canada, but immigrants from European-origin countries did not. Exposure to Canada was also positively associated with higher alcohol and tobacco consumption and body mass index. Canadian-born women of non-European descent were at higher risk of preterm birth and hospitalisation during pregnancy than their European-origin counterparts. Our findings suggest that the healthy migrant hypothesis and the immigrant paradox have limited generalisability. These hypotheses may be better conceptualised as outcome-specific and dependent on immigrants' ethnicity and length of stay in the receiving country.