MEASURING EQUITABLE HEALTH IMPROVEMENT:HOW IS SCOTLAND DOING?(A snapshot of health disparities in Scotland,and a new approach to tackling them) John Frank Director, Scottish Collaboration for Public Health Research and Policy: Professor and Chair, Public Health Research and Policy, University of Edinburgh c/o MRC Human Genetics Unit, Western General Hospital, Crewe Road, Edinburgh EH4 2XU email email@example.com
How are we monitoring health status andinequalities over time?• In report after report, across almost all developed nations, the great majority of health outcomes monitored at the population level are based on: • Mortality statistics, often summarized across all ages as life expectancy and sometimes combined with quality-of- life/morbidity data, as “health expectancy” – our most holistic routine measure • Routinely collected birth outcomes, especially birth-weight, gestational age, and combinations thereof • Hospitalization rates, usually by cause (often affected by small-area-variation due to health care factors, independent of disease burden) • Cancer – and, rarely, other – disease incidence • Self-reported survey data –e.g. self-assessed health status, smoking, height & weight, activity levels, food intake, etc. (“warts and all” – some cultural framing occurs; e.g. self-assessed health status)
Overarching Questions:1) Are Scottish health inequalities, as measured by theseinternational standard indicators, moving in the rightdirection?2) If not, why not?3) Could it be partly because these are in fact ratherinsensitive indicators, inherently difficult to budge in lessthan a human generation?4) What sort of indicators might be more amenable todemonstrating progress “within a decade” (assuming thatserious investments are made, in the interim, in reducingScottish health inequalities.)
Scottish HI Indicators in Current Use• Recent Scottish analyses of Health Inequalities trends and patterns, over the last decade or more, are among the most statistically sophisticated in the world• Despite this, they are liable to the criticism universally applicable to most routinely collected health outcomes in developed countries:
Criticism: major causes of mortality – andmany other routinely collected healthoutcomes -- are no longer very sensitiveto societal changes, in the short run• Conventional wisdom among epidemiologists: “Improved medical care – and indeed most deliberate health policies and programs – at least in developed countries, now only reduce broad categories of mortality rather slowly, and all-cause mortality very slowly.” • Life expectancy, and even all-cause mortality rates, seem subject to “epidemiological momentum / inertia:” they are hard to shift quickly, especially when deaths occur mostly among the elderly, where chronic disease and competing risks matter! • Exceptions: 1) universally accessible, revolutionary treatment advances in epidemic-level disease, e.g. HIV since the 1990s in Brazil; 2) rapidly worsening exposures with rather short latency to death, e.g. liver disease mortality, and alcohol-related deaths, in Scotland since the 1980s • Many other routinely collected outcomes, such as low birth-weight rates and hospitalization rates, suffer from other serious flaws.
1) Absolute SES range over time -- Low birth weight babies Scotland 1998-2005Source: Scottish Government Health Analytical Services (2008) Long-term monitoring of health inequalities
2a) Absolute range: Healthy life expectancy, Males – Scotland 1999- 2006 (Data not available 2003/04)Source: Scottish Government Health Analytical Services (2008) Long-term monitoring of health inequalities
2b) Absolute range: Healthy life expectancy, Females Scotland 1999-2006 (Data not available 2003/04)Source: Scottish Government Health Analytical Services (2008) Long-term monitoring of health inequalities
3a) Absolute range: Alcohol-related mortality 45-74y – Scotland 1998-2006 (European Age-Standardised Rates per 100,000)Source: Scottish Government Health Analytical Services (2008) Long-term monitoring of health inequalities
3b) Alcohol-related mortality amongst those aged 45-74y by Income- Employment Index: Scotland 2006 (European Age-Standardised Rates per 100,000)Source: Scottish Government Health Analytical Services (2008) Long-term monitoring of health inequalities
What major causes of death are clearlydeclining?• Coronary heart disease (CHD) age 45-74, showing a clear 45 % decline from 1997 to 2006, after a similar decline in the previous decade (some recent levelling-off below age 55 – obesity??) Stroke mortality has also declined, by almost as much, in most developed countries, BUT starting many decades earlier – role of improved diet/reduced salt consumption?• Most studies attempting to parse out the contributions of improved prevention, versus treatment, to the CHD mortality decline, show about half of the decline is due to each, but it is not possible to clearly distinguish which aspects of risk factor (e.g. blood pressure, serum cholesterol, smoking) reduction, before CHD symptoms, are due to each of: 1) inherent cultural trends; 2) public health programs to change lifestyle; 3) prevention in primary care [For example what has driven smoking declines!? – many factors!]• OK, but how is the SES gradient in CHD doing, in Scotland?
4a) Absolute range: CHD mortality, 45-74 years, Scotland1997-2006(European Age-Standardised Rates per 100,000)
4b) Absolute range: First-ever hospital admissions for heartattack<75y – Scotland 1997-2006 – i.e. those “arriving alive”(European Age-Standardised Rates per 100,000)
QUESTION:Why has the SES gradient in CHDmortality recently remained so muchbigger than that for heart-attack “arrivealive” hospital admissions?
Answer:• Example: ratio of bottom-SES decile’s rate to top-decile’s rate in 2006: CHD mortality ratio: 340/100 =3.4 AMI hospital’n ratio: 75/65 =1.15• Suggests that many of the low-SES deaths occur prior to hospital arrival, which could be due to any/all of: • More sudden death presentation of CHD, due in turn to “worse disease” at presentation/more primary and secondary tobacco exposure/worse fats in diets? • Delayed presentation – e.g. due to lack of awareness/denial of chest pain at home? • Worse ambulance response times and care? (Police escorts requested for ambulances entering some housing estates, but response can be slow?) • Systematically more “public” settings where sudden collapse occurs, among the privileged, allowing better chance of resuscitation/ early ambulance arrival?
Incident CHD in Scotland, 2000-4Sudden Deaths and AMI admissions 47% 53%Of 93,701 incident AMI events, 50,075 (53%) resulted in death, ofwhich 42,189 (84%) died within the first day – ergo, surelyprevention is at least as important as care?Should there be a focused research effort on sudden death here?
5) Absolute range: Cancer incidence (all sites) <75y – Scotland 1996-2005 (European Age-Standardised Rates per 100,000)Source: Scottish Government Health Analytical Services (2008) Long-term monitoring of health inequalities
Which Causes of Death Currently Contribute Most to RecentScottish Changes in Overall Mortality, and to ChangingInequalities? – A New Analysis by Age and SESAlastair H Leyland, Ruth Dundas, Philip McLoone, F Andrew Boddy.Inequalities in Mortality in Scotland, 1981-2001.MRC Social and Public Health Sciences UnitOccasional Paper Series no. 16Series Editors: Mark Petticrew, Kate HuntFebruary 2007ISBN: 1-901519-06-6Published by:MRC Social and Public Health Sciences Unit4 Lilybank GardensGlasgow G12 8RZ
Comments on foregoing four slides:• These graphs elegantly confirm our earlier impressions: that the death rates among Scottish young adults have steadily worsened over recent decades, due to “external” causes – first in males (1980s) and then spreading to females (1990s)• Beware of thinking, however, that the size of the y-axis-values, across various age-groups, are directly comparable; they are not, because they are proportionate mortality changes over time, as a multiple of the baseline death rate in that age-group, which varies exponentially with age among adults.
Comments on two previous “mountain” graphs:• These are now famous for their novel depiction of a complex SES death pattern – note the very creative use of colour!• They confirm that the main causes of the SES disparities in Scottish death rates are precisely the same “external” causes of death that are driving the increased overall mortality in young adults;• But mortality inequalities in late life are driven by the usual causes of death in older adults, chronic diseases, which are becoming less common overall, but are still very unequally distributed in Scotland.• “It is as if Scotland had two cemeteries, one for the old and one for the young, and the latter is filling up so fast, especially with poor youth, that space must be lent from the old people’s cemetery to meet the need, due to (mostly richer) old persons who now live longer.” (John Frank, April 2007). END OF “CORE” CONTENT FOR THIS LECTURE – REMAINING SLIDES ARE REALLY JUST FOR INTEREST, TO GIVE A SENSE OF PROF. FRANK’S CURRENT WORK!
Comments on two previous “mountain” graphs:• These are now famous for their novel depiction of a complex SES death pattern – note the very creative use of colour!• They confirm that the main causes of the SES disparities in Scottish death rates are precisely the same “external” causes of death that are driving the increased overall mortality in young adults;• But mortality inequalities in late life are driven by the usual causes of death in older adults, chronic diseases, which are becoming less common overall, but are still very unequally distributed in Scotland.• “It is as if Scotland had two cemeteries, one for the old and one for the young, and the latter is filling up so fast, especially with poor youth, that space must be lent from the old people’s cemetery to meet the need, due to (mostly richer) old persons who now live longer.” (John Frank, April 2007).
WHAT MIGHT BE MORE SENSITIVEINDICATORS OF SOCIAL INEQUALITIESIN HEALTH AND FUNCTION?Given the “prompt sensitivity to feasible change”of early childhood cognitive and educationaloutcomes, and their strong predictive power forlifelong function and health, what might aROUTINE surveillance system for such “upstream”indicators look like, for Scotland?
A Useful Example from Canada: HELP (Human EarlyLearning Partnership) at the University of British Columbia,Vancouver “The Early Child Development (ECD) Mapping Project involves implementation of the Early Development Instrument (EDI) in British Columbia (Canada) school districts, to assess the aggregate state of human development, at the Kindergarten level, in each sequential birth cohort. Kindergarten teachers in B.C. began to collect EDI data in 1999/2000, using one day annually of paid time. As of March 2004, all 59 school districts in B.C. had collected EDI data, which is fed back to all communities each year.”
“What the EDI Measures” The EDI gathers data, from K1 teachers, on five subscales of children’s “readiness to learn” aspects of development, age 5-6: • Physical health and well-being • Social competence. • Emotional maturity. • Language and cognitive development. • Communication skills and general knowledge.
The Public Health Challenge in Scotland• The public health problems in Scotland have been well described.• The real public health challenge now, is to develop novel interventions, policies and programmes that make a real difference to the lives of people in Scotland and reduce health inequalities, both within the short- to medium- and longer-term.• How can we best use the extraordinary Scottish public health talent to achieve this?
Scottish Collaboration for Public Health Research & Policy (SCPHRP)• To identify key areas of opportunity for developing novel public health interventions that address major health problems in Scotland.• To foster collaboration between government, researchers and the public health community to develop a national programme of intervention development, implementation and large-scale evaluation.• Build capacity within the public health community for collaborative research of the highest quality.
SCPHRP PrinciplesSCPHRP-sponsored research should:• Address determinants of health that are both important and potentially reversible.• Develop and test interventions that are feasible, socially acceptable, affordable, scalable and sustainable -- and that will result in measurable, equitable health improvement within a reasonable time-frame.• Constitute a legitimate Scottish niche, both within the UK and the wider international research landscapes.• Lie within the current -- or future -- capability (skills and person-power) of the Scottish public health community (researchers and decision-makers).
The Process• SCPHRP will convene a series of consensus workshops to prioritise potential interventions for development, and to establish a series of Working Groups organised around key preventive stages in the life course: • Early years • Teenage and early adulthood • Early to mid-working life • Later life• Each Working Group will develop a three-year work programme designed to support the development and piloting of promising and novel interventions, at the program and policy level.• SCPHRP will facilitate the work of the Working Groups and provide limited pump-prime funding.• Depending on the outcome of these preliminary studies, the final outputs from the Working Groups should be large-scale intervention-grant submissions to U.K. and Int’l agencies.
Priority Intervention Categories Selected bySCPHRP Workshop, Edinburgh, January 2009• Early Life: interventions to improve parenting, especially for high-risk families, with special attention to maternal-infant mental health outcomes• Teenage and Early Adult Life: interventions, including high-risk targeting, to facilitate social, cultural and family connectedness, and mentoring, so that young people make sound decisions about health- related behaviours, and manage life transitions successfully• Early to Mid-Working Life: Interventions to tackle our obesogenic environment: socio-cultural and physical• Later Life: Interventions to maintain function and independence as long as possible, so as to reduce unnecessary or premature disability and dependency
How to Reach Us John Frank firstname.lastname@example.org Sally Haw email@example.com Caroline Rees firstname.lastname@example.org Human Genetics Unit Western General Hospital, Crewe Rd., Edinburgh EH4 2XU Tel 0131-332-2471, ext. 2119