Value judgements about health inequality aversion

Shehzad Ali
Centre for Health Economics
University of York
Value judgements about health
inequality aversion: results of
two experimental studies
1

Research Team: Richard Cookson (York); Shehzad Ali (York);
Miqdad Asaria (York); Aki Tsuchiya (Sheffield)
With thanks to: Ruth Helstrip, James Koh, Matthew Robson,
Paul Toner and participants of the piloting session
Conference papers:
Ali, Cookson, Tsuchiya and Asaria (2014). Eliciting value
judgements about health inequality aversion: testing for framing
effects. Paper presented in HESG Sheffield in Jan 2014.
Cookson, Ali, Tsuchiya and Asaria (2015). Value judging, fast
and slow: an experimental study of the effects of slow thinking
interventions on expressed health inequality aversion. Paper to
be presented in HESG Leeds in Jan 2015.

Equity vs efficiency
• Value judgements are important for making
policy decisions
• Equity relates to fairness in the the
distribution of health and health care as
opposed to maximising the total sum
(efficiency)
• Potential trade-offs between efficiency and
equity

Public concern for equity, beyond “a
QALY is a QALY”
1. Severity of illness
2. Children vs. adults
3. Socioeconomic inequality in health
• Evidence suggests public concern for all three
issues
Dolan, P, Shaw, R, Tsuchiya, A and Williams, A. (2005). QALY
maximisation and people's preferences: a methodological
review of the literature Health Economics 14(2): 197-208.

Empirical social choice
• In recent years, the inter-
disciplinary field of
“empirical social choice”
has emerged to investigate
social norms about fairness
(Gaertner and Schokkaert,
2012; Konow, 2003)
• Not economic lab
experiments but
psychological experiments
to investigate people’s
views about fairness

Quantifying equity concerns
• Typically use questionnaire methods to quantify
the magnitude of inequality aversion in different
contexts (Shaw et al 2001, Abásolo, Tsuchiya,
2004, 2013; Dolan, Tsuchiya, 2011)
• The concern for inequality can be explicitly
incorporated in decision analysis using
methods such as Distributional Cost-
effectiveness Analysis (Asaria et al 2014) or
other approaches (Johri and Norheim 2012) in
the literature

Potential cognitive biases
• Estimates of inequality aversion are likely to be
influenced by cognitive biases
• We conducted two experimental studies to
assess reliability of value judgements about
health inequality aversion obtained from a
standard questionnaire instrument

Experimental Study 1
Reliability of a standard questionnaire
instrument for eliciting value judgements

Questionnaires
• A standard questionnaire is presented in four
formats
Large gains (in years): Individual level TO1
Small gains (in hours): Individual level TO2
Small gains ABSTRACT (in years): population level TO3
Small gains CONCRETE (in years): population level TO4

0 10 20 30 40 50 60 70 80
Richest Fifth
2nd Richest
Middle Fifth
2nd Poorest
Poorest Fifth
Expected Years of Life in Full Health
England and Wales
Quality adjusted life expectancy at birth
74
62 12
Source: Asaria, M, Griffin, S, Cookson, R, Whyte, S, Tappenden, P. (2012). Cost-equality analysis of
health care programmes – a methodological case study of the UK Bowel Cancer Screening Programme.
Paper presented to Health Economists Study Group in Exeter, January 2013.

Expected Years of Life in Full Health
England and Wales

Shaw, Dolan, Tsuchiya, Williams, Smith and Burrows, 2001.
"Development of a questionnaire to elicit public preferences
regarding health inequalities," Working Papers 040cheop,
Centre for Health Economics, University of York

Final choice
Programme A “dominates” Programme B:
more health for the rich and same health for the poor.
... But Programme B reduces health inequality.

Five views about health inequality
1. Pro-rich (AAAAA)
2. Health maximisers (EAAAA)
3. Weighted prioritarians (BXXXA)
4. Maximin (BBBBA)
5. Strict egalitarians (BBBBB)

TO2 Small Individual Questions

TO3 Small Population Questions: Abstract

Scenario for small population-level
“concrete” question
19
-0.001
0.000
0.001
0.002
0.003
0.004
0.005
Most Deprived IMD 4 IMD 3 IMD 2 Least Deprived
IncrementalPerPersonQALYsComparedtoNoIntervention
targeted universal
Bowel Cancer screening: Impact of Redesign on Health

TO4 Small Population Questions: Concrete

(1) Small versus
unrealistically large health
inequality reductions
(2) Population-level versus
individual-level descriptions
of health inequality
reductions
(3) Concrete versus
abstract intervention
scenarios
(4) Online versus face-to-
face mode of administration
(5) “Academic versus non-
academic” background
Large Individual
Questions TO1
Small Individual
Questions TO2
Small Population
Questions TO3
(abstract)
Small Population
Questions TO4
(concrete)

(1) Small versus
unrealistically large health
inequality reductions
(2) Population-level versus
individual-level descriptions
of health inequality
reductions
(3) Concrete versus
abstract intervention
scenarios
(4) Online versus face-to-
face mode of administration
(5) “Academic versus non-
academic” background
Large Individual
Questions TO1
Small Individual
Questions TO2
Small Population
Questions
(abstract) TO3
Small Population
Questions TO4
(concrete)

Pro-rich >7
Health maximiser 7
Weighted prioritarian 6.5
Weighted prioritarian 6
Maximin 3
Strict egalitarian <3
AAAAA
=AAAA
BAAAA
B=AAA
BBAAA
BB=AA
BBBAA
BBB=A
BBBBA
BBBB=
BBBBB
Non-
Egalitarian
Strong
Egalitarian
{
{
Response classification
B
A
A
A
A

Recruitment and Administration
Administration:
5-hour Saturday session in York city centre
•facilitated discussions in groups of five or six;
•individual completion of the questionnaire
Recruitment of face-to-face sample:
Advertisements in a monthly Your Local Link and 810 leaflets distributed
door-to-door in 10 of the most deprived streets in York.
Payment = £70
On-Line
Recruitment:
1) Website of the Centre for Health Economics at the University of York,
2) Social media,
3)York Local Link magazine
4) Jiscmail mailing list for health economists,
Payment = £0
Respondents divided into Non-academic (n = 83) & Academic (n = 46)
(n=129)
Face-to-face (n=52)

Results
Table 1: Descriptive statistics of the discussion group and on-line survey respond
Discussion group
(N = 52)
Online group:
non-academic
(N = 83)
Online group:
academic
(N = 46)
Baseline Statistic n Statistic n Statistic n
Male (%) 40.4% 21 32.5% 27 32.6% 15
Age (%)
Under 18 0.0% 0 0.0% 0 2.2% 1
18-34 21.2% 11 18.1% 15 39.1% 18
35-49 13.5% 7 15.7% 13 39.1% 18
50-64 38.5% 20 42.2% 35 17.4% 8
65+ 26.9% 14 24.1% 20 2.2% 1
Mean deprivation quintile (mean)
(1 = most deprived; 5 = most affluent)
3.71 51 3.17 83 3.39 33
Social attitude statements* (mean)
(1= strongly agree; 5= strongly disagree)
The creation of the welfare state is one
of Britain's proudest achievements.
1.42 52 1.36 82 1.37 46
Government should redistribute income
from the better-off to those who are less
well off.
2.86 51 2.05 82 2.07 46
*1 suggests most egalitarian and 5 suggests most non-egalitarian
Descriptive statistics of the discussion group and on-line survey respondents

Pro-rich (AAAAA);
Health maximiser (=AAAA);
Weighted prioritarian (BXXXA);
Maximiner (BBBB=);
Strict egalitarian (BBBBB)
** The vertical line indicates the
location of the median
respondent
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
O3: Small-
population…
O2: Small-average
question
O1: Large-average
question
Percentage of respondents
Online mode: academic
Pro-rich
Health maximiser
Weighted
prioritarian
Maximiner
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
D4: Concrete
question
D3: Small-
population…
D2: Small-average
question
D1: Large-average
question
Discussion mode
Pro-rich
Health maximiser
Weighted
prioritarian
Maximiner
Strict egalitarian
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
O3: Small-
population…
O2: Small-average
question
O1: Large-average
question
Online mode: non-academic
Pro-rich
Health maximiser
Weighted
prioritarian
Maximiner
Distribution of responses across principles of health justice
Results (cont.)

Table: Statistical tests (D = Discussion group; O = Online group)
First hypothesis Difference in % that are
strong egalitarian*
Difference in % that are
non-egalitarians*
Wilcoxon signed-rank equality test
on matched dataǁ
Large-average vs small-population question (D1 – D3) -0.8% (p = 0.937) -0.2% (p = 0.937) z = 0.458; p = 0.647
Large-average vs small-average question (D1 – D2) +9.2% (p = 0.377) -5.4% (p = 0.225) z = 1.964; p = 0.050
Large-average vs small-population question (O1 – O3) +2.6% (p =0.765) -3.8% (p =0.281) z = 0.979; p = 0.328
Large-average vs small-average question (O1 – O2) +2.46% (p =0.773) -5.1% (p =0.167) z = 1.915; p = 0.056
Second hypothesis Difference in % that are
strong egalitarian*
non-egalitarians*
Wilcoxon signed-rank equality test
on matched dataǁ
Small-average vs small-population question (D2 – D3) -9.9% (p = 0.350) +5.2% (p = 0.271) z = -1.313; p = 0.189
Small-average vs small-population question (O2 – O3) +0.1% (p =0.991) +1.4% (p =0.767) z = 0.311; p = 0.756
Third hypothesis Difference in % that are
strong egalitarian*
non-egalitarians*
Wilcoxon rank-sum equality test
on unmatched dataǂ
Small-population vs concrete question (D3 – D4) +18.6% (p = 0.080) -11.6% (p = 0.049) z = 3.244; p = 0.001
Fourth hypothesis Difference in % that are
strong egalitarian*
non-egalitarians*
on unmatched dataǂ
Large-average question (D1 – O1) +17.3% (p =0.059) -0.6% (p = 0.838) z =1.338; p = 0.181
Small-average question (D2 – O2) +10.6% (p =0.292) -0.3% (p = 0.954) z = 0.987; p = 0.324
Small-population question (D3 – O3) +20.7% (p =0.036) -4.1% (p = 0.329) z = 2.022; p = 0.043
Fifth hypothesis Difference in % that are
strong egalitarian*
non-egalitarians*
on unmatched dataǂ
Large-average question (Na1 – A1) +23.8% (p = 0.012) -6.6% (p = 0.114) z = 2.930; p = 0.003
Small-average question (Na2 – A2) +29.2% (p = 0.004) -6.9% (p = 0.283) z = 2.506; p = 0.012
Small-population question (Na3 – A3) +26.8% (p = 0.006) -1.05% (p = 0.838) z = 2.489; p = 0.013
Results (cont.)
* Strong egalitarians = maximiner or strict egalitarian; Non-egalitarians = pro-rich or health maximisers.

Conclusion (study 1)
• No evidence of effects of small versus unrealistically
large health inequality reduction scenarios (1) or
population-level descriptions (2)
• Evidence of an anti-egalitarian concrete scenario
effect (3)
• Weak evidence of an anti-egalitarian online mode of
administration effect (4): “socially desirable” face-to-
face responses?
• Clear evidence of an anti-egalitarian academic
sample selection effect (5): academics may be more
comfortable with cognitively demanding tasks?

Conclusion (cont.)
• Reassuring that no clearly significant effects of using
small rather than unrealistically large, or using
population-level rather than individual-level
presentations health gains
• The other effects are potential cause for concern
• Weakness:
– Gain egalitarianism over outcome egalitarianism
(Tsuchiya, Dolan, 2009). However, identical framing with a
fixed ratio of gains has been maintained
– Order of questions was not randomised

Experimental Study 2
Effects of slow thinking interventions on
expressed health inequality aversion

Thinking, fast and slow
• Questionnaire methods are
vulnerable to “fast thinking”
cognitive biases
• Kahneman defines two
systems:
– System 1: Fast, automatic,
emotional, subconscious
– System 2: Slow, effortful,
calculating, conscious
• Respondents may use simple
“like-dislike” approach rather
than carefully weighing the
competing values

“Slow thinking” interventions
• Video animation
– exposing subjects to rival points of view
• Interactive computer-based version of the
questionnaire
– Providing feedback on implied trade-offs between
health inequality and sum total health

Study design
Paper questionnaire
Paper group
Video animation
Paper questionnaire
Interactive questionnaire
Video animation
Interactive questionnaire
Interactive group

Yearsfortherich
Years for the poor
Indifference curves representing
different views on equity
With thanks to Matthew Robson

Recruitment and Administration
Administration:
5-hour Saturday session in Heslington East
Campus
Individual completion of the questionnaire
Recruitment:
N = 60 (two sessions with 30 participants each)
Advertisements in a monthly Your Local Link.
Payment = £50

Results
Sample characteristics
Paper group
(N = 29)
Interactive group
(N = 30)
Characteristic Statistic n Statistic n
Male (%) 38% 11 47% 14
Age (%)
18-34 31% 9 20% 6
35-49 7% 2 27% 8
50-64 38% 11 20% 6
65+ 24% 7 33% 10
Deprivation quintile group (mean)
(1 = most deprived; 5 = most affluent)
3.41 29 3.7 30
Social attitude statements(1) (mean)
(1= strongly agree; 5= strongly disagree)
The creation of the welfare state is one of Britain's
proudest achievements.
1.79 29 1.77 30
Government should redistribute income from the
better-off to those who are less well off.
3.03 29 3.10 30
Note: (1) 1 suggests most egalitarian and 5 suggests least egalitarian

Results (cont.)
Figure 1: Inferred principles of health justice by question and sample design* ** ***
* Complete case analysis, n = 30 in the interactive group, n = 29 in the paper group
** See table 2 for the response classification system corresponding to the five principles of health justice
*** The vertical line indicates the location of the median respondent
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Post-video interactive
Pre-video interactive
Post-video paper
Pre-video paper
Pro-rich
Health maximiser
Weighted prioritarian
Maximin
Strict egalitarian

Figure 2: Cumulative distribution of responses (1), (2)
Notes
(1)
Complete case analysis, n = 30 in the slider group and n=29 in the paper group
(2)
The trade off point represents the point of indifference in terms of the gain to the poorest fifth in programme
A, as shown in the response classification system in table 2.
Wilcoxon rank sum test
[p = 0.000]
0.000.200.400.600.801.00
>8 8 7.5 7 6.5 6 5.5 5 4.5 4 3.5 3 2.5 2 <2
Trade off point (number of years)
group = paper group = interactive
Wilcoxon rank sum test
[p = 0.004]
0.000.200.400.600.801.00
>8 8 7.5 7 6.5 6 5.5 5 4.5 4 3.5 3 2.5 2 <2
group = paper group = interactive
Wilcoxon sign rank test
[p = 0.000]
0.000.200.400.600.801.00
Cumulativeresponseproportion
>8 8 7.5 7 6.5 6 5.5 5 4.5 4 3.5 3 2.5 2 <2
Pre-video, paper Post-video, paper
Wilcoxon sign rank test
[p = 0.945]
0.000.200.400.600.801.00
Cumulativeresponseproportion
>8 8 7.5 7 6.5 6 5.5 5 4.5 4 3.5 3 2.5 2 <2
Pre-video, interactive Post-video, interactive
Pre-video vs. post-video (interactive)Paper vs. interactive (post-video)
Pre-video vs. post-video (paper)Paper vs. interactive (pre-video)
Results (cont.)

Figure: Paper group responses, pre- and post-video
>8
8
7.5
7
6.5
6
5.5
5
4.5
4
3.5
3
2.5
2
<2
>8 8 7.5 7 6.5 6 5.5 5 4.5 4 3.5 3 2.5 2 <2
Pre-video switching point
Results (cont.)

Table 3: Random effects ordered probit models of the five ordered response categories
Variables Without
respondent
covariates
With
respondent
covariates
Interactive ( 𝛽1) -2.32*** -2.18***
(0.417) (0.407)
Post-video ( 𝛽2) -1.49*** -1.50***
(0.344) (0.343)
Interactive*post-video ( 𝛽3) 1.70*** 1.70***
(0.451) (0.451)
Joint test of ( 𝛽2 + 𝛽3):
Video effect on interactive
0.21
(0.28)
0.20
(0.28)
Joint test of ( 𝛽1 + 𝛽3):
Interactive post-video vs. paper post-video
-0.63*
(0.34)
-0.49
(0.34)
Intercept 1 (strict egalitarian) -3.39***
(0.459)
-4.09***
(0.766)
Intercept 2 (maximin) -2.70*** -3.43***
(0.399) 0.727)
Intercept 3 (weighted prioritarian) -0.92*** -1.67**
(0.283) (0.649)
Intercept 4 (health maximiser) -0.23 -0.96
(0.264) (0.631)
Observations 118 118
Number of individuals 59 59
Notes:
(1) A positive coefficient indicates a difference in a more egalitarian direction
(2) Standard errors in parentheses; *** p<0.01, ** p<0.05, * p<0.1
(3) The respondent covariates were four age groups, sex and five deprivation quintile groups; coefficients on
the covariates are suppressed as none were significant.
Results (cont.)
Notes:
(1) A positive coefficient indicates a difference in a more egalitarian direction
(2) Standard errors in parentheses; *** p<0.01, ** p<0.05, * p<0.1
(3) The respondent covariates were four age groups, sex and five deprivation quintile groups; coefficients on
the covariates are suppressed as none were significant.

-.4-.3-.2-.1
0
.1.2.3.4
Pro-rich Health max Trader Maximin Strict Egal
Inferred principles of health justice
(post-video paper minus pre-video paper)
Change in predicted probabilities: ordered probit model
Figure: Marginal effects on probabilities, from ordered probit model
Results (cont.)

Conclusion (study 2)
• Both “slow thinking” interventions produced
significantly less egalitarian responses
• Paper group (before vs after): strong egalitarian
response reduced from 75% to 21%
– Due to strong egalitarians switching to weighted
prioritarians
• Interactive vs paper: strong egalitarian responses
were 23% vs 75%
• Fast thinking effect: treating equality as a “sacred
value”
• Potential “Social desirability bias”?

Conclusion (overall)
• Standard methods of eliciting value
judgements about inequality aversion are
vulnerable to cognitive biases
• “Slow thinking” interventions may reduce pro-
egalitarian bias
• Expressed inequality aversion is vulnerable to
scenario effect, sample selection and, to some
extent, on mode of administration

Value judgements about health inequality aversion

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