Long-Term Monitoring of Health Inequalities: Headline Indicators - October 2012

Annex 3 : Technical Notes

A2.1 Measurement of Inequalities

Different measures can give information about different aspects of inequalities. Some measures concentrate on the extremes of deprivation, whilst others include inequalities across the scale - taking into account the whole population. Absolute and relative measures can give quite different interpretations of inequalities. In addition to this, measures based on rates alone will not give insight into the scale of the problem.

Information about different measures of inequality and their calculation was based on work done by the Scottish Public Health Observatory, available at:

http://www.scotpho.org.uk/home/Publications/scotphoreports/pub_measuringinequalities.asp

The approach recommended by the expert group and adopted in this report uses a combination of measures, with the aim of giving a fuller understanding of the inequalities concerned.

• Relative Index of Inequalities (RII): How steep is the inequalities gradient?

The RII describes the gradient of health observed across the deprivation scale, relative to the mean health of the whole population.

The RII is the slope index of inequality (SII) divided by the population mean rate. The SII is defined as the slope of the "best fit" regression line showing the relationship between the health status of a particular group and that group's relative rank on the deprivation scale. An equal rate across the deprivation categories would give a horizontal line with a slope of zero (SII=0) and would indicate that there are no inequalities. The larger the absolute value of SII, the bigger the inequalities observed (see Figure 1).

The SII and RII have the advantage that they are based on data about the whole population, rather than just the extremes, and so take into account inequalities across the scale. They do however require that there is a reasonably linear relationship between the health indicator and deprivation. Another disadvantage is that the SII and RII are not intuitive and are relatively difficult to interpret and explain to a non-statistical audience.

Following discussion with colleagues from the Scottish Collaboration for Public Health Research and Policy (SCPHRP), we investigated the alcohol related indicators to assess possible non-linearity using a 'knot and spline' based approach^[7]. While there was evidence of non-linearity in some years, the technical expert group concluded that it was minor and that it did not invalidate the calculation of RII using the linear method. The group concluded that the linear methodology should be retained due to the complexity of non-linear methods, and the need of consistent reporting and general understanding.

• Absolute range: How big is the gap?

This measure describes the absolute difference between the extremes of deprivation - the rate in the most deprived minus the rate in the least deprived group.

This measure has the advantage that it is intuitive and straightforward to explain. It has the disadvantage that because it focuses only on the extremes of deprivation, it does not take account of patterns of inequalities observed across the intermediate groups.

• Scale: How big is the problem?

The aim of this measure is to give insight into the underlying scale of the problem and to put it in context, for example by presenting numbers involved and past trends at Scotland level.

A2.2 Income-Employment Index

The Short Life Technical Advisory Group also addressed the precise way in which deprivation should be defined for this work. The group agreed that the ideal would be to use individually linked records of health and socio-economic indicators, but acknowledged that these are not yet available. The preferred interim approach was to use the latest available versions of the Scottish Index of Multiple Deprivation (SIMD) income and employment domains. The reasoning behind this being that income / poverty / employment are felt to be the best indicators of deprivation for health inequalities analysis and because the possibility of being able to update these domains on a regular, perhaps annual basis, is being investigated.

In order to combine the SIMD income and employment domains, each domain was exponentially transformed to reduce averaging effects. Exponential transformation gives greater weighting to the most deprived ranking, so combining a datazone ranked most deprived with a datazone ranked least deprived would give a combined ranking skewed towards the deprived end of the scale. This is the method used to create the SIMD.

The income and employment domains have been given equal weighting when combined in the Income-Employment Index.

In line with the recommendations of the Short Life Technical Advisory Group, the Income-Employment Index deciles are population based. Datazone based deciles are produced by ranking the 6,505 datazones in Scotland according to their deprivation score and then dividing them into deciles based on number of datazones (so that those datazones ranked from 1 to 651 are in decile 1 and so on). Population basing the deciles uses the same approach but also takes into account the population sizes involved. The 6,505 datazones are ranked according to their deprivation score alongside a cumulative total of datazone populations. The cut-off for decile 1 is the point at which 10% of the population has been included, rounded to the nearest whole datazone. Population basing the deciles ensures that they contain equally sized populations, which is the best proxy to individual level indicators of deprivation available when using an area based measure. Equally sized populations in the deciles are also important for the types of inequalities analyses presented in this report.

A2.3 Notes to tables
P = Provisional
RII = Relative index of inequality
EASR = European age - standardised rate
WEMWBS = Warwick-Edinburgh mental wellbeing scale
ICD = International classification of disease
BW = Birth weight