Long-term monitoring of health inequalities: December 2017

Annex 1: Technical Notes

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/downloads/scotphoreports/scotpho071009_measuringinequalities_rep.pdf

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), indicating no inequalities. The larger the absolute value of SII, the greater the inequalities observed (see Figure 1).

Figure 1: Disease rate – Slope Index of Inequality

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 a reasonably linear relationship between the health indicator and deprivation (or income). Another disadvantage is that the SII and RII are relatively difficult to interpret for a non-statistical audience.

The technical expert group concluded in 2012 and re-iterated in 2015 that, while there was evidence of non-linearity in some years for some indicators, 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.

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.

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 income and employment domains. The reasoning behind this was 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 basis.

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 datazones in Scotland according to their deprivation score and then dividing them into deciles based on number of datazones. Population-basing the deciles uses the same approach but also takes into account the population sizes involved. The 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 ensures the deciles 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 considered to be important for the types of inequalities analyses presented in this report.

European age-standardised rates

Rates are age-standardised in order to show patterns over time on a consistent basis, taking account of changes in the age distribution of the Scottish population, therefore more clearly showing any underlying trend. Similar, age-standardisation allows comparisons of rates for different countries, by taking account of differences in the age distributions in the populations of each country.

The 2013 European Standard Population ( ESP) has been used to calculate European age-standardised rates included in this publication.

Equivalised household income

Equivalised household income is a measure of household income that takes account of the number of people in the household.

The method used in last year's report to derive deciles for the self-assessed health and limiting long-term conditions indicators is as below. It relates to households participating in the Scottish Health Survey and utilises the widely used McClements scoring system. ^[4]

1. A score was allocated to each household member, and these were added together to produce an overall household McClements score. Household members were given scores as follows:

First adult	0.61
Spouse/partner of first adult	0.39
Other second adult	0.46
Third adult	0.42
Subsequent adults	0.36
Dependant aged 0-1	0.09
Dependant aged 2-4	0.18
Dependant aged 5-7	0.21
Dependant aged 8-10	0.23
Dependant aged 11-12	0.25
Dependant aged 13-15	0.27
Dependant aged 16+	0.36

2. The equivalised income was derived as the annual household income (estimated by first adult) divided by the McClements score.

3. This equivalised annual household income was attributed to all members of the household, including children.

4. Households were ranked by equivalised income, and deciles were identified. Because income was obtained in banded form, there were clumps of households with the same income spanning the quintiles. It was decided not to split clumps but to define the quintiles as 'households with equivalised income up to decile 1' and so on.

5. All individuals in each household were allocated to the equivalised household income decile to which their household had been allocated.