Health inequalities, sustainability and inclusion: an agenda for statistics

1. Health inequalities, sustainability and inclusion: an agenda for statistics Giuseppe Costa Università di Torino

2. Do health inequalities (HIs) matter for a sustainable and inclusive development? Challenges for statistics. • About health inequalities • Facts • Mechanims • Solutions • Knowledge gaps • Policy implications: the role of evidence • Challenges for statistics: • Data, design, validity • The contribution of BES

3. Do health inequalities (HIs) matter for a sustainable and inclusive development? Challenges for statistics. • About health inequalities • Facts • Mechanims • Solutions • Knowledge gaps • Policy implications: the role of evidence • Challenges for statistics: • Data, design, validity • The contribution of BES

4. Income in the 2008 in Torino

5. Income in the 2008 in Torino Health expectancy at birth in Torino in the 2000’s Fonte: Studio Longitudinale Torinese

13. Mortality by education among males in Italy 2000-2007 Marinacci et al, 2011

14. Self assessed health (prevalence of bad and very bad) by education ITALIAN MALES 25-84 YEARS Elaborazione a cura del Servizio di Epidemiologia ASLTO3 su dati ISTAT, indagine multiscopo sulla salute 2013

15. HEALTH INEQUALITIES FIRST DETERMINANT OF HEALTH VARIATION EVERY WHEN IT IS MEASURED EVERY CONTEXT ETHEROGENEITY IN SIZE DUE TO POVERTY OF INDIVIDUAL RESOURCES (EDUCATION, CLASS, INCOME) ALWAYS IN FAVOUR OF THE MORE ADVANTAGED GRADIENT

16. Do health inequalities (HIs) matter for a sustainable and inclusive development? Challenges for statistics. • About health inequalities • Facts • Mechanims • Solutions • Knowledge gaps • Policy implications: the role of evidence • Challenges for statistics: • Data, design, validity • The contribution of BES

17. DEMAND CONTROL REWARD SUPPORT DEMAND CONTROL REWARD SUPPORT

18. SOCIAL POSITION = LIFE CONTROL Job strain in male workforce in Torino RISK FACTORS STRESS D’Errico et al., 2011 Elaborazioni su campione di occupati iscritti alla CGIL in Provincia di Torino

19. SOCIAL POSITION = LIFE CONTROL Smokers in Italy Males 2010-2012 Overweight in Italy Females 2010-2012 Low education High education Low education High education RISK FACTORS LIFESTYLES FONTE: PASSI 2010-2012 / Da: Costa G., Bassi M., Gensini G.F., Marra M., Nicelli A.L., Zengarini N.(2014) L’equità nella salute in Italia. Secondo rapporto sulle disuguaglianze sociali in sanità. Fondazione Smith Kline e Franco Angeli, Milano.

20. SOCIAL POSITION = LIFE CONTROL Population (%) living close to a waste disposal by area deprivation of residence, Italy 2001 RISK FACTORS ENVIRONMENT Fonte: FORASTIERE ET AL. 2011

21. SOCIAL POSITION = LIFE CONTROL Acute coronary disease In Torino, 2009 Coronary revascularization In Torino, 2009 - - + + RISK FACTORS BARRIERS TO CARE Elaborazioni su dati dello Studio Longitudinale Torinese – Servizio Sovrazonale di Epidemiologia ASL TO3

22. SOCIAL POSITION = LIFE CONTROL RISK FACTORS STRESS LYFESTILES ENVIRONMENT BARRIERS TO CARE DISEASE

23. Do health inequalities (HIs) matter for a sustainable and inclusive development? Challenges for statistics. • About health inequalities • Facts • Mechanims • Solutions • Knowledge gaps • Policy implications: the role of evidence • Challenges for statistics: • Data, design, validity • The contribution of BES

24. SOCIAL POSITION = LIFE CONTROL DISEASE UNEMPLOYMENT AND MENTAL HEALTH IN ITALY, 2013 RISK FACTORS STRESS LIFESTYLES ENVIRONMENT BARRIERS TO CARE Cases attributable to unemployment every year 388.545 Economic interventions against risk of poverty among unemployed minus 80.185 Back to unemploymnent rates pre-crisis minus 257.497 Fonte: Elaborazione Servizio di Epidemiologia ASLTO3 su dati ISTAT, indagine multiscopo sulla salute 2005 e 2013

25. SOCIAL POSITION = LIFE CONTROL DISEASE POPULATION COVERAGE IN BREAST CANCER SCREENING IN EMILIA ROMAGNA RISK FACTORS STRESS LIFESTYLES ENVIRONMENT BARRIERS TO CARE 1997-2000 2001-2003 % of cases diagnosed too late % of survivors at 5 years after diagnosisi Pacelli et al. 2014

26. - + SOCIAL POSITION = LIFE CONTROL DISEASE Differences in life expectancy at 65 anni by social class RISK FACTORS STRESS LIFESTYLES ENVIRONMENT BARRIERS TO CARE Costa et al., elaborazioni su dati dello Studio Longitudinale Torinese – Servizio Sovrazonale di Epidemiologia ASL TO3

27. Do health inequalities (HIs) matter for a sustainable and inclusive development? Challenges for statistics. • About health inequalities • Facts • Mechanims • Solutions • Knowledge gaps • Policy implications: the role of evidence • Challenges for statistics: • Data, design, validity • The contribution of BES

28. Death “attributable to educational inequalities explained by educational inequalities in measurable risk factors. Turin 2000’s Marra e Zengarini, 2012

29. Death “attributable to educational inequalities explained and not explained by educational inequalities in measurable risk factors Which the impact of CONTEXTUAL DETERMINANTS AND OTHER RISK FACTORS in the remaining 54%? 45,7% Marra e Zengarini, 2012

32. + 70% Impact of individual deprivation on mortality* + 5% + 7% + 14% + 1% Impact of area deprivation on mortality** *loweducation **composite deprivationindex

33. RESULTS NPE: Italy

34. Facts Explanations Solutions Responsibilities www.disuguaglianzedisalute.it

35. Do health inequalities (HIs) matter for a sustainable and inclusive development? Challenges for statistics. • About health inequalities • Facts • Mechanims • Solutions • Knowledge gaps • Policy implications: the role of evidence • Challenges for statistics: • Data, design, validity • The contribution of BES

36. The WHO Commissionon Social Determinants of Health (CSDH) – Overarching recommendations Improve the conditions in which people are born, grow, live, work, and age Tackle the Inequitable Distribution of Power, Money, and Resources Measure and Understand the Problem, Evaluate Action, Expand the Knowledge Base, Develop the Work Force

37. Country clusters by level of policy response Cluster 1: Relatively positive and active response to health inequalities. At least one national response to HIs or comprehensive regional HI policy responses. Cluster 2: Variable response to health inequalities. No explicit national policy on HIs, but at least one explicit regional response or a number of other policies with some focus on health inequalities. Cluster 3: Relatively undeveloped response to health inequalities. No focused national or regional responses to health inequalities, no explicit health inequality reduction targets (though there may be targeted actions on the social determinants of health).

38. Many community of practices arising… at least one health equity audit exercise for each by the end of 2015 Cooperation Migrants Global health Media Civil society Monitoring Economy Labour PRP Colleges INMP project’stakeholders National Health System Clinical governance Ministries (non health) Scientific societies Social and economic workforce and representatives OOSS Enterprises Volunteers associations

39. Do health inequalities (HIs) matter for a sustainable and inclusive development? Challenges for statistics. • About health inequalities • Facts • Mechanims • Solutions • Knowledge gaps • Policy implications: the role of evidence • Challenges for statistics: • Data, design, validity • The contribution of BES

40. Monitoring health and social determinants of health across the lifecourse • Health and health care measurements by socioeconomic position, sex, geographical distribution • Early years • An indicator of early child development at age 5 • Youth • Proportion of young people not in education/ training or employment • An adult poverty measure • A measure of social isolation and/or poverty at older ages Marmot, Lancet 2013

41. Measuring SES in the 2011 census Education Employment Contextual characteristics Family support Material resources Marital status Educational credentials Housing tenure * Deprivation index Employment status Occupational position * Household typology * available only in the 2011 sample based census

42. Knoledge gaps in indicators: the precariousness

43. At least one type of functional limitation* by age Compression of functional limitation? 2.5 years post- ponement *difficulty in movement, difficulty in communication (views, heard, word), limitation of ambulation, difficulties in the functions of everyday life National Health Interview Survey, 2000-2005-2013 - Italy

44. At least one type of functional limitation by economic resources Larger for the more advantaged? 2005 2000 2013 National Health Interview Survey, 2000-2005-2013 - Italy

45. Zarulli et al, BMJopen 2013

46. Do health inequalities (HIs) matter for a sustainable and inclusive development? Challenges for statistics. • About health inequalities • Facts • Mechanims • Solutions • Knowledge gaps • Policy implications: the role of evidence • Challenges for statistics: • Data, design, validity • The contribution of BES

47. Relative importance of the size of health inequalities matters? Advancement in the development of actions to reduce health inequalities % of mortality explained by educational inequalities Marra and Zengarini in Eikemo T et al, 2012 http://www.euro-gbd-se.eu/fileadmin/euro-gbd-se/public-files/EURO-GBD-SE_Final_report.pdf

48. Multiple Factors, Competing Agendas and Diverse Interest Groups

49. Focus on the Co-Production of Results Benefits for health Benefits for other sectors Benefits for societal goals Equity & Health Equity as common measures of public policy performance

50. Benessere Equo e SostenibileWellbeing Equitable and Sustainable Multidimensional aspects of quality of life, including health Guarantee for next generations Focus on distribution of wellbeing: including inequalities