World Research and Innovation Congress - Brussels – 5 th June 2013

1. Development of European deprivation indices for public health policy to tackle social inequalities in healthCarole Pornet World Research and Innovation Congress - Brussels – 5th June 2013

2. How tackling social inequalities in health? • Socioeconomic status is established as a main determinant for health and tackling social inequities is a priority for numerous international and national agencies for health.

3. How tackling social inequalities in health? • Socioeconomic status is established as a main determinant for health and tackling social inequities is a priority for numerous international and national agencies for health. • To be efficient, such policy needs to be based on a well-documented knowledge of kind and magnitude of social inequalities and on underlying mechanisms. • Studying and tackling social disparities in health implies the ability: • to measure them accurately • to compare them between different areas or countries • to follow trends over time (HCSP, 2009).

4. Whatis the initial value of ecological indices? • Information required to assess the socioeconomic status is in routine not available at individual level. • To overcomethislack, socioeconomiccharacteristicmeasureamentsatresidence area are regularlyused to approximateindividualsocioeconomicstatus: ecological indices. • Addresses or zip codes are required to connectclinical data to ecological indices (geocoding).

5. Whatis the initial value of ecological indices? • Information required to assess the socioeconomic status is in routine not available at individual level. • To overcomethislack, socioeconomiccharacteristicmeasureamentsatresidence area are regularlyused to approximateindividualsocioeconomicstatus: ecological indices. • Addresses or zip codes are required to connectclinical data to ecological indices (geocoding). • Unlikeindicatorsatindividuallevel: availability for all individuals

6. Whatis the addedvalue of composite ecological indices? • Compared to basic indicators at geographical level, composite ecological indices represent: • a more comprehensive approach to deprivation, • a more homogeneous distribution in a whole territory (Gentil C., GRELL 2011). • Measure of deprivation of living residence area •  « proxy » of individualdeprivation •  background takenintoaccount (positive and negativeexternalities)

7. A widevariety of ecological deprivation indices in Europe… • Measurement of social inequalities greatly varies in Europe from one country to another, even from one area to another within a country for 3 main reasons: • Determinants of social inequalities depend on the context. • The great majority of ecological indices are opportunistic, i.e. created for a given area or country, and for a given health topic. • Most of the ecological indices are deprivation indices developedfromcensus data, used as a ‘proxy’ of individualdeprivationmeasure but withoutreferring toindividualdeprivation experience.

8. The concept of relative deprivation • The poor are “the persons whose resources (material, cultural and social) are so limited as to exclude them from the minimum acceptable way of life in the Member State to which they belong” (Council of the European Union, 1985). • outcomeelements: “the exclusion from the minimum acceptable way of life”, which covers material, cultural and social aspects • inputelements: “...due to a lack of resources”.

9. The concept of relative deprivation “Poverty can be defined objectively and applied consistently only in terms of the concept of relative deprivation. […] Individuals, families and groups in the population can be said to be in poverty when they lack the resources to obtain the type of diet, participate in the activities and have the living conditions and amenities which are customary, or at least widely encouraged or approved, in the societies to which they belong. Their resources are so seriously below those commanded by the average individual or family that they are, in effect, excluded from ordinary living patterns, customs or activities.” (Townsend, 1979) • Relative deprivation • depends on context • is defined by a threshold: below the average of the society.

10. The concept of relative deprivation • The Townsend approach is built on the importance of participation in the society to which the person belongs, i.e. relative deprivation occurs when people “cannot obtain, at all or sufficiently, the conditions of life – that is, the diets, amenities, standards and services – which allow them to play the roles, participate in the relationships and follow the customary behaviour which is expected of them by virtue of their membership of society” (Townsend, 1987, 1993). • In Peter Townsend’s theory of relative deprivation: • poverty can be defined as a lack of sufficient resources • and “deprivation” is an outcome of poverty.

11. Deprivation: outcome of poverty • The concept of deprivation covers the various conditions, independent of income, experienced by people who are poor(Townsend, 1987). • Poverty: • Income poverty= householdwhose total equivalisedincomeis< 60% median national equivalised household income* • Subjective poverty= « Ability to make ends meet » 1. With greatdifficulty 2. Withdifficulty 3. Withsomedifficulty 4. Fairlyeasily 5. Easily 6. Veryeasily *as defined by EUROSTAT The equivalent scale is the so-called “OECD-modified equivalence scale” which assigns a value of: • 1 to the household head, • 0.5 to each additional adult member • 0.3 to each child.

12. Deprivation: outcome of poverty • Poverty: • Income poverty= householdwhose total equivalisedincomeis< 60% median national equivalised household income • In France, in 2006: “Poor” households = 14.2% • Subjective poverty= « Ability to make ends meet » 1. With greatdifficulty 2. Withdifficulty 3. Withsomedifficulty 4. Fairlyeasily 5. Easily 6. Veryeasily = 16%

13. Deprivation: outcome of poverty • Poverty: • Income poverty= householdwhose total equivalisedincomeis< 60% median national equivalised household income • In Portugal, in 2006: “Poor” households: 20.7% • Subjective poverty= « Ability to make ends meet » 1. With greatdifficulty=15.7% 2. Withdifficulty 3. Withsomedifficulty 4. Fairlyeasily 5. Easily 6. Veryeasily

14. Currentdifficulties in analyses of social inequalities in health • No gold standard of deprivation • Multiplicity of deprivation indices

15. Currentdifficulties in analyses of social inequalities in health • No gold standard of deprivation • Multiplicity of deprivation indices • Comparison of kind and magnitude of social inequalities in health and a-fortiori comparison of underlying mechanisms between different areas or countries in Europeare thus prevented.

16. How overcoming the lack of comparability and appropriateness? • The first step of a consistent European public health policy aimed for tackling social inequalities consists in creating a ‘homogenous’ reliable, relevant and accurate tool for measuring social deprivation.

17. How overcoming the lack of comparability and appropriateness? • The first step of a consistent European public health policy aimed for tackling social inequalities consists in creating a ‘homogenous’ reliable, relevant and accurate tool for measuring social deprivation. • Using deprivation indices based on: • ashared mode of construction • ashared concept of relative deprivation • the samedatabase (same questionnaire) couldovercome the lack of comparability and appropriateness

18. Objectives and principles of construction • Builtfrom data available in census • Best reflects the different dimensions of social deprivation, including the perceived poverty • Replicable in (European) space and over the time • Replicable in (European) space •  Indices would not becomposed of the sameelements in different European countries BUT willbebuiltaccording the sameprinciples in all countries • Replicable over the time •  Indices willbecontinuallyupdatedaccordingevolutions of modalities and national census data, BUT alwaysaccording the sameprinciples

19. Objectives and principles of construction Census Population

20. Objectives and principles of construction First step: Construction of an individualdeprivation indicator Census Population Individual deprivation indicator used as gold standard

21. Objectives and principles of construction First step: Construction of an individualdeprivation indicator EU-SILC* European individual survey of deprivation • From a European surveyspecificallydesigned to study deprivation: the EU-SILC* survey Individual deprivation indicator used as gold standard *European Union-Statistics on Income Living Conditions

22. EU-SILC The EU-SILC 2006 EU-27: Austria Belgium Cyprus CzechRepublic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Netherlands Poland Portugal Slovakia Slovenia Spain Sweden United Kingdom Bulgaria + Iceland + Norway Malta 26 COUNTRIES Romania

23. EU-SILC The EU-SILC survey • Developed by Eurostat (the StatisticalOffice of the European Union) • Standardised questionnaire involvingannualinterviewing of a representativepanel of households and individuals: • 60 500 households • ≈130 000 individualsaged ≥16 yrs • Designed to study deprivation and covers a wide range of domains: • income (includingvarious social benefits), • health, • education, • housing, • perceivedpoverty, • demographics, • employmentcharacteristics.

24. Objectives and principles of construction First step: Construction of an individual indicator EU-SILC* European individual survey of deprivation Individual deprivation indicator used as gold standard *European Union-Statistics on Income Living Conditions

25. Objectives and principles of construction First step: Construction of an individual indicator EU-SILC* European individual survey of deprivation Individual deprivation indicator is composed of “enforced lacks”, i.e. lacks due to insufficient resources and thus problems of affordability, rather than lacks resulting from choices or lifestyle preferences (Mack and Lansley, 1985). Individual deprivation indicator used as gold standard *European Union-Statistics on Income Living Conditions

26. 1st step: construction of an individualdeprivationindicator 1.1 Selection of fundamentalneeds EU-SILC European Individual Survey of Deprivation Fundamentalneeds: goods/services for which < 50% of householdsdid not possess/realizebecausetheycould not afford(but would like to have, i.e. a lack is an “enforced lack” and does not simply reflect a choice, but a renonciation) and theirlackreflects deprivation.

27. 1st step: construction of an individualdeprivationindicator EU-SILC 1.1 Selection of fundamentalneeds Individual deprivationindicator Fundamentalneeds: goods/services for which < 50% of householdsdid not possess/realizebecausetheycould not afford(but would like to have, i.e. a lack is an “enforced lack” and does not simply reflect a choice, but a renonciation) and theirlackreflects deprivation.

28. Currentsteps: « …. in space» Construction of 5 Europeandeprivation indices EU -SILC Census EDI Individual deprivation indicator • May 2012 : • Steps 1 and 2 of • construction of 5 EDI: • France • Italy • Portugal • Spain • UK 28

29. EU -SILC 1st step: construction of an individualdeprivationindicator 1.1 Identification of people’sfundamentalneeds Individual deprivation indicator *of amount = povertythreshold per one consumption unit independently of the size and structure of the household for a country, e.g.: in France €800 29

30. EU -SILC 1st step: construction of an individualdeprivationindicator 1.2 Selection of fundamentalneedsassociated with both incomepoverty and subjective poverty by multivariatelogisticregression Individual deprivation indicator 30 *Data weighted on non-response and adjusted on sample design of the French EU-SILC survey 2006. In bold, selectedfundamentalneedsbecausetheywereassociated with incomepoverty and with subjective poverty. in italic: p>0.05.

31. EU -SILC 1st step: construction of an individualdeprivationindicator 1.2 Selection of fundamentalneedsassociated with both incomepoverty and subjective poverty Individual deprivation indicator 31

32. EU -SILC 1st step: construction of an individualdeprivationindicator 1.3 Definition of an individualdeprivationindicator Individual deprivation indicator • In France, for incomepoverty and subjective poverty, best fit = model 2 Legend of axis models: 1: 'poor‘= lack of at least 1 item among the 4 vs no item lacking 2: ‘poor'= lack of at least 2 items among the 4 vs lack at max 1 item 3: 'poor'= lack of at least 3 items among the 4 vs lack at max 2 items 4: 'poor'= lack all the 4 items In France: householdsare defined as deprived if theycannotaffordat least 2 fundamentalneedsamong the 4 retained, as not deprived in all other cases. 32

33. 1st step: construction of an individualdeprivationindicator EU -SILC 1.3 Definition of an individualdeprivationindicator Individual deprivation indicator 33

34. EU -SILC 1st step: construction of an individualdeprivationindicator 1.3 Definition of an individualdeprivationindicator Individual deprivation indicator 34

35. Objectives and principles of construction 1ststep: Construction of an individual indicator EU-SILC* European individual survey of deprivation • 2 enforcedlacksamong: • Holidays • Unplannedexpense • Meat, fish or vegetarianequivalent • Keeping house sufficiently warm pays 1 *European Union-Statistics on Income Living Conditions

36. Objectives and principles of construction 1ststep: Construction of an individual indicator EU-SILC* European individual survey of deprivation • 2 enforcedlacksamong: • Holidays • Unplannedexpense • Car • Keeping house sufficiently warm pays 1 *European Union-Statistics on Income Living Conditions

37. Objectives and principles of construction 1ststep: Construction of an individual indicator EU-SILC* European individual survey of deprivation • 2 enforcedlacksamong: • Holidays • Unplannedexpense • Computer pays 1 *European Union-Statistics on Income Living Conditions

38. Objectives and principles of construction 1ststep: Construction of an individual indicator EU-SILC* European individual survey of deprivation • 2 enforcedlacksamong: • Meat or fish or vegetarianequivalent • Unplannedexpense • Car • Keeping house sufficiently warm • Phone (including mobile phone) pays 1 *European Union-Statistics on Income Living Conditions

39. Objectives and principles of construction 1ststep: Construction of an individual indicator EU-SILC* European individual survey of deprivation • 2 enforcedlacksamong: • Holidays • Unplannedexpense • Car • Keeping house sufficiently warm • Computer pays 1 *European Union-Statistics on Income Living Conditions

40. Objectives and principles of construction 2ndstep: Research of common data in EU-SILC / Census EU-SILC European individual survey of deprivation Census Population Individual deprivation indicator used as gold standard

41. Objectives and principles of construction 2ndstep: Research of common data in EU-SILC / Census EU-SILC European individual survey of deprivation Population census Identical variables in both datasets Individual deprivation indicator used as gold standard

42. Objectives and principles of construction 2ndstep: Research of common data in EU-SILC / Census EU-SILC European Individual Survey of Deprivation Census Population Identical variables in both datasets Individual deprivation indicator used as gold standard country 1

43. Objectives and principles of construction 2ndstep: Research of common data in EU-SILC / Census EU-SILC European Individual Survey of Deprivation Census Population Identical variables in both datasets Individual deprivation indicator used as gold standard country 2

44. Objectives and principles of construction 2ndstep: Research of common data in EU-SILC / Census EU-SILC European Individual Survey of Deprivation Census Population Identical variables in both datasets Individual deprivation indicator used as gold standard country 3

45. Objectives and principles of construction 3rdstep: Construction of the index used ataggregatedlevel EU-SILC European Individual Survey of Deprivation Census Population Identical variables in both datasets Individual deprivation indicator used as gold standard

46. 3rd step: Construction of the « French EDI » EU -SILC IRIS 3.1. Selection of those variables associated with the individualdeprivationindicator by multivariatebinarylogisticregression* EDI Individual deprivationindicator Census 1999 N =19 253 *Data weighted on non-response and adjusted on sample design of the French EU-SILC survey 2006.

47. 3rd step: Construction of the « French EDI » EU -SILC IRIS 3.2. Weighting of selected variables which compose the aggregate deprivation index* EDI Individual deprivationindicator Census 1999 N =19 253 *Data weighted on non-response and adjusted on sample design of the French EU-SILC survey 2006.

48. Objectives and principles of construction 3rdstep: Construction of the index used ataggregatedlevel EU-SILC European Union-Statistics on Income Living Conditions Census Population Identical variables in both datasets 2 1 Geographical deprivation index: the European Deprivation Index EDI Individual deprivation indicator used as gold standard 3

49. EU -SILC IRIS EDI Individual deprivation indicator Census 1999 0.1107 x % overcrowdingi+ 0.3401 x % no access to a system of central or electricheatingi+ 0.2285 x % foreignnationalityi+ 0.5185 x % no access to a cari+ 0.3682 x % unskilledworker-farmworkeri+ 0.4056 x % single-parent householdi+ 0.4513 x % householdwith ≥6 personsi+ 0.1906 x % lowlevel of educationi+ 0.4662 x % unemploymenti+ 0.5508 x % non-owneri. 49

50. EU -SILC Census EDI Individual deprivation indicator Census 1999 Distribution of the EDI score in France (N = 49,989 IRIS) : 50