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Socioeconomic Status and Health


Marmot (2003): 'The point I wish to draw out of these figures is that if the ... Marmot, 2003: ... (Marmot, Perspec Biol Med 2003;46 (suppl 3):S17). Wagstaff ... – PowerPoint PPT presentation

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Title: Socioeconomic Status and Health

Socioeconomic Status and Health
  • An overview of the evidencefor a
    connectionbetween wealth and health
  • Ottawa, August, 2006

  • Which indicators of health wealth to use?
  • Individual evidence for link between SES and
  • Comparisons between societies
  • Comparisons within societies (Britain, USA,
  • Societal level income inequality and health

Health Indicators
  • All-cause mortality
  • Gives an overview non-specific doesnt weight
    by age
  • Infant mortality
  • Sensitive to socio-economic development to
    medical care
  • PYLL
  • Selects causes weights by age at death
  • Morbidity indicators
  • Usually partial coverage how available?
  • QoL
  • Captures non-fatal outcomes subjective (bias?)

Socioeconomic Indicators
  • No ideal indicator. Some options
  • Wealth
  • Income readily measurable (in most societies),
    but only covers part of the picture doesnt
    apply well to elderly, to housewives, etc.
    Individual or family income? How to correct for
    family size?
  • Occupation
  • Reasonably comparable across countries may have
    direct relevance to health (exposures, hazards)
    difficult to classify score doesnt apply well
    to retired, housewives, children, etc.
  • Education
  • May be driving force behind occupation and
    income permanent unaffected by market
    fluctuations applies to those not in labour
    force established early in life so may not
    reflect subsequent changes
  • Composite indicators
  • Blend of above choice of weights for components
    is difficult.

1. Socioeconomic Status and Health
  • (1a) Comparisons Between Societies

The Preston Curve (Preston SH. Population Studies
197529231-248)Note the non-linearity of the
relationship. This becomes crucial in
subsequent argumentsas we compare individual and
aggregate statistics
Data source World Bank Report, 1983
Sixteen years later have things changed? As
before, the health of the rich is not much
affected by changes in income, so transfers from
rich to poor would improve overall health.
Hence, poverty is important in poor countries
and the equity of income distribution is
important in richer countries.
Source 1998 World Bank Report
  • (1b) Inequalities Within Societies
  • Data from Britain, where most
  • of the analyses began.
  • Consider mortality in ages 15 64,
  • i.e. adult, but premature mortality

Have things improved? Certainly!
Standardized mortality rates, England and Wales,
1841 to 1971
Source Townsend P, Davidson N. Inequalities in
health the Black Report. Penguin books, 1992
However there are major inequities. An early
example the Black Report
Age-Standardized Mortality Rates per 1,000 at
Ages 15 to 64 by Occupational Class, United
Kingdom, 1971
Source Townsend P, Davidson N. Inequalities in
health the Black Report. Penguin books, 1992
Life expectancy in England and Wales, by social
class, 1972-76 and 1992-96
Source Marmot M. Perspec Biol Med 2003 46
(Suppl 3) Table 1
The effect holds for both sexesSMR by
Occupational Class for Ages 15 to 64, England
Wales, 1970-72
And for many individual causes of death
Respiratory Deaths for Ages 15-64 by Occupational
Class,England Wales, 1970-72
And also among children All-cause SMRs (ages 0
14) by occupational class, England Wales,
Most of the Effect Lies at Low Income Levels
Earnings and SMRs (UK, 1970)
1970 Earnings Pounds per Week
Source Wilkinson Class and Health,1986 pg. 110
Is it only premature mortality that shows a
social gradient?SMRs by occupational class and
age at death. England Wales, 1981-83
Age at death
Source Whitehead M. The Health Divide, table
11. Penguin books, 1992.
And disparities appear to be increasingTrends
in SMRs over Timein UK Men Aged 15 - 64
Partly Skilled Skilled Manual
Intermediate Professional
Source Wilkinson RG Class and Health. London,
Tavistock, 1986 Table 1.1
The effect occurs from birthPerinatal Death
Rates (up to day 7) by Occupational Class
England Wales, 1970-79
Class V
Class I
Source Wilkinson RG Class and Health. London,
Tavistock, 1986 Table 6.8
Postneonatal Death Rates (28 days-1yr.) by
Social Class England Wales, 1970-79
Class V
Class I
Source Wilkinson RG Class and Health. London,
Tavistock, 1986 Table 6.7
Whitehall 2 Cohort Study Mortality Trends over
Time in Men Initially Aged 40-64
Cumulative Probability of death (per cent)
Professional Executive
Year of follow-up
Source Marmot et al. Lancet 19913371387-1393
Potential Years of Life Lost (All Causes) England
Wales, 1971 1991Message there are two-fold
differences in mortality rates across
occupational groups. The deficit occurs mainly
from the lowest class. While overall mortality
rates have fallen over the 20 years, the
inequality has remained.
Occupational Class V IV III II I
Potential Years of Life Lost (Accidents
Violence). England Wales, 1971 - 1991
Social Class V IV III II I
  • The Black Report was published in 1980 and,
    despite government attempts to hide it, produced
    significant reactions
  • For example, the British Health Education Council
    published The Health Divide in 1988. It focused
    on inequities (inequalities perceived as being
  • Other countries in Europe began to investigate
    whether they, too, experienced health
    disparities. Many countries reported to the WHO
    that health disparities increased during the
  • This shifted health disparities up the political
  • Marmot (2003) The point I wish to draw out of
    these figures is that if the life expectancy gap
    can increase, it can, in principle, decrease. If
    we think this is a problem worth tackling, the
    challenge is to understand the reasons for the
    social gradient in order to do something about

(ii) Data from Canada, where Statistics Canada
began to take notice in the 1990s
Crude and age- standardized mortality rates,
Canada, 1920-2000
Deaths per 1000 population
Age-standardized mortality rates from
cardiovascular disease, Canada, 1951-1995
Deaths per 100,000 population
Deaths avoided due to declining death rates in
Canada Numbers of deaths that would have
occurred in 1989 if 1971 rates had applied.
Age Males Females Total lt 1
2,336 1,680 4,016 1 - 14 896
599 1,495 15 - 34 1,373 822
2,195 35 - 54 5,547 2,597 8,144 55 -
74 12,265 7,238 19,503 75 5,707
12,037 17,744 Totals 28,124
24,973 53,097
Life expectancy at birth by age and sex, Canada,
Life expectancy (years)
So, what about Social Class?Life Expectancy at
Birth, Canada, 1971 and 1986
Females, 1986 Females, 1971 Males,
1986 Males, 1971
(High) Income Quintiles
Life expectancy at birth, by income quintile,
urban Canada, 1971 1986
  • Income classified by proportion of census tract
    falling below Stats Canada low income threshold
  • Quintiles within each CMA
  • Apparently, gradient leveled somewhat by 1986
  • Wilkins et al. Health Reports 19881137

High Low
Cumulative fetal and infant mortality by weeks
since beginning of pregnancy, by maternal
education, Québec, 1990-91
Per 1000 total births
Weeks since beginning of pregnancy
Infant Mortality by quintiles of wealth, Canada
1971 - 1996
per 1,000
Source Russ Wilkins, Socioeconomic inequality
in health outcomes.Statistics Canada, 2003
Potentially Modifiable Mortality
  • Potential years of life lost, Canada 1986, prior
    to age 75
  • Includes infant deaths
  • For each cause they subtracted rates in quintile
    1 from other quintiles. The result is expressed
    as a percentage how much improvement would occur
    if everyone had the rate in the highest income

Diminishing Disparities in Infant Mortality,
Canada 1971 - 1996
  • Poor-Rich Total-Rich Excess
  • Year RD RR RD RR Deaths
  • 1971 9.8 1.97 4.8 1.47 2028
  • 1986 4.8 1.82 1.7 1.29 666
  • 1991 2.9 1.64 1.3 1.29 577
  • 1996 2.6 1.67 1.3 1.33 513

RD difference in infant mortality rates between
rich and poor RR ratio of mortality rates,
poor rich Excess deaths number of deaths
that would have been avoided had death rates for
rich applied to all deaths
Source Russ Wilkins, Socioeconomic inequality
in health outcomes, 2003
Low Income and Low Birth Weight Ottawa Area, 1991
Rates of Low Birth Weight, 1990-92
Percentage of Families Below Low Income Cutoff
(Ross Wolfson, Statistics Canada)
Why is birth weight important? The Barker
hypothesis. Death rates from IHD by birth weight
(n 15,726)
Death Rate
Birthweight (kg)
Source Barker DJP et al. Weight in infancy and
death from ischaemic heart disease. Lancet
Examples of associations between SES indicators
Income and School Achievement Eastern Ontario,
of children scoring below Ontario standards
Percentage of Families Below Low Income Cutoff
(Educational Quality Assurance Office of Ontario)
(iii) U.S.A.
The effect of income is much greater among poor
people. Data from U.S. National Longitudinal
Mortality Survey (1980-1990)(graph based on a
logit model of the data)
10-year age-adjusted probability of dying
Family Income in 1980
Source Deaton A. Health, inequality and
economic development
And race has a greater effect among the
poorLife Expectancy at age 45 by Family Income,
Race and Sex. United States, averaged over
White Females
Black Females
White Males
Black Males
Life Expectancy at age 45
lt10,000 10,000- 15,000-
25,000 14,999
24,999 Family Income
Source GA Kaplan et al. In Promoting Health
Intervention Strategies from Social and
Behavioral Research. Institute of Medicine,
2000, page 40
Low Birth weight, by Education and Race /
Ethnicity, United States, 1996
Years of Education
Low Birthweight per 1,000 Live Births
White Black Hispanic Native
Source GA Kaplan et al. In Promoting Health
Intervention Strategies from Social and
Behavioral Research. Institute of Medicine,
2000, page 44
Mortality by Family Income, MRFIT
Annual family income in thousands of US dollars
2. Income Inequality and Health
  • As countries become wealthier and move through
    the epidemiologic transition, the leading cause
    of differences in mortality changes from material
    deprivation to social disadvantage.
  • Inequality hypothesis proposed in late 1970s
    Rodgers, Flegg and others. In industrial
    countries, mortality rises with range of incomes
    (Gini coefficient) in the society.
  • The Wilkinson Hypothesis (1990s) for defined
    geographical areas, mortality rises with the
    level of disparity in incomes.
  • Corollary occupation and education gradients in
    health do not occur in societies with low income
  • Material deprivation provokes poverty and
    infectious disease social disadvantage provokes
    stress and chronic disease.
  • (2 a) Comparisons Across Countries

Life Expectancy and Income Inequality, 1970
Life expectancy (M F combined)
r -0.81
More equal
Less equal
Gini coefficients of inequality of distribution
of income, standardized for household size
Adapted from Wilkinson R. Unhealthy societies
the afflictions of inequality. London, Routledge,
1996, p 84.
Income Inequality and Life Expectancy, 1981
W. Germany
r 0.86
Social Class Differences in IMR in England
Wales, Compared to Sweden
England Wales
Occupational class
Note Income inequality is substantially higher
in Britain than in Sweden
Source R. Wilkinson. Unhealthy societies the
afflictions of inequality. Routledge, 1996
Changes in the Dispersion of Income, 1980 - 1991
United Kingdom
United States
Austria France
Denmark, Sweden
Germany Norway
Note the chart shows the ratio of the earnings
of someone at the 90th centile of income to the
earnings of someone at the 10th centile,
artificially set at 1 for 1980. Source OECD
Some difficulties in nation-level studies
  • Lack of good quality international data,
    collected in consistent manner in different
    countries. E.g., in some studies Sweden is rated
    very egalitarian, in others less so than Britain!
  • Results seem to vary according to era from which
    data taken
  • Failures to replicate. Mellor Milyo found that
    controlling for education removes effect (for
    infant mortality). Judge et al found correlation
    of -0.17 (n.s.)
  • General conclusion income inequality does not
    appear to drive overall mortality in industrial
    countries may do so for infant mortality.

2 (b) Comparisons Within Countries
  • These appear to avoid some of the difficulties in
    cross-national comparisons data are usually
    collected by a single agency (e.g., Statistics
  • Income data usually collected via the census
    (rather than surveys). Correlation usually
    found lots of replications. Usually around 0.7
    (i.e. explains half of the difference between
  • Wagstaff The first point to emerge from these
    studies is that they all confirm that income
    inequality is strongly associated with mortality,
    even after controlling for the average level of
    community income. (Annu Rev Public Health

Illustration of Within-Country Results
Inequality and the log-odds of mortality. U.S.,
Source Deaton A. Health, inequality and
economic development http//
Questions Concerns
  • Data are pooled across ethnic (etc) groups
    presumably income inequality is a proxy for
    various other factors. As you focus down onto
    selected groups the association (not
    surprisingly?) is reduced. So, if the effect
    comes from inequality between groups (e.g.,
    blacks whites in the US), is this merely a
    proxy for race, and does income inequality have
    no direct effect?
  • There is an issue of scale what inequality
    should we use when analysing individual data
    (country level, state level, community or
    neighbourhood level?) What is the persons
    reference point?
  • Individual-level analyses generally show very
    modest inequality effects (RR 1.2, etc)
  • General conclusion is that health is an
    increasing, nonlinear function of absolute income
  • So, there may be no direct effect of income
    inequality at all, but race, geography, social
    support services, or ?

Categories of Explanation (EPI 6181 topic 2)
  • Theories that explain the pattern of
    relationships between SES and health cf. the
    economic literature (e.g., Wagstaff, below).
    What form does it take?
  • Theories of mechanisms for the link e.g.,
    lifestyles, genetics, access to care. How does
    it work?
  • Theories on determinants of the relationship
    the field of population health. Why does it

The concave income-health relationship explanation
The blue line shows the familiar concave
relationship of income and health Consider two
people A and B. Mean income µ. Their aggregate
health is represented by the green line this is
extended to the ordinate. Redistribute 1000
from A to B (dotted arrows),reducing income
inequity. µ stays the same. Overall average
health now shown by red line. Redistributing
income has caused overall healthto rise, because
the damage to As health is less (because the
blue curve is flatter)than the improvement to
B B1000
A-1000 A
See, e.g., Wagstaff and van Doorslaer. Annual
Review of Public Health 2000 21 543.
The Debate over Relative or Absolute Income
  • It is logical that there is a minimum income
    required for basic amenities (food and shelter).
    In very poor places, this is the limiting factor
    in health.
  • But in richer places most people are above the
    poverty line, does improvement in health reflect
    increase in absolute wealth, or is it driven by
    something else, such as relative wealth? (and if
    so, how and why?)
  • Marmot, 2003 The GNP in Costa Rica is about
    2,000 per person life expectancy for men is 74
    years. Among black men in the U.S., mean income
    is around 26,000 and life expectancy is 66.
    Adjusting for different buying power brings the
    Costa Rica figure to about 6,000 per person,
    still one-quarter of the US figure, and yet they
    live 8 years longer.

  • A consistent finding is that within countries or
    states, individual health is related to
    individual income, but comparing between states
    average health is independent of average income,
    but is negatively related to income inequality.
    I.e., it depends on which comparison you are
    making (within or across places)
  • Wilkinson argued (for richer countries)
    Mortality is associated with relative income.
    Someone with an absolute income that equals half
    of the US average might do better to be
    moderately well off in Greece or Spain than poor
    in the US (BMJ 1998 316 1611) and health is
    powerfully affected by social position
  • Relative inequality in income may correspond to
    absolute discrimination and social exclusion.
    (Marmot, Perspec Biol Med 200346 (suppl 3)S17).

Wagstaff van Doorslaers hypotheses
  • Economic perspective what is the main driver in
    the relationship
  • Absolute income?
  • Relative income?
  • Deprivation?
  • Relative position?
  • Income inequality?
  • Conclusion it depends very much whether you are
    explaining individual health, or community, or
    population health patterns
  • Annual Review of Public Health 200021543

Poverty may explain the link between income
inequality and health
Two populations, equal in mean income, but
different in levels of income inequality
Population A
Population B
Mean income
Poverty line
Population B shows a much wider spread of
incomes high income inequality. Substantial
numbers of people fall below the poverty line
andaccordingly their health suffers, pulling the
average health statistics downward
Population A shows a narrow spread of
incomeslittle income inequality.No-one falls
below the poverty lineand health is reasonably
Deatons presentation of relative income.
Imagine two groups with different average income
(the purple group is further to the right).
Within each group health rises with income
(solid sloping lines). But they have equal
average health (the ellipses are the same
vertical height). However, when you combine the
two groups, you increase income inequality but
the association between health and income is
reduced (dotted line). Hence, within each group,
relative income is more important than absolute
income, but on combining groups income inequality
becomes more significant.
Group 1
Group 2
Source Deaton A. Health, inequality economic
The processes are complex and may change over
time. The wealth of a mother may affect the
health of her child, and from the previous
slides, it may very well be relative income that
counts. But the following diagram makes the
point that a mothers income relative to the
average income varies according to her age.
Young mothers are (on average) poorer than older
ones and the disparities have grown over time.

Age at delivery
Source C. Lochhead. ISUMA 2000141-44.
Is it the indicator of Class?
  • Goldblatt (1990) compared professional men living
    in their own home and who had access to a car
    (SMR 67) to all men who lacked access to a car
    and lived in rented accommodation (SMR 123).
    This gradient is similar to that based on the
    occupational classification, so maybe the
    occupational approach is not bad.
  • Other studies (Carstairs Townsend) used
    area-based indicators of social and material
    deprivation. They found consistent relationships
    with a range of health indicators again, it may
    not make much difference which indicators of
    class you use.

Here an index of deprivation is based on nine
variables, which should compensate for
inadequacies in any one of them. Life Expectancy
at Birth, by decile of deprivation gender. New
Zealand, 1995-97
Life Expectancy, in years
Deprivation decile (composite score of nine
Source Social inequalities in Health New
Zealand 1999. N.Z. Ministry of Health
Do conventional risk factors account for link
between SES and mortality? Prevalence of Regular
Smoking, by deprivation decile gender (ages
45-64) New Zealand, 1996
regular smokers
Deprivation decile (composite score of nine
Source Social Inequalities in Health New
Zealand 1999. N.Z. Ministry of Health
Prevalence of obesity among women, by SES and by
SES of parents. U.S. data.
(N in each group ranges from 291 to 362)
Socioeconomic status
Note lower SES women are more often obese than
their parents higher SES slightly less obese
the disparities appear to be increasing.
Source Goldblatt PB et al. Social factors in
obesity. JAMA 19651921039-1044.
Prevalence of high blood pressure, high
cholesterol and obesity, Canada, 1986-92, by
educational level
Years of Education
Source Federal Task force on Population Health,
Prevalence of Activity Limitation (ages 15),
Canada, 1991
(High) Income Quintiles
Statistics Canada. Report of 1991GSS.
The previous slides suggest that SES affects risk
factors.So, lets adjust for conventional risk
factors and see if the SES Health link remains,
or if it was due to the SES distribution of risk
factors. Data from Whitehall I Cohort Ten-Year
Relative Risks of Death (all causes)   (a)
unadjusted, and (b) adjusting for CVD risk factors
Relative risk
Relative risk
(b) Adjusted for smoking, BP cholesterol
(a) Raw data
Civil service occupational categories Other
Clerical Professional
Relative Risk of Death from CVD by Occupational
Grade, Showing Differences that can be Explained
by Conventional Risk Factors. Whitehall I
Study.Message most of the variation (black
bars) is not attributable to common risk factors.
So, what does SES, or class represent??
Other B.P. Smoking Cholesterol
Could it be access to good quality medical care?
MaybeTrends in age-standardized mortality from
causes that are, and are not, amenable to
medical treatment
Deaths unrelated to quality of care
Hungary, Czech,Poland
Canada, U.S.
Germany, U.K.
Hungary, Czech,Poland
Deaths amenable to care
Germany, U.K.
Canada, U.S.
Source Boys RJ et al. Br Med J 1991303879-883.
The contribution of medical care is to treat
illness when it occurs, not to prevent its
occurrence M. Marmot.
Complications! Interaction between occupational
class and country of origin for immigrants to
Britain. Black Report
Age-Standardized Mortality Rates per 1,000 at
Ages 15 to 64 by Occupational Class and Country
of Immigration, United Kingdom, 1971
This is bizarre!! Why the reverse trend for
Some conclusions
  • Poverty is clearly linked to health
  • Income inequality is a useful marker of risk, but
    represents the likely occurrence of other factors
    that adversely affect health
  • Depends on level of investigation of the
    phenomenon individual vs. community-level vs.
    population health
  • Interactions are likely. Sen (Development and
    Freedom, 1999) relief from any one of several
    interlinked deprivations helps to promote relief
    from the others
  • This course will try to identify the inter-linked
    deprivations that affect health
  • Will review theories of 3 types What?, How? and