a national achievement?: changes in inequalities in risk ...€¦ · disease in australia philip...

A national achievement?: A national achievement?: Changes in inequalities in risk Changes in inequalities in risk

factors for cardiovascular factors for cardiovascular disease in Australiadisease in Australia

Philip Clarke and Alison Hayes, Philip Clarke and Alison Hayes,

School of Public Health, University of Sydney

Work in Progress

Structure of the seminarStructure of the seminar

Background on inequality measures & Background on inequality measures & Achievement index;Achievement index;

Main focus on how to represent changes in Main focus on how to represent changes in inequalities and mean health;inequalities and mean health;

Some examples from selfSome examples from self--reported reported cardiovascular risk factors from Australian cardiovascular risk factors from Australian National Health Surveys.National Health Surveys.

Inequality comparisonsInequality comparisons

25%

Poor Rich

75%

Poor Rich

Hea

lthM

orbi

dity

50%

50%

50%

50%

75%

25%

Time 1 Time 2

Decreased?

Remained the same?

Increased?

Have inequalities:

Case for decreasing inequalitiesCase for decreasing inequalities

25%

Poor Rich

75%

Poor Rich

Hea

lthM

orbi

dity

50%

50%

50%

50%

75%

25%

Time 1 Time 2 Relative inequalitiesin “health”

Ratio= Health of RichHealth of Poor

Time 1 50%/25%=2

Time 2 75%/50%=1.5

Inequalities have decreased

Case for no change in inequalitiesCase for no change in inequalities

25%

Poor Rich

75%

Poor Rich

Hea

lthM

orbi

dity

50%

50%

50%

50%

75%

25%

Time 1 Time 2 Absolute inequalitiesin “health”

Time 1 50%-25%=25%

Time 2 75%-50%=25%

Inequalities have remained the same

Case for increasing inequalitiesCase for increasing inequalities

25%

Poor Rich

75%

Poor Rich

Hea

lthM

orbi

dity

50%

50%

50%

50%

75%

25%

Time 1 Time 2

Poor Rich Poor Rich

75%

25%

Hea

lthM

orbi

dity

50%

50%

50%

50%

25%

75%

Time 1 Time 2 Relative inequalitiesin “morbidity”

Ratio= Morbidity of PoorMorbidity of Rich

Time 1 75%/50%=1.5

Time 2 50%/25%=2

Inequalities have Increased!

Reads like a script from Reads like a script from ““Yes MinisterYes Minister””

Jim Hacker MP:Jim Hacker MP: ““So Humphrey are health So Humphrey are health inequalities rising or declining?inequalities rising or declining?””

Sir Humphrey:Sir Humphrey: ““Well Minister in terms of measures Well Minister in terms of measures of morbidity, inequalities are increasing, but in of morbidity, inequalities are increasing, but in terms of absolute inequalities they remain the terms of absolute inequalities they remain the same, and if instead we measure inequalities in same, and if instead we measure inequalities in terms of health they are actually declining.terms of health they are actually declining.””

Concentration curves Concentration curves

0 1

1

cumulativeproportion of morbidity

Cumulative proportion of population ranked by income/socioeconomic status

L(S3 )L(S2 )L(S1 )

Concentratio

n index

-ve indicatesPro-rich Inequality

Concentration curves Concentration curves

0 1

1

cumulativeproportion

of good-health


L(S3 )L(S2 )L(S1 )

Concentratio

n index

+ve indicatesPro-rich Inequality

Generalized concentration curves Generalized concentration curves

0 1

μ

cumulativemorbidity


L(S3 )L(S2 )L(S1 )

Gen Concentratio

n index

Extended Concentration indexExtended Concentration index

∑=

−−=n

iii Ry

nC

1)1(21

μ

∫ >−−−= −1

0

2 1,)()1()1(1)( vdppLpvvvC v

Wagstaff (2002) Inequality aversion, health inequalities, health achievement, JHE.

1

1)1(1)( −

=

−−= ∑ vi

n

ii Ry

nvvCμ

Inequality aversionInequality aversion

Wagstaff (2002)

How do we make meaningful How do we make meaningful comparisons across time?comparisons across time?

% o

f pop

ulat

ion

Health Measure

Poorest Richest

100%

0%

MeanTime 2

MeanTime 1

Average health hasincreased

Absolute and Relativeinequalities have declined

Had to argue things are not improving

More difficult caseMore difficult case%

of p

opul

atio

n

Health Measure

Poorest Richest

100%

0%

MeanTime 2

MeanTime 1

Average health hasincreased

Absolute inequalities

Relative inequalities

Hard to say if things are improving

Achievement IndexAchievement Index

121122

222111

22

)()()()(

)()())(1()(

μμυμυμυμμυμμ

υυμ

−>−−>−

>−=

CCCC

IvICvI

-15

-10

-5

0

5

10

15

-100 -80 -60 -40 -20 0 20 40 60 80 100

Diff. inequality (G2-G1)D

ifference in mean health (μ

2 -μ1 )

Madagascar

Kazakhstan

Egypt

Chad

45

12

NW

SW SE

NE

Region of increasing achievement

Incremental health achievement plane relative to Haiti

-50

-40

-30

-20

-10

10

20

30

-100 -80 -60 -40 -20 0 20 40 60 80 100

Incremental Effect

Incr

emen

tal C

ost

Kazakhstan

Egypt

Madagascar

Chad

-15

-10

-5

0

5

10

15

-100 -80 -60 -40 -20 0 20 40 60 80 100

Diff. inequality (G2-G1)D

ifference in mean health (μ

2 -μ1 )Madagascar

Kazakhstan

Egypt

Chad

45

NW

SW SE

NERegion of increasing achievement

-0.006

-0.005

-0.004

-0.003

-0.002

-0.001

0

0.001

0.002

0.003

0.004

0.005

-0.006 -0.004 -0.002 0 0.002 0.004 0.006 0.008 0.01

Change in mean health

Cha

nge

in a

bsol

ute

ineq

ualit

y

Increases in mean health

Increases in absolute inequality(v=2)

)2()2( 1122 CC μμ −

12 μμ −


Increases in mean health


)8()8( 1122 CC μμ −

12 μμ −

-0.015

-0.01

-0.005

0

0.005

0.01

0.015

-0.01 -0.005 0 0.005 0.01 0.015

Incr

emen

tal C

ost

Probability of increase in health acheivement

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Inequality aversion (v)

Prob

abili

ty o

f inc

reas

ing

ache

ivem

ent

Series2

Cardiovascular risk in Australia Cardiovascular risk in Australia

NHS survey populationNHS survey population

Individuals participating in the last four ABS National Individuals participating in the last four ABS National Health Surveys, conducted in:Health Surveys, conducted in:–– 19891989--90, 1995, 2001, 200490, 1995, 2001, 2004--5.5.–– N=54,241, 53,828, 26,862, 25,906N=54,241, 53,828, 26,862, 25,906

Expanded surveys available onExpanded surveys available on--line from 2001 via the line from 2001 via the remote access data laboratory (RADL)remote access data laboratory (RADL)Urban and rural areas throughout all states and territoriesUrban and rural areas throughout all states and territoriesNonNon--institutionalized residential population;institutionalized residential population;Collects selfCollects self--reported information on health status, health reported information on health status, health behavior, health use (mainly over previous 2 weeks)behavior, health use (mainly over previous 2 weeks)Demographic and socioDemographic and socio--economic factors, e.g. selfeconomic factors, e.g. self--reported household incomereported household income

55.0 (53.2)52.2 (49.8)44.9 (43.5)39.0 (38.4)Overweight or obese

2.1 (1.8)2.8 (2.2)4.2 (4.6)5.0 (4.8)Previous heart disease

10.2 (9.1)9.4 (7.8)7.3 (7.7)10.9 (10.9)High cholesterol

5.1 (4.6)4.7 (4.2)3.0 (3.0)2.5 (2.3)Diabetes

22.8 (25.6)22.5 (24.5)24.1 (25.0)28.2 (29.1)Smoker

(33.7)29.6 (29.2)33.1 (32.4)35.9 (35.7)No exercise

15.4 (13.8)14.8 (12.9)15.0 (14.5)20.4 (20.5)High blood pressure

Risk factors %

39.940.232.733.9% over 50 years

51.252.850.450.9% female

15,00413,16715,71334,078N

2005200119951989Survey Year

Vigorous Vigorous ExercizeExercizePrevalence of vigorous exercise

0

0.05

0.1

0.15

0.2

0.25

0.3

0 2 4 6 8 10 12

19891995

20012005

Overweight, or obeseOverweight, or obeseprevalence of overweight or obese by income decile

0

0.1

0.2

0.3

0.4

0.5

0.6

0 2 4 6 8 10 12

Income decile

BM

I

1989

1995

2001

ObeseObeseAge and sex standardised prevalence of obesity by income quintile

0

0.05

0.1

0.15

0.2

0.25

0 2 4 6 8 10 12

1989199520012005

Smoking statusSmoking statusAge and sex standardised prevalence of smoking by income decile

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0 2 4 6 8 10 12

1989

1995

2001

2005

Diabetes (Type I & II)Diabetes (Type I & II)Age and sex standardised diabetes prevalence by income decile

0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0 2 4 6 8 10 12

1989

1995

2001

High cholesterolHigh cholesterolAge and sex standardised high cholesterol

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

0 2 4 6 8 10 12

1989

1995

2001

High blood pressureHigh blood pressureAge and sex standardised prevalence of high blood pressure

0

0.05

0.1

0.15

0.2

0.25

0 2 4 6 8 10 12

1989

1995

2001

-0.04

-0.03

-0.02

-0.01

0

0.01

0.02

0.03

0.04

0.05

-0.14 -0.12 -0.1 -0.08 -0.06 -0.04 -0.02 0 0.02 0.04 0.06



Cha

nge

in a

bsol

ute

ineq

ualit

y

Normal weightVig. ExerciseNon Smokers

1995

2001

19952001

2005

2005

-0.04

-0.03

-0.02

-0.01

0

0.01

0.02

0.03

0.04

0.05

-0.14 -0.12 -0.1 -0.08 -0.06 -0.04 -0.02 0 0.02 0.04 0.06



Cha

nge

in a

bsol

ute

ineq

ualit

y

DiabetesCholesterolBlood pressure

1995 2001 1995

2001

20052005

1995

2005

Smoking statusSmoking statusAge and sex standardised prevalence of smoking by income decile

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0 2 4 6 8 10 12

1989

1995

2001

2005

Measuring achievement: smokingMeasuring achievement: smoking

0.29180.70820.0358-0.03580.048-0.140.2562005

0.28130.71870.0363-0.03630.048-0.1480.2452001

0.2880.7120.038-0.0380.051-0.1520.251995

0.31950.68050.0285-0.02850.04-0.0980.2911989

AImAIhμCIHμCImCIhCImMean Survey year

Measuring achievement Measuring achievement AI vs v parameter for smoker

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0 5 10 15 20 25 30 35

1989

1995

2001

2005

Overweight, or obeseOverweight, or obeseprevalence of overweight or obese by income decile

0

0.1

0.2

0.3

0.4

0.5

0.6

0 2 4 6 8 10 12

Income decile

BM

I

1989

1995

2001

Overweight & obeseOverweight & obese

0.44040.45960.0084-0.00840.018-0.01570.5322005

0.49650.5035-0.00150.0015-0.0030.0030.4982001

0.4450.5550.01-0.010.018-0.0230.4351995

0.40160.59840.0177-0.01770.029-0.0460.3841989

AIm(v=2)

AIh(v=2)

μCIH(v=2)

μCIm(v=2)

CIhCImMean Survey year

a national achievement?: changes in inequalities in risk ...€¦ · disease in australia philip...

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