건강 형평성 측정도구

Health Inequality Measures

References

1. Harper S, Lynch J. Methods for Measuring Cancer Disparities: Using Data Relevant to Healthy People 2010 Cancer-Related Objectives. NCI Cancer Surveillance Monograph Series, Number 6. Bethesda, MD: National Cancer Institute, 2005. NIH Publication No. 05-5777.

2. Harper S, Lynch J. Measuring health inequalities. In: Oakes JM, Kaufman JS (eds). Methods in Social Epidemiology. John Wiley & Sons, Inc., 2006. pp.134-168.

3. Regidor E. Measures of health inequalities: part 1. J Epidemiol Community Health. 2004 Oct;58(10):858-61.

4. Regidor E. Measures of health inequalities: part 2. J Epidemiol Community Health.2004 Nov;58(11):900-3.

5. Anand S, Diderichsen F, Evans T, Shkolnikov VM, Wirth M. Measuring disparities in health: methods and indicators. In: Evans T, Whitehead M, Diderichsen F, Buyia A, Wirth M (eds). Challenging Inequities in Health. New York: Oxford University Press, 2001, pp.49-67.

6. Mackenbach JP, Kunst AE. Measuring the magnitude of socio-economic inequalities in health: an overview of available measures illustrated with two examples from Europe. Soc Sci Med. 1997 Mar;44(6):757-71.

7. Wagstaff A, Paci P, van Doorslaer E. On the measurement of inequalities in health. Soc Sci Med. 1991;33(5):545-57.

상대 불평등과 절대 불평등은 각각 어떤

의미를 지니는가?

1600

1800

2000

2200

2400

1809

2334

서울시의 인구10만명당 성연령표준화 사망률(2000-2004년)

525

1600

1800

2000

2200

2400

서초

구강

남구

송파

구동

작구

양천

구서

대문

구영

등포

구도

봉구

광진

구강

동구

중구

용산

구종

로구

마포

구관

악구

구로

구강

서구

은평

구성

북구

성동

구노

원구

중랑

구금

천구

강북

구동

대문

구

1809

2334

서울시의 인구10만명당 성연령표준화 사망률(2000-2004년)

525

인구10만명당 525명의

사망자수 차이의 의미는?

525 (인구10만명당) * 36만명(강북구 인구)=1890명

1890명/5년=연간 378명

강남구에 비하여 강북구에서는

강북구 주민 378명을 가득 태운 점보여객기가

매년 추락하는 것과 같다.

만약 우리 나라 모든 지역주민들이 서초구의 사망률을 따른다면?

지난 5년간(2000-2004년까지) 우리 나라 총 사망자(1,239,200명)의31%인 384,152명을 살릴 수 있었다

다음은 절대적 건강 불평등 측정도구인가? 상대적건강 불평등 측정도구인가?

• SMR (standardized mortality ratio)• Adjusted mortality rate• Odds ratios• Relative index of inequality• Slope index of inequality

개별 측정도구의 소개

Classification of Measures of Health Inequality

• Harper and Lynch, 2006

• Measures of total inequality– Individual-mean differences– Inter-individual differences

• Measures of social group inequality

• Measures of average disproportionality

Measures of Social Group Inequality

• Pairwise comparisons– Risk/rate difference (RD), Prevalence difference (PD)– Relative risk/rate ratio (RR), Odds ratio (OR), Prevalence ratio (PR)

• Regression-based measures– Slope Index of Inequality (SII)– Relative Index of Inequality (RII)

• Population impact measures– Population Attributable Risk– Index of Disparity– Between-Group Variance

Regression-based Summary Measures

• SII, RII– 서열이있는사회경제적위치지표

– 모든집단정보를활용하여요약지표를산출

– 시간에따라사회집단별분포가다른경우유용

– 사회경제적위치에있어극단간의차이를의미

• SII

• RII

• Pamuk, 1988

Kunst-Mackenbach RII

•

• The Kunst-Mackenbach RII is more like a traditional relative risk measure in that it compares the health of the extremes of the social distribution, but it is estimated using the data on all social groups and is weighted to account for social-group sizes.

Age-adjusted Educational Rate Ratios for Mortality in Korean Women Aged 30-59

2000-20011990-1991

Education Pop. % RR (95% CI) Pop. % RR (95% CI)

No education 8.7 2.8 (2.0-3.8) 3.2 3.2 (2.5-4.0)

Elementary 31.4 2.8 (2.1-3.7) 16.1 2.8 (2.3-3.4)

Middle or High 52.1 1.3 (1.0-1.8) 61.9 1.6 (1.3-1.9)

College+ 7.9 1.0 18.7 1.0

인구 구조의 변화를 감안한건강 불평등 지표(예: relative index of inequalities)의계산 원리

Relative Position Indicator in the Process of RII/SII Calculation

RII와 SII의용도

• 서열이있는사회경제적위치지표에서사용

• 시계열적인인구구성변화를고려하여건강수준에서의

상대불평등크기를비교하기위하여사용

• 건강불평등양상을요약적으로표현하기위하여사용

Use of RII and SII in documenting mortality inequalities

Khang et al. Soc Sci Med 2009

Changes in SMR (Standardized Mortality Rates) of Korean Aged 25-59 by Education

Elementary- Middle or High College+

No.

of d

eath

/ 10

0,00

0

0

200

400

600

800

1000

1200

1400

Males,1990-1991

Males,1995-1996

Males,2000-2001

Females,1990-1991

Females,1995-1996

Females,2000-2001

SMR=585

SMR=495

SMR=391

SMR=225

SMR=180

SMR=143

RII=7.31 RII=7.87 RII=7.62 RII=4.69 RII=4.00 RII=3.41

Khang et al. J EpidemiolCommunity Health 2004

Changes in Relative Index of Inequality for Suicide Mortality according to an Area SEP indicator

1.0

1.1

1.2

1.3

1.4

1.5

1.6

1995-1997 1998-1999 2000-2001 1995-1997 1998-1999 2000-2001

P=0.02 P=0.01

남성 여성

강영호 등. 예방의학회지 2005

Prevalence ratio (PR), and relative index of inequality (RII) of current cigarette smoking by calendar year and socioeconomic position indicators among men aged 25-64

1995 1999 2003 2006 P for trend

Men

Education

RII (95% CI) 1.25 (1.22-1.28) 1.31 (1.27-1.35) 1.51 (1.45-1.57) 1.57 (1.50-1.63) <0.0001

Occupational class

PR (95% CI) of manual vs. non-manual 1.15 (1.13-1.17) 1.17 (1.15-1.20) 1.23 (1.20-1.26) 1.27 (1.23-1.30) <0.0001

PR (95% CI) of others vs. non-manual

1.03 (1.00-1.06) 1.06 (1.03-1.09) 1.11 (1.07-1.15) 1.13 (1.09-1.17) <0.0001

Employment status

PR (95% CI) of non-standard vs.standard 1.12 (1.10-1.14) 1.13 (1.11-1.16) 1.26 (1.23-1.30) 1.32 (1.28-1.36) <0.0001

PR (95% CI) of others vs. standard 1.06 (1.04-1.07) 1.06 (1.04-1.08) 1.14 (1.11-1.17) 1.16 (1.13-1.19) <0.0001

Income quartile

RII (95% CI) NA 1.09 (1.06-1.13) NA 1.27 (1.22-1.32) <0.0001

p<0.001 P=0.214

P=0.095P=0.006

p<0.001 P=0.023

p<0.001

p<0.001 P=0.456

P=0.307

Khang et al. Nicotine & Tobacco Res 2009

Use of RII in presenting changes in explanatory ability

Khang et al. Soc Sci Med 2009

Relative indices of inequalities (RII values), and slope indices of inequalities (SII values), among South Korean men aged 35-

64 years (N=692,471)

Jung-Choi et al. J Epidemiol Community

Health 2011

Population Attributable Risk (PAR)

• Measures of the population burden– Associated with differential health between groups

Index of Disparities

• 기준값과개별군의 값의차이를요약지표로표현

• 기준군의 rate에에대한분율로표현

Between-Group Variance

• Squared deviations from a population average

Measures of Average Disproportionality

• Entropy indices– Theil index– Mean log deviation– Atkinson’s measure– Gini coefficient– Concentration index

• Combining health disparity and average health– Health Achievement Index (HAI)

Theil Index

• Summarize disproportionality between shares of health and shares of population

• Continuous outcome variables

pi = proportion of the population in group i

ri = ratio of the prevalence or rate of health in group I relative to the total rate, ri = yi/u where yi is the rate of health in group i, and u is the total population rate

Gini coefficient

• Measure of association between– Each social group’s share of population– Its share of health

• Gini coefficient is the ratio of– Area between

• Line of equality and• Lorenz curve

– To the total area of the triangle beneath the line

Concentration index

• Derived from a concentration curve– Population is ordered first by social-group status

• Y-axis– Cumulative share of ill health: Relative CI– Cumulative amount of ill health: Absolute CI

• Range of RCI– Continuous: -1 ~ ＋1– Non-continuous: μ – 1 ＋ (1/n) ~ 1 – μ ＋ (1/n)

측정 도구의 선정

• 건강형평성의정의에근거하여선택

• 자료의성격(ordering 여부등)에의하여선택

• 절대지표와상대지표

• 측정도구의제안– Graph (trends in adjusted rate)– 짝비교의 경우: RR (risk ratio) + RD (risk difference)– 서열이 있는 경우: RII (relative index of inequality)+SII (slope index of

inequality), ACI (absolute concentration index)+RCI (relative concentration index)

– 서열이 없는 경우: DGV (between group variance) + Theil index/Mean log deviation

Odds Ratio vs Prevalence Ratio

Khang YH, Yun SC, Lynch JW. Monitoring trends in socioeconomic

health inequalities: It matters how you measure. BMC Public Health 2008

Odds vs. Probability

0

1

2

3

4

5

0 0.2 0.4 0.6 0.8

Probability

Odd

s

odds probability

(a) Relationship between probability and odds.

(b-d) Odds ratio (OR) and prevalence ratio (PR) according to prevalence of low social class when prevalence of high social class was fixed to 0.1 (b), 0.3 (c), and 0.5 (d).

Hypothetical example* of trends of odds ratio and prevalence ratio by social class (low versus high class)

Time 1 Time 2

Low class High class Low class High class

Outcome prevalence (P) 0.75 0.60 0.60 0.43

Odds, P/(1-P) 3.00 1.50 1.50 0.75

OR † 2.00 1.99

PR‡ 1.25 1.40

OR = odds ratio; PR = prevalence ratio.*This example can be replicated when there is no other confounding variable.†OR (odds ratio) was calculated by Plow class/(1–Plow class) ÷ Phigh class/(1–Phigh class). ‡ PR (prevalence ratio) was calculated by Plow class ÷ Phigh class.

PR: 1.11 = 91.1%/81.9% in 1984

PR: 1.84 = 51.1%/27.7% in 1993 Bartley et al. J Epidemiol Community Health 2000

PR: 1.88 = 48.8%/25.9% in the 1980s

PR: 1.91 = 45.7%/23.9% in the 1990s

Kunst et al. Int J Epidemiol 2005

Khang et al. BMC Public Health 2008

Khang et al. BMC Public Health 2008