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. 2011 Dec;89(4):658-93.
doi: 10.1111/j.1468-0009.2011.00646.x.

Best practice guidelines for monitoring socioeconomic inequalities in health status: lessons from Scotland

John Frank  1 , Sally Haw
Affiliations

Best practice guidelines for monitoring socioeconomic inequalities in health status: lessons from Scotland

John Frank et al. Milbank Q. 2011 Dec.

Abstract

Context: In this article we present "best practice" guidelines for monitoring socioeconomic inequalities in health status in the general population, using routinely collected data.

Methods: First, we constructed a set of critical appraisal criteria to assess the utility of routinely collected outcomes for monitoring socioeconomic inequalities in population health status, using epidemiological principles to measure health status and quantify health inequalities. We then selected as case studies three recent "cutting-edge" reports on health inequalities from the Scottish government and assessed the extent to which each of the following outcomes met our critical appraisal criteria: natality (low birth weight rate, LBW), adult mortality (all-cause, coronary heart disease [CHD], alcohol-related, cancer, and healthy life expectancy at birth), cancer incidence, and mental health and well-being.

Findings: The critical appraisal criteria we derived were "completeness and accuracy of reporting"; "reversibility and sensitivity to intervention"; "avoidance of reverse causation"; and "statistical appropriateness." Of these, the most commonly unmet criterion across the routinely collected outcomes was "reversibility and sensitivity to intervention." The reasons were that most mortality events occur in later life and that the LBW rate has now become obsolete as a sole indicator of perinatal health. Other outcomes were also judged to fail other criteria, notably alcohol-related mortality after midlife ("avoidance of reverse causation"); all cancer sites' incidence and mortality (statistical appropriateness due largely to heterogeneity of SEP gradients across different cancer sites, as well as long latency); and mental health and well-being ("uncertain reversibility and sensitivity to intervention").

Conclusions: We conclude that even state-of-the-art data reports on health inequalities by SEP have only limited usefulness for most health and social policymakers because they focus on routinely collected outcomes that are not very sensitive to intervention. We argue that more "upstream" outcome measures are required, which occur earlier in the life course, can be changed within a half decade by feasible programs and policies of proven effectiveness, accurately reflect individuals' future life-course chances and health status, and are strongly patterned by SEP.

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Figures

Figure 1
Figure 1
Absolute Range: Healthy Life Expectancy, Males, Scotland, 1999/2000 to 2007/2008 (data not available for 2003/2004) Source: Scottish Government Analytical Services Division 2010.
Figure 2
Figure 2
Absolute Range: Healthy Life Expectancy, Females, Scotland, 1999/2000 to 2007/2008 (data not available for 2003/2004) Source: Scottish Government Analytical Services Division 2010.
Figure 3
Figure 3
Absolute Range: All-Cause Mortality, Those Aged <75 years, Scotland, 1997–2008 (European age-standardized rates per 100,000)r = revised. Source: Scottish Government Analytical Services Division 2010.
Figure 4
Figure 4
Absolute Range: CHD Mortality, Those Aged 45 to 74 years, Scotland, 1997–2008 (European age-standardized rates per 100,000) Source: Scottish Government Analytical Services Division 2010.
Figure 5
Figure 5
Relative Index of Inequality (RII): CHD Mortality, Those Aged 45 to 74 Years, Scotland, 1997–2008 (RII = SII divided by population mean rate) Source: Scottish Government Analytical Services Division 2010.
Figure 6
Figure 6
Absolute Range: Alcohol-Related Mortality, Those Aged 45 to 74 Years, Scotland, 1998–2008 (European age-standardized rates per 100,000) Source: Scottish Government Analytical Services Division 2010.
Figure 7
Figure 7
Alcohol-Related Mortality, Those Aged 45 to 74 by Income-Employment Index, Scotland, 2008 (European age-standardized rates per 100,000) Source: Scottish Government Analytical Services Division 2010.
Figure 8
Figure 8
Absolute Range: Hospital Admissions for Heart Attack, Those Aged <75 years, Scotland, 1997–2008 (European age-standardized rates per 100,000) Source: Scottish Government Analytical Services Division 2010.
Figure 9
Figure 9
Absolute Range: Low Birth-Weight Babies, Scotland, 1998–2008 (as a percentage of all live singleton births)r = Revised Source: Scottish Government Analytical Services Division 2010.
Figure 10
Figure 10
Absolute Range: All Cancers' Incidence, Those Aged <75 years, Scotland, 1996–2007 (European age-standardized rates per 100,000) Source: Scottish Government Analytical Services Division 2010.
Figure 11
Figure 11
Absolute Range: All Cancers' Mortality, Those Aged 45 to 74 Years, Scotland, 1997–2008 (European age-standardized rates per 100,000) Source: Scottish Government Analytical Services Division 2010.
Figure 12
Figure 12
All-Cause Mortality, USSR, 1984–1994 Source: Leon et al. 1997 (page 385).
Figure 13
Figure 13
Mortality from Neoplasms, USSR, 1984–1994 Source: Leon et al. 1997 (page 385).
Figure 14
Figure 14
Absolute Range: Mean WEMWBS Score, Scotland, 2008/2009 Source: Scottish Government Analytical Services Division 2010.
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