Project Title:

Equality, inequality and health in Scotland

Project Number:

2012_003

Researchers:

Andrew Millard (Scottish Public Health Observatory)
Gerry McCartney (Scottish Public Health Observatory)

Start Date:

Approved on 19-06-2012

Summary:

Research question:

Is the inequality in health outcomes by social class the same when stratified by protected characteristics* as it is across the whole population?

Objectives:

From 1991-2010
Compare health outcomes by social class stratified by:

• Age group at 1991 (0-14, 15-24, 25-34, 35-44, 45-54, 55-64)
• Sex
• ethnicity
• disability (although subject to reverse causation)
• religion/belief (practising and raised religion assessed at 2001, aged 0-74)

Calculate, by stratum, age-standardised (not for agegroup) all-cause hospital discharge rates, bed days per 100,000 person years and mortality rates.

Triangulate, using for each stratum, mean levels of General Health at 2001 predicted by SES at 1991, and Cox’s Proportional Hazards for death.

Background:

The ‘Equally Well’ report¹ from the Scottish Government took note of how socio-economic factors and low income interact with the protected characteristics and health behaviours to produce health inequalities. Although a number of previous reports^2-12 have discussed an increase in health inequalities, there is little systematic work from the UK examining the potential interaction between individual protected characteristics (as defined under the Equality Act 2010) and socio-economic status in determining health outcomes. The Marmot review¹³ postdates ‘Equally Well’ and considers protected characteristics under the heading of ‘the social determinants of health’. Marmot describes a model¹⁴ where material circumstances (residential area, social support, health-related behaviours) are influenced by socio-economic position which (Marmot says) ‘itself is influenced by individual characteristics’. Thus there is a theoretical justification for looking at the interaction. There has been some work in the UK on SES and ethnicity,^15,16 suggesting that socioeconomic effects should be shown when analyzing differences in health between protected characteristics.¹⁷ One aspect of that would be looking for the interaction between them. In the USA, detailed studies of specific conditions have traced connections between class, ethnicity, and health risks. Krieger and colleagues¹⁸ showed different trends in premature mortality by income quintile from 1960 to 2001 in white groups and people of colour. To improve knowledge of these issues in Scotland, the study aims to quantify how health outcomes vary by protected characteristics and to ascertain any interaction between social class and equality group in determining health outcomes.

*The Equality Act 2010 identifies nine protected characteristics, including four not mentioned above: sexual orientation, transgender status, pregnancy/maternity and marriage/civil partnership. These four are not included in the present study either because no data relating to them is included in the Scottish Longitudinal Study or because they are not of central relevance to the Equality Act, being covered by other legislation (pregnancy/maternity) or subject to more limited provisions of the Equality Act (marriage/civil partnership). These characteristics are ‘protected’ according to the Equality Act in that organizations are not in general allowed to discriminate against, harass, or victimise anyone because they have a protected characteristic. All of the Equality Act protected characteristics are important because there is evidence that unfair treatment can be based on these characteristics. There is some evidence also that health varies systematically by some of these characteristics.

References:

1. Equally Well: Report of the Ministerial Task Force on Health Inequalities Scottish Government 2008 http://www.scotland.gov.uk/Publications/2008/06/25104032/4


2. Inequalities in health: report of a working party. Black D, Morris J, Smith C, Townsend P. London: Department of Health and Social Security, 1980.


3. Independent Inquiry into Inequalities in Health: 1998 Acheson report


4. Towards a Healthier Scotland. Scottish Executive 1999.


5. Tackling Health Inequalities 2002 Cross-Cutting Review: Treasury Review


6. Improving Health in Scotland: The Challenge. March 2003.


7. Securing Good Health for the Whole Population Wanless Report (commissioned by HM Treasury) 2004.


8. Measuring Inequalities in Health Working Group. Inequalities in Health. Edinburgh, Scottish Parliament, 2003.


9. Delivering for Health. Scottish Executive 2005.


10. Concepts and principles for tackling social inequalities in health: Levelling up Part 1. World Health Organization. 2006


11. Health in Scotland 2006 Annual Report of the Chief Medical Officer


12. Inequalities in mortality in Scotland 1981-2001. Leyland AH, Dundas R, McLoone P, Boddy FA. MRC Social and Public Health Sciences Unit Occasional Papers no 16. Glasgow: MRC Social and Public Health Sciences Unit, 2007.


13. Fair Society, Healthy Lives. The Marmot Review, Strategic Review of Health Inequalities in England post 2010. Marmot, M., Allen, J.,Goldblatt, P., Boyce, T., McNeish, D., Grady, M., Geddes.,I. www.ucl.ac.uk/marmotreview


14. Commission on Social Determinants of Health (2008) CSDH Final Report: Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva: World Health Organization. p43


15. Nazroo, J. Y. (1997) The health of Britain's ethnic minorities: findings from a national survey, London: Policy Studies Institute.


16. Nazroo, J. Y. (1998a) 'Genetic, cultural or socio-economic vulnerability? Explaining ethnic inequalities in health', Sociology of Health and Illness, 20, 5, 710-730


17. Nazroo JY., Karlsen, S., Ethnic inequalities in health: social class, racism and identity. Research Findings 10 From the Health Variations Programme, ESRC, 2001.


18. Krieger N, Rehkopf DH, Chen JT, Waterman PD, Marcelli E, Kennedy M. The Fall and Rise of US Inequities in Premature Mortality: 1960-2002. PLoS Med 2008 Feb 26;5(2):e46. http://dx.doi.org/10.1371%2Fjournal.pmed.0050046

Related Outputs (viewable on CALLS Hub):

• Does the socio-economic gradient in all-cause mortality apply across equality subgroups in Scotland?
• Mortality differences and inequalities within and between ‘protected characteristics’ groups, in a Scottish Cohort 1991–2009