https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)60240-2.pdf

Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study

Increasing social inequalities in health in the United States and elsewhere, coupled with growing inequalities in income and wealth, have refocused attention on social class as a key determinant of population health. Routine analysis using conceptually coherent and consistent measures of socioeconomic position in US public health research and surveillance, however, remains rare. This review discusses concepts and methodologies concerning, and guidelines for measuring, social class and other aspects of socioeconomic position (e.g. income, poverty, deprivation, wealth, education). These data should be collected at the individual, household, and neighborhood level, to characterize both childhood and adult socioeconomic position; fluctuations in economic resources during these time periods also merit consideration. Guidelines for linking census-based socioeconomic measures and health data are presented, as are recommendations for analyses involving social class, race/ethnicity, and gender. Suggestions for research on socioeconomic measures are provided, to aid monitoring steps toward social equity in health.

Measuring Social Class in US Public Health Research: Concepts, Methodologies, and Guidelines

This glossary presents a comprehensive list of indicators of socioeconomic position used in health research. A description of what they intend to measure is given together with how data are elicited and the advantages and limitation of the indicators. The glossary is divided into two parts for journal publication but the intention is that it should be used as one piece. The second part highlights a life course approach and will be published in the next issue of the journal.

https://jech.bmj.com/content/jech/60/1/7.full.pdf

Indicators of socioeconomic position (part 1)

PURPOSE—Interest in the effects of neighbourhood or local area social characteristics on health has increased in recent years, but to date the existing evidence has not been systematically reviewed. Multilevel or contextual analyses of social factors and health represent a possible reconciliation between two divergent epidemiological paradigms—individual risk factor epidemiology and an ecological approach.
DATA SOURCES—Keyword searching of Index Medicus (Medline) and additional references from retrieved articles.
STUDY SELECTION—All original studies of the effect of local area social characteristics on individual health outcomes, adjusted for individual socioeconomic status, published in English before 1 June 1998 and focused on populations in developed countries.
DATA SYNTHESIS—The methodological challenges posed by the design and interpretation of multilevel studies of local area effects are discussed and results summarised with reference to type of health outcome. All but two of the 25 reviewed studies reported a statistically significant association between at least one measure of social environment and a health outcome (contextual effect), after adjusting for individual level socioeconomic status (compositional effect). Contextual effects were generally modest and much smaller than compositional effects.
CONCLUSIONS—The evidence for modest neighbourhood effects on health is fairly consistent despite heterogeneity of study designs, substitution of local area measures for neighbourhood measures and probable measurement error. By drawing public health attention to the health risks associated with the social structure and ecology of neighbourhoods, innovative approaches to community level interventions may ensue.


Keywords: socioeconomic status; local area; contextual analysis; hierarchical analysis

https://jech.bmj.com/content/jech/55/2/111.full.pdf

Multilevel Analyses of Neighbourhood Socioeconomic Context and Health Outcomes: a Critical Review

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(06)69041-7.pdf

Prevalence of disorders of the autism spectrum in a population cohort of children in South Thames: the Special Needs and Autism Project (SNAP).

A measure of deprivation has been devised using data from the 1981 Census about area characteristics which may be considered to reflect material deprivation, and a score is calculated for each postcode sector in Scotland. The routine data sources provide information for a range of health measures which are shown to be strongly linked to levels of deprivation, with specific causes--respiratory conditions, cancer of the lung and cancer of the cervix--exhibiting very considerable differentials in respect of both mortality and cancer morbidity. Nevertheless not all causes exhibit this positive association. This area-based measure provides a valuable tool for the analysis of health data in relation to socio-economic circumstances which overcomes many of the limitations which arise in the use of the more traditional measure of social class. Like social class however it depends on data from the census which are available only at ten-yearly intervals. Other existing data sources are suggested which could possibly provide relevant information on area characteristics and populations for inter-censal years.

Deprivation and health in Scotland.

A number of indexes of deprivation which have been devised or adopted for use by the health services are examined in relation to their performance in explaining the variation observed in a range of health measures, using data for postcode sectors in Scotland The Scottish deprivation score and the Townsend index are found to explain most variation, and to adhere most closely to the concept of material disadvantage The Jarman score is less effective as a result of the inclusion of individual variables which are seen to correlate very weakly, even negatively, with the health indicators The use of these measures in relation to resource allocation and the new GP contract is discussed

Which deprivation? A comparison of selected deprivation indexes

STUDY OBJECTIVE--To examine the use of deprivation indices in relation to health. DESIGN--This paper reviews selected publications which illustrate the diversity of use of deprivation indices in the past decade. Most of this work is based in the major routine databases which exist in this country: the census, population, mortality, cancer register, and health service records all now incorporate a postcode identifier which permits the derivation of data at small area level, and thus the examination of health events in relation to the characteristics of that area - usually ward or postcode sector. The small area approach provides a valuable tool both in deprivation and in other epidemiological studies which examine the influence of the environment on health. SETTING--The setting is various journals and official publications. MAIN RESULTS--The link between deprivation and health has been clearly demonstrated in a number of studies, with populations living in deprived areas exhibiting levels of mortality, particularly below the age of 65, which vastly exceed those in affluent areas. In the decade 1981-91, these differentials increased in Scotland and the Northern Health Region and inequalities in health are shown to have widened. Analysis shows that particular causes of death and sites of cancer are more likely to reflect the influence of socio-economic factors. The work so far mostly shows the associations between these factors and health measures and more investigation is required into the determinants of health, which are likely to reside as much in past as in current circumstances. A measure of deprivation has proved of value in excluding the likely variation in the incidence of disease in studies directed towards determining the influence of the physical environment on populations living in the vicinity of possible harmful industrial processes. A deprivation measure has been adopted by the Department of Health as a basis for making enhanced payments to general practitioners for patients living in these areas, but the resource allocation formula for allocating funds to regional authorities has failed to incorporate such a measure in the formula. CONCLUSIONS--An area measure of deprivation has proved a valuable tool in examining differentials in health and death and is likely to prove of continuing value to health authorities in planning the delivery of health care. Future work should strive to examine the determinants of health as well as the associations, although this is unlikely to be possible through the routine databases which have provided the main basis for analysis so far.

Deprivation indices: their interpretation and use in relation to health.

Mortality rates for males aged 20 to 64 in Scotland (1980-1982) display an increasing gradient both by social class (from class 1 to 5) and by the deprivation category of the area (from affluent to deprived) in which the event occurred. Social classes also exhibit gradients in mortality across deprivation categories, the corresponding rates in the most deprived category being around twice those in the most affluent areas. The gradients by deprivation category remain after standardizing for differences in social class composition. Within health boards in Scotland populations show only minor variability in terms of social class, while their composition on the dimension of deprivation is markedly diverse, and the classification of populations by the deprivation category of their area of residence appears to offer a superior basis for the explanation of differences in mortality between health boards than does social class. This evidence of area effects supports a proposal for area socioeconomic characteristics to be adopted as key variables in epidemiological analysis, and for an area classification to be designed and incorporated in the 1991 census output for use on a consistent basis.

Vera Carstairs

Papers

Deprivation and health in Scotland.

Which deprivation? A comparison of selected deprivation indexes

Deprivation indices: their interpretation and use in relation to health.

Deprivation and mortality: an alternative to social class?

Deprivation, mortality and resource allocation.