Introduction to International Health – Assignment 1 Lecture

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Hi my name is David Peters and this talk I’m going to talk about health inequities we’re going to introduce some concepts and terms as well as some introduce some ways of measuring inequity and and by the way this will help with your with your assignment so equality or inequality is really about being the same or inequality or differences when we talk about inequity you know we’re often adding another element to it it’s because it usually adds an element an element above fairness related to those differences or inequalities and inequalities is really about you know an unfairness or injustice sometimes in health and in economics we talk about horizontal equity sometimes about vertical equity so horizontal equity is about treating equals as equals so those with the same condition should get the same type of health treatment for example and vertical equity is treating unequals unequally for example those who need to have greater health needs would get more care or you know in economics you might say those that are wealthier might pay more taxes than others in their BIA distribution so that’s the the vertical versus horizontal these have some implications for the way you interpret measures of equity and otherwise so health inequities is really when we’re talking about inequalities or disparities between groups or between individuals related to health and these could be health determinants like risk factors nutrition that could be about health services or they could be about health outcomes such as illness death mortality issues but note that often many programs in the past have focused on average or aggregate levels for example the Millennium Development Goals the MDGs focused on average levels of achieving health such as mortality reduction for example the new sustainable development is SPG’s Development Goals tries to address some of the issues of inequalities when they talk about universal health care for example but health inequity is really a central concept of a central issue in global health because we’re concerned about poor health conditions both risks for poverty or risk for illness and opportunities among vulnerable populations as I mentioned we’re concerned about what is fair or what is unjust and sometimes inequalities in themselves lead to more harmful consequences not just for those that are worse off but for everyone a common assumption we have that doesn’t host well but is commonly that kamek does is that health inequalities or inequities are not self-correcting they don’t correct themselves on their own health markets don’t work to correct inequalities for example and therefore they require interventions policies and programs that address inequities so I think well what are the ways in which people can be disadvantaged ways in which they are vulnerable or the ways in which inequities show up well they are often related to the social determinants and here you may have seen this figure before us when you look at the determinants of health many of the deterrents are outside the health sector and although we put health in the middle we could easily put any of these other concepts in but they are related to socioeconomic poverty of course many ways in which you can describe poverty as well but food nutrition education and environment gender social capital all ways in which that all ways that contribute to health and and illness but all ways in which people can be different than which there can be inequalities and create inequities in the in health so you know if you look at the ways in which people are disadvantaged sometimes it’s due to economic concerns income or wealth differences with social differences differences in education or occupation differences in social capital access to to social things that communities have for example or there might be differences that are cultural differences in caste ethnicity languages religion sexual orientation sometimes there’s just demographic differences between youth and elderly or other kinds of disabilities physical mental might create disadvantage in different populations but you might say well cable there’s lots of ways in which people they’re different but what are the dimensions of disadvantage that you know how does that lead to affecting people’s health what are the mechanism by which this happened now you can look at this from a mechanistic point of view that sometimes it’s because those disadvantages are differential exposures may be different save changes to the differences in physical environments such as housing or exposure to biologic or other environmental toxins for example where differences in behavior diet or powerful practices they might be differences in opportunities educational opportunities access to health care and knowledge about which you can do or the kind of care that you can get the kinds of community resources that you may have in order to to affect your health now they’re basically well they’re many ways of looking at it but there are at least four different models that explain how these inequities in health occur one of them is a cultural behavioral type of point of view that says basically that the differences in health these health inequities or results from differences in behavioral or lifestyle choices that led to ill healthy or whether you choose to smoke for example are the cultural norms and environmental factors and we just talked about that might lead to differences there’s also you know a psychosocial model that looks at really the the different psychological stresses that are different that that affect people differently particularly you know if you have less control on type of working or job security if you have less social support or if you live in areas that have higher crime for example or warfare that it said that these types of stresses that actually cause I’ll help and indirectly through these effects on behavioral and lifestyle questions then there’s a more which you might call a materialistic type of approach or model in which you look at differences due to exposure to material factors that are outside of your control such as housing for example or workplace hazards and that’s what causes some of the differences and then you know a fourth model might be considered a life course model that really says that the inequalities at any particular age are the results in differences from an accumulation of these cultural behavioral psychosocial and materialistic type of factors that build up over the life period or occur at certain time stages of life anyway these are sort of theoretical constructs that help help to describe the pathways but you know whatever however they work it is useful to in fact measure these things one of the things we’ve found in health is that if you have policies that are addressing inequalities or addressing the poor on vulnerable populations you actually need to be explicit about not just the policy but measuring how things change and so I’m going to introduce some ways of looking at this some ways of measuring it and recognize that there are many approaches and not all of them quantitative that are helpful in describing and understanding health inequality you know and the other thing I would raise about this is that every time in which you make measurement of something it’s not only something that is measurable and and other dimensions may not be measurable that may or may not be more important but they also reflect this type of conceptual or philosophical concern about how you look at inequality and so because of that it is often useful in a given circumstance to look at more than one type of measurement of inequality now what what most of these measurements have of an equality or basically three components one is a health-related measure now this might be a risk factor for health it might be a health need access to care it might be the differences or the quality of care or your health status itself whether you’re alive and dead for example or disabled or or or ill a second component is some way of identifying groups or individuals that are that difference and again this might be along socio-economic types of parameters or any of those dimensions that we’ve talked about previously and then you have to have a method for how do you make the comparisons so those are the three components a health measure a measure of identifying groups and the measure of making the comparisons so what we’re gonna do is talk about those methods and that’s gonna be used to measure economic disparity and health which is part of your assignment it actually is question four and where you’re going to put the results in Table four as well so we start off with a measure of economic of the economic measure so economic status can be measured by things that could be my income it could be by consumption or it could be by wealth which is basically the assets that people have now the what’s commonly used in demographic and health surveys in particularly lower middle-income countries where you don’t have good measures of income and consumption is very hard to measure very tedious so you use assets or wealth to see what happens with people own actually what we do is we’re going to conceptually we’re going to put the population divided into equal groups in this case quintiles or favorites and I’m going to put them in a row from poorest to least poor or wealthy in your perspective and then we’re going to assess by a health outcome or health services across the income groups so we’re going to look at two mortality rates and the set of health services that’s the health component and then we’re going to have two types of comparisons one is this low high poor rich ratio and then the concentration index so the concentration index is very different though the local high ratio is pretty intuitive you take the poorest quintile and you compare it to the richest quintile and that’s basically like a rate ratio comparison which we’ll talk about in epidemiology the concentration index is a little different it’s more like the Lorenz curve or Gini coefficient and what you have here is a graph showing you how a concentration index is created so what you have here in this case is taken from real data from Brazil and what we’ve done is we’ve put the the sample of the population is listed here from zero to a hundred percent this case by income but we’re going to do it by wealth you’re examples and then you have the proportion of children that are underweight so instead of mortality we’re going to use underweight and basically what you have is a this is the quality line this 45 degree line from zero to 100 and basically the quality line says that for every 25 percent of the population they account for 25% of the cumulative underweight children so if it’s perfectly equal it goes along that line so what happens here is that we have the Equality line and then we have the actual line here taking the two points in time 1987 and 1994 and the way we measure the concentration index is actually this space between the actual curve and the Equality line the 45-degree line and this which is curve here is called the concentration curve and it’s two kinds in the area in here is the is what what the concentration index is it has a value between minus one and positive one with zero being on the line here being perfectly equal and if it’s less than one you see that the variable is more is more when we say more concentrated among the poor more common among the poor so what you see here is that in 1987 25% of the children had about 30 percent of the accumulative the poorest 25% had more than thirty percent of the underweight so it’s concentrated so that would be a negative number as you can see between 1990’s 87 and 94 the concentration actually the curve actually moved outward so it actually became more inequitable over time the concentration index because a larger R because more negative over that time so that’s how it’s calculated in what it looks like here’s some work that my team did in India looking at nationally at data different types of services again the red line here is the Equality line but we see here in this case these are services so services are a good thing as opposed to underweight or mortality and so what we found here is that immunizations and outpatients through primary health care tended to be concentrated among the poor that the correction received more of these services but that these ones here the other side of the line inpatient hospital care and occasional hospital care tended to be used the concentration index was the other way they’re positive that means that rich we’re getting more of these services and again it was cumulative population and accumulated benefit or services in this point so what you’re going to do in your case is you’re going to take data from the files that we provide on demographic Health Survey data on mortality as well child mortality and under-five mortality and infant mortality and then a set of Health Services for that are pretty common and basically used for home basic health service for maternal child care you’re going to use a file where we that’s labeled the simplified concentration index calculator and this is basically a tool you can use to calculate the concentration index and you get quartile data or a quintile data every quintile as we’ve shown in these graphs about one more type of mortality and basic health services so that it actually will calculate the low high ratio which you could easily with the calculator or pen and pencil and then the concentration index which takes a little bit more work in therefore it’s easier with the with the spreadsheet to be able to do that and then you’re going to record your answers on Table four and then you’re going to have some interpretations around that which you’re going to answer in the in question form so if you look at it your data is going to look like this you’re going to think that I’ve actually put all the countries that are cases in one place you’re going to have say the infant mortality rate and then you’re going to have a country listed here and then you have the low second third fourth fifth quintile is in a population average you’re going to put these numbers into the into the spreadsheet and calculate the calculate thing it will calculate actually the concentration index for you similarly you’re going to look at some health services and antenatal in antenatal care and do the same thing this is what if you actually look at the file that calculates the concentration index it takes group data and you could enter data here in these blue area where it says enter data from low to high quintile you can only edit these blue spaces in the file and you put your country mortality and health services data you actually just put them in right here the quintile means we don’t know we didn’t offer you the the data to put in the actual numbers here or just you so just leave this alone for now you need that data if you want to calculate the standard errors the variance on these things if you wanted to do statistical testing on it right now we’re just looking at the this mean the main concentration in the next to the high-low ratio when you put in the numbers it will calculate for you the low high ratio of concentration index and if you had these other numbers that these would be meaningful the standard errors and the t-test to see whether it’s statistically significant chances are that leaving a thousand will is pretty close for most countries and it will give you a good idea if it’s close to significant or not if you just leave them alone and the spreadsheet will also give you a graph to actually show you that concentration curve as well so hopefully when you leave here you’ll actually have a tool that you can use and you can tell your your prospective employer that yeah I can calculate concentration and that’s a measure way to look measure health inequities you’re going to then put your data into the are your results into you tell you will answer your questions and and then you know Bob’s your uncle done well yeah that part of the assignment so hopefully with this you’ll have gotten an idea of the types of ways of looking at health inequities giving you a tool that you can use to measure to ways of measuring economic disparities in health and with that you’ll be able to do more in-depth analysis further on it and think more about the this vexing problem of health inequities which is really a unifying principle of what we tried to do what we tried to address in because thanks very much

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