Measuring Health Equity: Beyond Description

The Ecosystem of Health Equity Measures: A Workshop

Sam Harper

McGill University

2023-06-21

Adapted from McGuire et al. (2006)

Moving beyond description is essential for progress

From description to explanation

• The “substance” we want to decompose is health inequality—a difference in health between social groups.

• Ultimately, we want to know why health inequalities are changing over time, or why they differ between populations

  • Risk factors?
  • Demographic composition?
  • Social conditions?

• Unpacking the ‘components’ of health inequality is an opportunity to better integrate the monitoring of health inequalities with the etiology of health inequalities.

• Racial inequality in BP due to risk factors?
• Tobacco, sodium, alcohol, BMI

…black participants with [high] blood pressure level have generally better risk factor characteristics… but the risk factors that we studied could not explain the higher blood pressure levels observed among black participants.

Basu et al. (2015)

Grappling with intersectional identities

• Health inequalities generated by interlocking systems of power and oppression.

• But often studied by single axes of:

  • Race, ethnicity, gender, sexual orientation, age, disability status, socioeconomic position, geography
  • Inattention to joint effects

• Inadequate data systems

Image credit: Culture Amp

New approaches to measurement

• Multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA)
• Partial pooling of (intersectoral) social strata
• Can reveal heterogeneity beyond simple additive effects.

See Evans et al. (2018), Merlo (2018).

• MAIHDA allows a deeper look at multi-dimensional heterogeneity.

Persmark et al. (2020) on the probability of reporting opioid use disorder.

Decomposition also provides opportunities to reconcile trends and explanations for inequalities.

Source: The Economist, Jan 4th, 2018.

Power of simple narratives

Our contribution was to link drug overdoses, suicides, and alcohol-related deaths, to note that all were rising together, that together they were afflicting mostly whites, and that, among that group, the long fall in total mortality had stopped or reversed. We also chose the collective label “deaths of despair,” which helped publicize the combined epidemic and emphasize that it included more than just drug overdose.

Case and Deaton (2020). Also see Case and Deaton (2015)

• Focus on low educated, rural, middle aged white men
• Emphasis on pain and disintegration of economic opportunties

“The rural opioid crisis of prescription drugs is largely a story of growing spatial inequality and of places left behind.”

Source: Richard Florida, Bloomberg, Dec 5, 2019

• Narratives about inequalities are opportunities for investigation.
• Theories must be reconciled with plausible links to population patterns of exposure.
• We ‘decomposed’ the recent life expectancy decline.

Harper et al. (2021)

• Rural-urban mortality gap began widening in 1980s.

• Slower CVD declines.

Source: Author’s calculations.

The story of rural opioid deaths masks population-wide impacts.

Ignores large (growing) impact of CVD.

Source: Author’s calculations.

Years of life lost 2014-2017, by gender, race, and cause

Harper et al. (2021)

Years of life lost 2014-2017, by gender, race, and cause

Harper et al. (2021)

• Much faster increases in opioid overdoses among Blacks and American Indian and Alaska Natives in recent years.

• Cannot be chiefly explained by the loss of economic opportunities among rural white men.

Source: Pew Research Center

Access to better data improves science

• 30 confidential data centers created 1994-2019.
• Improved researcher productivity.
• Stronger research designs.
• Outputs from improved access saw increased citation by policy documents.

Nagaraj and Tranchero (2023)

Parting thoughts

• Novel empirical methods exist to go beyond just describing health inequalities.

• When used properly, explanatory methods can help to provide key evidence on why health inequalities exist and change over time.

• Narratives matter: they identify heroes and villains, emphasize particular causes and populations, set the agenda for interventions, and minimize alternative explanations and solutions.

References

Basu S, Hong A, Siddiqi A. Using decomposition analysis to identify modifiable racial disparities in the distribution of blood pressure in the united states. Am J Epidemiol. 2015 Aug;182(4):345–53.

Case A, Deaton A. Rising morbidity and mortality in midlife among white non-hispanic americans in the 21st century. Proc Natl Acad Sci U S A. 2015 Dec;112(49):15078–83.

Case A, Deaton A. Deaths of despair and the future of capitalism. In: Deaths of despair and the future of capitalism. Princeton University Press; 2020.

Evans CR, Williams DR, Onnela JP, Subramanian SV. A multilevel approach to modeling health inequalities at the intersection of multiple social identities. Soc Sci Med. 2018 Apr;203:64–73.

Harper S, Riddell CA, King NB. Declining life expectancy in the united states: Missing the trees for the forest. Annu Rev Public Health. 2021 Apr;42:381–403.

McGuire TG, Alegria M, Cook BL, Wells KB, Zaslavsky AM. Implementing the institute of medicine definition of disparities: An application to mental health care. Health services research. 2006;41(5):1979–2005.

Merlo J. Multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) within an intersectional framework. Soc Sci Med. 2018 Apr;203:74–80.

Nagaraj A, Tranchero M. How does data access shape science? Evidence from the impact of U.S. Census’s research data centers on economics research [Internet]. National Bureau of Economic Research; 2023 Jun. Available from: https://doi.org/10.3386%2Fw31372

Persmark A, Wemrell M, Evans CR, Subramanian S, Leckie G, Merlo J. Intersectional inequalities and the US opioid crisis: Challenging dominant narratives and revealing heterogeneities. Critical Public Health. 2020;30(4):398–414.