Monitoring Health Inequalities Research Articles

Underserved groups could be better considered within population-based eye health surveys: a methodological study

ObjectivesIn pursuit of health equity, the World Health Organization has recently called for more extensive monitoring of inequalities in eye health. Population-based eye health surveys can provide this information, but whether underserved groups are considered in the design, implementation, and reporting of surveys is unknown. We conducted a systematic methodological review of surveys published since 2000 to examine how many population-based eye health surveys have considered underserved groups in their design, implementation, or reporting. Study Design and SettingWe identified all population-based cross-sectional surveys reporting the prevalence of objectively measured vision impairment or blindness. Using the PROGRESS + framework to identify underserved groups, we assessed whether each study considered underserved groups within 15 items across the rationale, sampling or recruitment methods, or the reporting of participation and prevalence rates. Results388 eye health surveys were included in this review. Few studies prospectively considered underserved groups during study planning or implementation, for example within their sample size calculations (n = 5, ∼1%) or recruitment strategies (n = 70, 18%). The most common way that studies considered underserved groups was in the reporting of prevalence estimates (n = 374, 96%). We observed a modest increase in the number of distinct PROGRESS + factors considered by a publication over the study period. Gender/sex was considered within at least one item by 95% (n = 367) of studies. Forty-three percent (n = 166) of included studies were conducted primarily on underserved population groups, particularly for subnational studies of people living in rural areas, and we identified examples of robust population-based studies in socially excluded groups. ConclusionMore effort is needed to improve the design, implementation, and reporting of surveys to monitor inequality and promote equity in eye health. Ideally, national-level monitoring of vision impairment and service coverage would be supplemented with smaller-scale studies to understand the disparities experienced by the most underserved groups.

Trends in socioeconomic inequalities in life expectancy and lifespan variation in Chile.

Socioeconomic disparities in life expectancy are well-documented in various contexts, including Chile. However, there is a lack of research examining trends in life expectancy inequalities and lifespan variation over time. Addressing these gaps can provide crucial insights into the dynamics of health inequalities. This study utilizes data from census records, population surveys, and death certificates to compare the life expectancy and the lifespan variation at age 26 of individuals according to their rank in the distribution of years of education within their own birth cohort. The analysis spans three periods (1991, 2002, and 2017) and focuses on two educational groups: individuals in the first (lowest) quintile and tenth (highest) decile of educational attainment. Changes in life expectancy are disaggregated by major causes of death to elucidate their contributions to overall trends. Consistent with existing literature, our findings confirm that individuals with lower education levels experience lower life expectancy and higher lifespan variation compared to their more educated counterparts. Notably, by 2017, life expectancy for individuals in the lowest quintile of education has caught up with that of the top decile in 1991, albeit with contrasting trends between genders. Among women, the gap has reduced, while it has increased for males. Moreover, lifespan variation decreased (increased) over time for individuals in the tenth decile (first quintile). The leading causes of death that explain the increase in life expectancy in women and men in the tenth decile as well as women in the first quintile are cardiovascular, cancer, respiratory and digestive diseases. In the case of males in the first quintile, few gains have been made in life expectancy resulting from cancer and a negative contribution is associated with digestive conditions. This study underscores persistent socioeconomic disparities in life expectancy in Chile, emphasizing the importance of ongoing monitoring of health inequalities across different demographic segments. The gender-specific and educational gradient trends highlight areas for targeted interventions aimed at reducing health disparities and improving overall population health outcomes. Further research is warranted to delve into specific causes of death driving life expectancy differentials and to inform evidence-based policy interventions.

Child mortality inequalities and socioeconomic determinants of health in Iran, 2016-2018.

Measuring health inequalities is essential to inform policy making and for monitoring implementation to reduce avoidable and unfair differences in health status. We conducted a geospatial analysis of child mortality in Iran using death records from the Ministry of Health and Medical Education from 2016 to2018 stratified by sex, age, province, and district, and household expenditure and income survey data from the Statistical Center of Iran collected in 2017. We applied multilevel mixed-effect models and detected significant inequality in child mortality and the impact of socioeconomic factors, especially household income. We advocate for using mortality rate for young children (< 5 years old) as an indicator for assessing the impact of interventions to reduce inequalities among various socioeconomic groups. We also recommend to design and implement comprehensive and longitudinal data collection systems for accurate, regular, and specific monitoring of health inequalities.

Identifying health inequities using a health system performance assessment: findings from Germany

Abstract Background Reducing health inequities is an important goal of high-performing health systems. Therefore, health inequities need to be assessed systematically, continuously and for all relevant aspects of a health system. The tool “health system performance assessments” (HSPA) aims at monitoring and evaluation the achievement of predefined goals and therefore the overall performance of a national health system. The aim of this study was to identify health inequities using a national HSPA. Methods A pilot study for a national HSPA in Germany was conducted between 2020 and 2023. The underlying framework defined the health system goals (e.g., access, quality, population health) and the respective indicators. Equity analyses (e.g., age, gender, socioeconomic factors, geographical region, type of health insurance) were conducted for each indicator to highlight inequities. Results Inequities were found for all health system goals. For example, unmet needs (“access”) were higher among people in the lowest income quintiles and in suburban areas. Potentially inadequate medication among the elderly (“quality”) was found more often for women and people 85+ years. The prevalence of infectious diseases (“population health”) was higher among men. Conclusions Using a national HSPA to discover health inequities can help identify these in all areas and for all goals of a health system and monitor their development over time. The systematic and continuous assessment within an HSPA is an important prerequisite for identifying and evaluating measures aiming at reducing health inequities. Key messages • A national health system performance assessment is useful for identifying and monitoring health inequities on a system level. • Health inequities (e.g., regarding age, gender, geographic region) were found for every goal of the German health care system.

Home working and social and mental wellbeing at different stages of the COVID-19 pandemic in the UK: Evidence from 7 longitudinal population surveys.

Home working has increased since the Coronavirus Disease 2019 (COVID-19) pandemic's onset with concerns that it may have adverse health implications. We assessed the association between home working and social and mental wellbeing among the employed population aged 16 to 66 through harmonised analyses of 7 UK longitudinal studies. We estimated associations between home working and measures of psychological distress, low life satisfaction, poor self-rated health, low social contact, and loneliness across 3 different stages of the pandemic (T1 = April to June 2020 -first lockdown, T2 = July to October 2020 -eased restrictions, T3 = November 2020 to March 2021 -second lockdown) using modified Poisson regression and meta-analyses to pool results across studies. We successively adjusted the model for sociodemographic characteristics (e.g., age, sex), job characteristics (e.g., sector of activity, pre-pandemic home working propensities), and pre-pandemic health. Among respectively 10,367, 11,585, and 12,179 participants at T1, T2, and T3, we found higher rates of home working at T1 and T3 compared with T2, reflecting lockdown periods. Home working was not associated with psychological distress at T1 (RR = 0.92, 95% CI = 0.79 to 1.08) or T2 (RR = 0.99, 95% CI = 0.88 to 1.11), but a detrimental association was found with psychological distress at T3 (RR = 1.17, 95% CI = 1.05 to 1.30). Study limitations include the fact that pre-pandemic home working propensities were derived from external sources, no information was collected on home working dosage and possible reverse association between change in wellbeing and home working likelihood. No clear evidence of an association between home working and mental wellbeing was found, apart from greater risk of psychological distress during the second lockdown, but differences across subgroups (e.g., by sex or level of education) may exist. Longer term shifts to home working might not have adverse impacts on population wellbeing in the absence of pandemic restrictions but further monitoring of health inequalities is required.

Site-Specific Cancer Incidence by Race and Immigration Status in Canada 2006-2015: A Population-Based Data Linkage Study.

The Canadian Cancer Registry (CCR) does not collect demographic data beyond age and sex, making it difficult to monitor health inequalities. Using data linkage, we compared site-specific cancer incidence rates by race. The 2006 and 2011 Canadian Census Health and Environment Cohorts are population-based probabilistically linked datasets of 5.9 million respondents of the 2006 long-form census and 6.5 million respondents of the 2011 National Household Survey. Race was self-reported. Respondent data were linked with the CCR up to 2015. We calculated age-standardized incidence rate ratios (ASIRR), comparing group-specific rates to the overall population rate with bootstrapped 95% confidence intervals (CI). We used negative binomial regressions to adjust for socioeconomic variables and assess interactions with immigration status. The age-standardized overall cancer incidence rate was lower in almost all non-White racial groups than in the overall population, except for White and Indigenous peoples who had higher incidence rates than the overall population (ASIRRs, 1.03-1.04). Immigrants had substantially lower age-standardized overall cancer incidence rates than nonimmigrants (ASIRR, 0.83; 95% CI, 0.82-0.84). Stomach, liver, and thyroid cancers and multiple myelomas were the sites where non-White racial groups had consistently higher site-specific cancer incidence rates than the overall population. Immigration status was an important modifier of cancer risk in the interaction model. Differences in cancer incidence between racial groups are likely influenced by differences in lifestyles, early life exposures, and selection factors for immigration. Data linkage can help monitor health inequalities and assess progress in preventive interventions against cancer. See related commentary by Withrow and Gomez, p. 876.

Health Equity Assessment Toolkit (HEAT and HEAT Plus): exploring inequalities in the COVID-19 pandemic era

BackgroundThe Sustainable Development Goals have helped to focus attention on the importance of reducing inequality and ‘leaving no one behind’. Monitoring health inequalities is essential for providing evidence to inform policies, programmes and practices that can close existing gaps and achieve health equity. The Health Equity Assessment Toolkit (HEAT and HEAT Plus) software was developed by the World Health Organization to facilitate the assessment of within-country health inequalities.ResultsHEAT contains a built-in database of disaggregated health data, while HEAT Plus allows users to upload and analyze inequalities using their own datasets. Version 4.0 of the software incorporated enhancements to the toolkit’s capacity for equity assessments. This includes a multilingual interface, interactive and downloadable visualizations, flexibility to analyze inequalities using any dataset of disaggregated data, and the built-in calculation of 19 summary measures of inequality. This paper outlines the improved features and functionalities of the HEAT and HEAT Plus software since their original release, highlighted through an example of how the toolkit can be used to assess inequalities in the COVID-19 pandemic era.ConclusionsThe features of the HEAT and HEAT Plus software make it a valuable tool for analyzing and reporting inequalities related to the COVID-19 pandemic, as well as its indirect impacts on inequalities in other health and non-health areas, providing evidence to inform equity-oriented interventions and strategies.

A Scoping Review of Approaches to Improving Quality of Data Relating to Health Inequalities.

Identifying and monitoring of health inequalities requires good-quality data. The aim of this work is to systematically review the evidence base on approaches taken within the healthcare context to improve the quality of data for the identification and monitoring of health inequalities and describe the evidence base on the effectiveness of such approaches or recommendations. Peer-reviewed scientific journal publications, as well as grey literature, were included in this review if they described approaches and/or made recommendations to improve data quality relating to the identification and monitoring of health inequalities. A thematic analysis was undertaken of included papers to identify themes, and a narrative synthesis approach was used to summarise findings. Fifty-seven papers were included describing a variety of approaches. These approaches were grouped under four themes: policy and legislation, wider actions that enable implementation of policies, data collection instruments and systems, and methodological approaches. Our findings indicate that a variety of mechanisms can be used to improve the quality of data on health inequalities at different stages (prior to, during, and after data collection). These findings can inform us of actions that can be taken by those working in local health and care services on approaches to improving the quality of data on health inequalities.

Health Inequality Monitoring channel on OpenWHO: capacity strengthening through eLearning

BackgroundHealth inequality monitoring can generate important evidence to inform and motivate changes to policy, programmes and practices. However, the potential of health inequality monitoring practices to quantify inequalities between population subgroups and track progress on the advancement of health equity is under-realized. Capacity strengthening on health inequality monitoring can play an important role in enhancing political will for the generation and use of disaggregated data and for wider adoption of this practice to inform health decision-making. There is a lack of widely available and accessible training materials related to health inequality monitoring that may be used by a range of stakeholders.ObjectiveIn this paper, we describe the design, development and implementation of the Health Inequality Monitoring channel on the OpenWHO eLearning platform. We discuss the anticipated impact and potential opportunities for these eLearning courses to contribute to strengthened health inequality monitoring practices.ResultsThe Health Inequality Monitoring channel on the OpenWHO platform is a self-directed learning environment, designed to meet the immediate learning needs of users. The channel contains three series of courses: health inequality monitoring foundations courses; topic-specific health inequality monitoring courses; and health inequality monitoring skill building courses. Courses are primarily targeted to monitoring and evaluation officers, data analysts, academics and researchers, public health professionals, medical and public health students, and others with a general interest in health data and inequality monitoring. ConclusionsWHO eLearning courses on health inequality monitoring are addressing the need for capacity strengthening in the collection, analysis and reporting of inequality data. They introduce learners to the foundational concepts, best practices, tools and skills required to conduct health inequality monitoring. The courses on the Health Inequality Monitoring channel demonstrate how technical information can be simplified and presented to broad audiences in a manner that is highly accessible to learners. The Health Inequality Monitoring channel on OpenWHO is an innovative and necessary addition to existing tools and resources to support the advancement of health equity.

Characteristics of Composite Deprivation Indices Used in Public Health: A Scoping Review Protocol.

Introduction: A deprivation index has become a more popular tool to rank levels of deprivation within different geographic areas. It is extensively used for monitoring health inequalities, evaluating health care services, developing and modifying health policies and programs, and allocating health resources equitably. Our objectives are (1) to explore the relevant literature to describe features of composite deprivation measures; (2) create a list and classification of original deprivation indices. We will develop the classification of indices to systematize knowledge and improve the functional utility of the information. Methods: Any original deprivation index mentioned in peer-reviewed or grey literature documents will be eligible for inclusion if it assesses deprivation at a population level and used in relation to health. The study area will be limited to the geographic areas of North America, Europe, Australia, and New Zealand. Tables and a narrative summary will be used to describe features of deprivation indices. Diagrammatic form will be used to create the classification of deprivation indices. Discussion: Practically, the results of this study could facilitate finding a common language among researchers and specialists who create and use deprivation indices, thus helping the development and implementation of appropriate deprivation indices for different countries.

Colorectal Cancer Incidence, Inequalities, and Prevention Priorities in Urban Texas: Surveillance Study With the "surveil" Software Package.

BackgroundMonitoring disease incidence rates over time with population surveillance data is fundamental to public health research and practice. Bayesian disease monitoring methods provide advantages over conventional methods including greater flexibility in model specification and the ability to conduct formal inference on model-derived quantities of interest. However, software platforms for Bayesian inference are often inaccessible to nonspecialists.ObjectiveTo increase the accessibility of Bayesian methods among health surveillance researchers, we introduce a Bayesian methodology and open source software package, surveil, for time-series modeling of disease incidence and mortality. Given case count and population-at-risk data, the software enables health researchers to draw inferences about underlying risk and derivative quantities including age-standardized rates, annual and cumulative percent change, and measures of inequality.MethodsWe specify a Poisson likelihood for case counts and model trends in log-risk using the first-difference (random-walk) prior. Models in the surveil R package were built using the Stan modeling language. We demonstrate the methodology and software by analyzing age-standardized colorectal cancer (CRC) incidence rates by race and ethnicity for non-Latino Black (Black), non-Latino White (White), and Hispanic/Latino (of any race) adults aged 50-79 years in Texas’s 4 largest metropolitan statistical areas between 1999 and 2018.ResultsOur analysis revealed a cumulative decline of 31% (95% CI –37% to –25%) in CRC risk among Black adults, 17% (95% CI –23% to –11%) for Latino adults, and 35% (95% CI –38% to –31%) for White adults from 1999 to 2018. None of the 3 observed groups experienced significant incidence reduction in the final 4 years of the study (2015-2018). The Black-White rate difference (per 100,000) was 44 (95% CI 30-57) in 1999 and 35 (95% CI 28-43) in 2018. Cumulatively, the Black-White gap accounts for 3983 CRC cases (95% CI 3746-4219) or 31% (95% CI 29%-32%) of total CRC incidence among Black adults in this period.ConclusionsStalled progress on CRC prevention and excess CRC risk among Black residents warrant special attention as cancer prevention and control priorities in urban Texas. Our methodology and software can help the public and health agencies monitor health inequalities and evaluate progress toward disease prevention goals. Advantages of the methodology over current common practice include the following: (1) the absence of piecewise linearity constraints on the model space, and (2) formal inference can be undertaken on any model-derived quantities of interest using Bayesian methods.

COVID-19 pandemic: the role of community-based pharmacy practice in health equity.

The COVID-19 pandemic disrupted the landscape of primary care practice, creating new gaps in chronic disease management and worsening existing health disparities. Community-based pharmacy practices have played a critical role in responding to the pandemic; however, their role in promoting health equity and addressing existing health disparities has not been fully characterized. The objective of this commentary is to highlight some of the challenges and opportunities to cultivate an equitable plain field for communities to overcome significant health crises. Moreover, this commentary underscores the potential role of integrating community-based pharmacies into the public health infrastructure. It is uncommon to find an individual or an organization that has not been impacted by the pandemic. As painful as it has been to lose so many lives due to COVID-19 infection, it is critical to dedicate the time to reflect on how we arrived at this point. Compounding this global health crisis, the pandemic did not weigh equally on all community members, but rather some population groups carried the brunt of the pandemic more than others. The disproportionate burden of COVID-19 has uncovered significant gaps in our healthcare system and the global public health response. Understanding how we arrived at that point in the pandemic is a crucial first step toward achieving health equity. While many factors have led us onto the pandemic path, using national and global health frameworks to address health disparities and monitor health inequalities are worth discussing to delineate a roadmap to optimal population health. As these pandemic lessons challenge the status quo throughout communities, facing these new realities allows us to envision a roadmap for social justice, health equity, and innovative models to optimize health. Leveraging community-based pharmacy services could promote health equity, close growing health gaps, increase access to health care, and rapidly detect and respond to public health threats.

Monitoring Health Inequalities in 12 European Countries: Lessons Learned from the Joint Action Health Equity Europe.

To raise awareness about health inequalities, a well-functioning health inequality monitoring system (HIMS) is crucial. Drawing on work conducted under the Joint Action Health Equity Europe, the aim of this paper is to illustrate the strengths and weaknesses in current health inequality monitoring based on lessons learned from 12 European countries and to discuss what can be done to strengthen their capacities. Fifty-five statements were used to collect information about the status of the capacities at different steps of the monitoring process. The results indicate that the preconditions for monitoring vary greatly between countries. The availability and quality of data are generally regarded as strong, as is the ability to disaggregate data by age and gender. Regarded as poorer is the ability to disaggregate data by socioeconomic factors, such as education and income, or by other measures of social position, such as ethnicity. Few countries have a proper health inequality monitoring strategy in place and, where in place, it is often regarded as poorly up to date with policymakers’ needs. These findings suggest that non-data-related issues might be overlooked aspects of health inequality monitoring. Structures for stakeholder involvement and communication that attracts attention from policymakers are examples of aspects that deserve more effort.

Exploring the potential for a new measure of socioeconomic deprivation status to monitor health inequality

BackgroundMonitoring health inequalities is an important task for health research and policy, to uncover who is being left behind – and where – and to inform effective and equitable policies and programmes to tackle existing inequities. The choice of which measure to use to monitor and analyse health inequalities is thereby not trivial. This article explores a new measure of socioeconomic deprivation status (SDS) to monitor health inequalities.MethodsThe SDS measure was constructed using the Alkire-Foster method. It includes eight indicators across two equally weighted dimensions (education and living standards) and specifies a four-level gradient of socioeconomic deprivation at the household-level. We conducted four exercises to examine the value-added of the proposed SDS measure, using Demographic and Health Surveys data. First, we examined the discriminatory power of the new measure when applied to outcomes in four select reproductive, maternal, neonatal, and child health (RMNCH) indicators across six countries: skilled birth attendance, stunting, U5MR, and DTP3 immunisation. Then, we analysed the behaviour and association of the new SDS measure vis-à-vis the DHS Wealth Index, including chi-squared test and Pearson correlation coefficient. Third, we analysed the robustness of the SDS measure results to changes in its structure, using pairwise comparisons and Kendal Tau-b rank correlation. Finally, we illustrated some of the advantageous properties of the new measure, disaggregation and decomposition, on Haitian data.Results1) Higher levels of socioeconomic deprivation are generally consistently associated with lower levels of achievements in the RMNCH indicators across countries. 2) 87% of all pairwise rank comparisons across a range of SDS measure structures were robust. 3) SDS and DHS Wealth Index are associated, but with considerable cross-country variation, highlighting their complementarity. 4) Haitian households in rural areas experienced, on average, more severe socioeconomic deprivation as well as lower levels of RMNCH achievement than urban households.ConclusionsThe proposed SDS measure adds analytical possibilities to the health inequality monitoring literature, in line with ethically and conceptually well-founded notions of absolute, multidimensional disadvantage. In addition, it allows for breakdown by its dimensions and components, which may facilitate nuanced analyses of health inequality, its correlates, and determinants.

Summary Measures of Health Inequality: A Review of Existing Measures and Their Application.

Measuring and monitoring health inequalities is key to achieving health equity. While disaggregated data are commonly used to assess differences in health between different population subgroups, summary measures of health inequality also play a vital role in monitoring health inequalities. Building on disaggregated data, they quantify the level of inequality in a single number and are useful to compare inequality over time and across different health indicators, programmes and settings. We provide a comprehensive overview of existing summary measures of health inequality, including their definition, calculation, interpretation and application. The use of these measures is illustrated based on an example from the WHO’s Health Equity Monitor database using the WHO’s Health Equity Assessment Toolkit (HEAT) software. We discuss the strengths and limitations of different measures and provide guidance for selecting suitable summary measures for analysing health inequalities and communicating results. Summary measures of health inequality should form an integral part of health inequality monitoring to inform equity-oriented policies and programmes.

THE REPRODUCTIVE HEALTH IN ROMANIA -CURRENT STATUS.

Currently, at national level, two representative actions could provide information for supporting policy making in the field of reproductive health, and these two public health actions need improvements in certain aspects: The Reproductive Health Study in Romania (RHS), and the National Health Programme for Mother and Child Health (NHP-MCH). After decades of sexual education and family planning interventions, reproductive health in Romania is still a matter of concern. The current image of this field in Romania is difficult to be precisely configured having few elements and data in this sense. Main available indicators highlight a low contraception use, a high rate of abortion and high birth rate among adolescents is mainly the consequence of insufficient information on contraception among all population strata. Implementation of an action towards the development of a health inequality monitoring system would be of great importance for getting timely information on this subject, and it is favoured by the increased political awareness on the topic after joining EU, the inequalities that should be reduced as mentioned by the National Health Strategy 2014-2020, the existence of structures needed to develop a health inequality monitoring system and the declared political will. Monitoring reproductive health inequalities would provide information on the necessary actions to be implemented towards reaching a better reproductive health, and would also serve as an action implementation evaluation tool. A special attention should be payed to vulnerable groups: young population in rural communities, low socio-economic and educational status, and persons with mental disabilities. Keywords: Reproductive health, monitoring, inequalities, Romania Normal 0 false false false EN-US X-NONE X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:Table Normal; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:; mso-padding-alt:0cm 5.4pt 0cm 5.4pt; mso-para-margin-top:0cm; mso-para-margin-right:0cm; mso-para-margin-bottom:8.0pt; mso-para-margin-left:0cm; line-height:107%; mso-pagination:widow-orphan; font-size:11.0pt; font-family:Calibri,sans-serif; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:Times New Roman; mso-bidi-theme-font:minor-bidi; mso-ansi-language:EN-US; mso-fareast-language:EN-US;}

Health inequalities -development of a monitoring system in Finland

Abstract Background Health in Finland has developed positively in recent decades, but there are still large differences between population groups. Wide inequalities persist between socio-economic groups, for example by education, occupational status and income, in different domains of health such as self-reported health, morbidity, and mortality. Our aim in the sub-project of the Joint Action Health Equity Europe was to describe the status of national health inequality monitoring in Finland, and to present ideas for improving the situation, including the key indicators to be monitored. Methods Several nationally representative registers and population surveys are the key sources of health information in Finland. We summarized information on the current state of socioeconomic health inequalities and their development over the past decades to identify research based health topics and indicators, selecting those where clear differences have been identified between education or income groups among the working-aged people. Results We recommend 13 indicators to monitor and evaluate socio-economic health inequalities in the Finnish adult population. They cover five topics: health status, functioning, work ability, lifestyles and social factors. The recommended indicators are in line with the Nordic recommendation of inequality indicators and allow comparison between EU countries. This is the first step in developing a full monitoring system. The second step is needed to reach an agreement on the implementation. Conclusions High-quality population survey and register data make it possible to monitor health inequalities in Finland. Register-based data need to be supplemented with population surveys, both health interview and health examination surveys, to provide necessary information on risk factors, functioning and perceived health. Key messages The key characteristics of successful systematic monitoring of health inequalities are regularity, up-to-date information, validity of selected indicators and coverage of the most important phenomena. Monitoring enables identification of health needs which must be recognized in policy-making, targeting of services, regional benchmarking and support for health impact assessment in policy-making.

1074The role of epidemiology in improving the health of people with disability

Abstract Focus and outcomes for participants The symposium will focus on the role of epidemiologists in building an evidence base to improve the health of the 15% of the world’s population with disability who currently experience vast health inequalities. Participants will be introduced to new ways of conceptualising disability in epidemiology; state of the art approaches to monitoring disability-related socio-economic and health inequalities; methodological challenges and solutions to address the biases due to misclassification, confounding and reverse causation; and the application of causal mediation analysis and natural experiments in identifying potential policy solutions. Participants will gain a greater understanding of how epidemiological methods can be applied to improve the health of people with disability, as well as insights and ideas for their research. A network of epidemiologists interested in this topic will be generated to foster ongoing communication and collaborative opportunities. Rationale for the symposium, including for its inclusion in the Congress The health of disabled people has largely been ignored by epidemiologists. This is despite emerging evidence that people with disability experience poorer health because of factors unrelated to their impairment, including socio-economic disadvantage, discrimination, and violence. However, turning epidemiologists’ efforts to the health of people with disability presents conceptual and methodological challenges, some of which are unique to the content area. Participants will be shown a suite of approaches that can be deployed to address these problems. Participatory methods and innovative graphical and statistical methods for analysing disability-related health inequalities, approaches rarely used in epidemiology, will be covered. The symposium will also concentrate on the application of methods to optimise causal inference in the presence of multiple potential biases, and methods that simulate randomised controlled trial conditions to model policy interventions. Presentation program The presentations are from researchers from the CRE-DH, funded through Australia’s National Health and Medical Research Council organised four themes. Theme 1: Conceptualisation of disability We will present findings from a scoping review of original articles in epidemiology journals and will argue that, while, disability is usually conceptualised in epidemiology as an outcome, reconceiving of disability as an exposure, mediator and/or effect modifier can provide important insights on the determinants of health of people with disability. Theme 2: Monitoring disability-related inequalities We will demonstrate how the CRE-DH has used participatory methods, where people with disability are ‘experts through lived experience’, to develop indicators to monitor disability-related inequalities and design a National Community Attitudes survey. We will demonstrate innovative ways to graphically illustrate prevalence, absolute and relative inequalities simultaneously, and discuss how hierarchical Bayesian methods can be used to overcome inadequate power due to disaggregation and assess inequalities under uncertainty. Theme 3: Approaches to minimising bias We will talk about how biases can affect estimates of disability prevalence and disability-outcome associations, including reverse causation, confounding and misclassification. We will discuss a range of approaches we have used to address these challenges including modelling incident (rather than prevalent) disability, using fixed effects models and propensity score approaches, and approaches to addressing misclassification bias drawing on examples from our program of research. Theme 4: Identification of policy interventions We will discuss methods that can be used to model the impact of policies on the health of people with disability using examples from our research. We will present the results of a causal mediation analysis modelling the impact of different employment policy interventions on mental health outcomes. We will illustrate the value of natural policy experiments for estimating effects of policy changes on employment and health of people with disability using two examples – the 2014 reassessment of Disability Support Pensioners under stricter impairment tables and the introduction of Australia’s National Disability Insurance Scheme. The symposium will conclude with a facilitated discussion focussed on how epidemiologists can come together internationally to grasp the opportunities and address the challenges in research focussed on the health of people with disabilities. Names of presenters Professor Anne Kavanagh, PhD Dr Nicola Fortune, PhD Dr George Disney, PhD Dr Zoe Aitken Dr Samia Badji, PhD

Geographical socioeconomic inequalities in healthy life expectancy in Japan, 2010-2014: An ecological study

ABSTRACTSBackgroundArea differences in life expectancy (LE) and healthy life expectancy (HLE) in large geographical units have been monitored around the world. Area characteristics may be based on culture, history, socioeconomic status and discrimination in smaller geographical units, so it is important to consider these when looking at health inequality. We aimed to evaluate LE, HLE, and non-healthy life expectancy (NHLE) in 1707 municipalities using Areal Deprivation Index (ADI) in Japan for the first time.MethodsWe calculated the observed LE, HLE, and NHLE using death, population, and Long-term care insurance data for 2010-2014 and applied the variance weighted least squares model to estimate LE, HLE, and NHLE by 100 percentiles using the standardized ADI.FindingsThe estimated LE, HLE, and NHLE became lower as the deprivation index worsened: the differences between the most and least deprived areas for HLE were 2·49 years for LE and 2·32 years for HLE in males; 1·22 years for LE and 0·93 years for HLE in females. The observed LE and HLE in the most deprived areas were much lower than other areas.InterpretationUsing ADI has enabled us to see the disparity within municipalities precisely. LE and HLE outlier for the 100th percentile might be linked to historical areal deprivation and marginalization. Precise monitoring of socioeconomic status-based health inequalities could help manage these inequalities by identifying the groups most in need of intervention.FundingThe Ministry of Education, Science and Culture of Japan (a Grant-in-Aid for Scientific Research [A] No. 20H00040 and 18H04071).

Self-Perceived Health and Its Associations with Social Factors and Perceived Environmental Quality in Southern Kazakhstan: a Cross-Sectional Study

Introduction: Self-perceived health (SPH) has been shown to be a valid proxy indicator of health status in epidemiological studies. Substantial social variations in SPH have been previously reported from Kazakhstan. Southern Kazakhstan is among the poorest regions of the country with limited health information in international peer-reviewed literature. Aim: The aim of this study was to assess SPH in Southern Kazakhstan and its associations with selected social factors and perceived environmental quality. Methods: Altogether, 1 148 permanent residents of the Turkistan region aged 16-63 years participated in a cross-sectional study. Data on SPH, age, gender, ethnicity, marital status, education, perceived environmental quality, smoking and alcohol consumption were collected by a questionnaire. Associations between SPH and selected socio-demographic and geographical variables were assessed using multivariable logistic regression. Crude and adjusted odds ratios (OR) were calculated. Results: Poor, satisfactory, good and very good SPH was reported by 4.4 %, 27.1 %, 55.3 % and 13.2 % of the participants, respectively. Men (OR = 2.11; 95 % CI: 1.53-2.89), cohabiting responders (OR = 2.37; 95 % CI: 1.30-4.35), those who perceived environmental quality as unhealthy (OR = 2.12; 95 % CI: 1.31-3.43) or satisfactory (OR = 1.75; 95 % CI: 1.16-2.66), smokers (OR = 1.64; 95 % CI: 1.02-2.64), alcohol drinkers (OR = 1.44; 95 % CI: 1.00-2.06) and residents of Ordabasinski district (OR = 1.98; 95 % CI: 1.22-3.23) were more likely to report poorer health (poor+satisfactory combined) than their counterparts in the reference categories in the final multivariable model. Conclusions: The observed variations in SPH in Southern Kazakhstan contribute to the knowledge on inequalities in health in Kazakhstan and warrant monitoring of health inequalities on the national level. Further research in Southern Kazakhstan should address the factors behind the associations documented in this study.