How Other Countries Use Deprivation Indices-And Why The United States Desperately Needs One

Integrating public health and medicine to address social determinants of health is essential to achieving the Triple Aim of lower costs, improved care, and population health. There is intense interest in the United States in using social determinants of health to direct clinical and community health interventions, and to adjust quality measures and payments. The United Kingdom and New Zealand use data representing aspects of material and social deprivation from their censuses or from administrative data sets to construct indices designed to measure socioeconomic variation across communities, assess community needs, inform research, adjust clinical funding, allocate community resources, and determine policy impact. Indices provide these countries with comparable data and serve as a universal language and tool set to define organizing principles for population health. In this article we examine how these countries develop, validate, and operationalize their indices; explore their use in policy; and propose the development of a similar deprivation index for the United States.

Proposed new industry code on unhealthy food marketing to children and young people: will it make a difference?

Reducing the exposure of children and young people to the marketing of unhealthy foods is a core strategy for reducing the high overweight and obesity prevalence in this population. The Advertising Standards Authority (ASA) has recently reviewed its self-regulatory codes and proposed a revised single code on advertising to children. This article evaluates the proposed code against eight criteria for an effective code, which were included in a submission to the ASA review process from over 70 New Zealand health professors. The evaluation found that the proposed code largely represents no change or uncertain change from the existing codes, and cannot be expected to provide substantial protection for children and young people from the marketing of unhealthy foods. Government regulations will be needed to achieve this important outcome.

Is cost-related non-collection of prescriptions associated with a reduction in health? Findings from a large-scale longitudinal study of New Zealand adults

OBJECTIVE

To investigate whether cost-related non-collection of prescription medication is associated with a decline in health.

SETTINGS

New Zealand Survey of Family, Income and Employment (SoFIE)-Health.

PARTICIPANTS

Data from 17 363 participants with at least two observations in three waves (2004-2005, 2006-2007, 2008-2009) of a panel study were analysed using fixed effects regression modelling.

PRIMARY OUTCOME MEASURES

Self-rated health (SRH), physical health (PCS) and mental health scores (MCS) were the health measures used in this study.

RESULTS

After adjusting for time-varying confounders, non-collection of prescription items was associated with a 0.11 (95% CI 0.07 to 0.15) unit worsening in SRH, a 1.00 (95% CI 0.61 to 1.40) unit decline in PCS and a 1.69 (95% CI 1.19 to 2.18) unit decline in MCS. The interaction of the main exposure with gender was significant for SRH and MCS. Non-collection of prescription items was associated with a decline in SRH of 0.18 (95% CI 0.11 to 0.25) units for males and 0.08 (95% CI 0.03 to 0.13) units for females, and a decrease in MCS of 2.55 (95% CI 1.67 to 3.42) and 1.29 (95% CI 0.70 to 1.89) units for males and females, respectively. The interaction of the main exposure with age was significant for SRH. For respondents aged 15-24 and 25-64 years, non-collection of prescription items was associated with a decline in SRH of 0.12 (95% CI 0.03 to 0.21) and 0.12 (95% CI 0.07 to 0.17) units, respectively, but for respondents aged 65 years and over, non-collection of prescription items had no significant effect on SRH.

CONCLUSION

Our results show that those who do not collect prescription medications because of cost have an increased risk of a subsequent decline in health.

Is change in global self-rated health associated with change in affiliation with a primary care provider? Findings from a longitudinal study from New Zealand

AIMS

To investigate the association of self-rated health and affiliation with a primary care provider (PCP) in New Zealand.

METHODS

We used data from a New Zealand panel study of 22,000 adults. The main exposure was self-rated health, and the main outcome measure was affiliation with a PCP. Fixed effects conditional logistic models were used to control for observed time-varying and unobserved time-invariant confounding.

RESULTS

In any given wave, the odds of being affiliated with a PCP were higher for those in good and fair/poor health relative to those in excellent health. While affiliation for Europeans increased as reported health declined, the odds of being affiliated were lower for Māori respondents reporting very good or good health relative to those in excellent health. No significant differences in the association by age or gender were observed.

CONCLUSIONS

Our data support the hypothesis that those in poorer health are more likely to be affiliated with a PCP. Variations in affiliation for Māori could arise for several reasons, including differences in care-seeking behaviour and perceived need of care. It may also mean that the message about the benefits of primary health care is not getting through equally to all population groups.

Equity in statin use in New Zealand

INTRODUCTION

Preventive medications such as statins are used to reduce cardiovascular risk. There is some evidence to suggest that people of lower socioeconomic position are less likely to be prescribed statins. In New Zealand, Maori have higher rates of cardiovascular disease.

AIM

This study aimed to investigate statin utilisation by socioeconomic position and ethnicity in a region of New Zealand.

METHODS

This was a cross-sectional study in which data were collected on all prescriptions dispensed from all pharmacies in one city during 2005/6. Linkage with national datasets provided information on patients' age, gender and ethnicity. Socioeconomic position was identified using the New Zealand Index of Socioeconomic Deprivation 2006.

RESULTS

Statin use increased with age until around 75 years. Below age 65 years, those in the most deprived socioeconomic areas were most likely to receive statins. In the 55-64 age group, 22.3% of the most deprived population received a statin prescription (compared with 17.5% of the mid and 18.6% of the least deprived group). At ages up to 75 years, use was higher amongst Maori than non-Maori, particularly in middle age, where Maori have a higher risk of cardiovascular disease. In the 45-54 age group, 11.6% of Maori received a statin prescription, compared with 8.7% of non-Maori.

DISCUSSION

Statin use approximately matched the pattern of need, in contrast to other studies which found under-treatment of people of low socioeconomic position. A PHARMAC campaign to increase statin use may have increased use in high-risk groups in New Zealand.

Government funding of health research in New Zealand

An analysis of levels of government health research funding carried out in 2008 demonstrated that funding in New Zealand, after adjustment for population size, was less than one-third of that in Australia, less than one-fifth of that in the United Kingdom, and about 10% of that in the United States. This was perceived to be a major obstacle to the recruitment and retention of clinical and academic staff in our hospitals and universities. We have now repeated these analyses to determine the current state of these comparisons. From 2009 to the present funds for direct funding of research through the Health Research Council (HRC) have remained static at $54m. As a result of inflation of research costs (principally salaries) this represents a decrease of approximately one-quarter in the quantum of research funded by the HRC over the last 4 years. Current funding rates in the comparator countries, population-adjusted and converted to NZ$, are 3.4-fold higher in Australia, 4.5-fold higher in the United Kingdom, and 9.7-fold higher in the United States. Urgent and sustained action is needed to correct these major disparities in government health research funding if the quality of academic and clinical staff in our public institutions is to be maintained.

Equity in statin use in New Zealand

INTRODUCTION: Preventive medications such as statins are used to reduce cardiovascular risk. There is some evidence to suggest that people of lower socioeconomic position are less likely to be prescribed statins. In New Zealand, Maori have higher rates of cardiovascular disease. AIM: This study aimed to investigate statin utilisation by socioeconomic position and ethnicity in a region of New Zealand. METHODS: This was a cross-sectional study in which data were collected on all prescriptions dispensed from all pharmacies in one city during 2005/6. Linkage with national datasets provided information on patients’ age, gender and ethnicity. Socioeconomic position was identified using the New Zealand Index of Socioeconomic Deprivation 2006. RESULTS: Statin use increased with age until around 75 years. Below age 65 years, those in the most deprived socioeconomic areas were most likely to receive statins. In the 55–64 age group, 22.3% of the most deprived population received a statin prescription (compared with 17.5% of the mid and 18.6% of the least deprived group). At ages up to 75 years, use was higher amongst Maori than non-Maori, particularly in middle age, where Maori have a higher risk of cardiovascular disease. In the 45–54 age group, 11.6% of Maori received a statin prescription, compared with 8.7% of non-Maori. DISCUSSION: Statin use approximately matched the pattern of need, in contrast to other studies which found under-treatment of people of low socioeconomic position. A PHARMAC campaign to increase statin use may have increased use in high-risk groups in New Zealand. KEYWORDS: Ethnic groups; New Zealand; prescriptions; socioeconomic status; statins

Holding a mirror to society? The sociodemographic characteristics of the University of Otago's health professional students

AIM

To describe the sociodemographic characteristics of students accepted into eight health professional programmes at the University of Otago.

METHODS

Student data were obtained from the University of Otago's central student records system. Data were obtained in anonymous, summary form. New Zealand population data were obtained from Statistics New Zealand. Descriptive statistics were calculated.

RESULTS

In 2010 health professional students at the University of Otago were largely from outside the Otago region (88.1%). 59.6% were female and 84.8% were either New Zealand citizens or permanent residents. Within the domestic student cohort, 65.0% of students self-identified as being within the New Zealand European and Other category (compared with 75.3% of the national population), 34.2% as Asian (compared with 11.1%), 6.3% as Maori (compared with 15.2%), and 2.3% as Pacific (compared with 7.7%). A large proportion of students came from high socioeconomic areas and only 3.4% of students had attended secondary schools with a socioeconomic decile of less than 4.

CONCLUSION

Schools and Faculties within the University of Otago's Division of Health Sciences do not achieve the sociodemographic mirror of society we hope for, and we strive to improve both our selection processes, within the constraints and limitations of the available selection tools, and our student support mechanisms. We will continue to refine these policies and work with other key stakeholders in better preparing school leavers for health professional programmes.

Gender differences in financial barriers to primary health care in New Zealand

INTRODUCTION

Gender differences in health status and use of health care services have been established in the developed world with less attention paid to gender differences in financial barriers to primary care. Such barriers represent potentially avoidable mortality and morbidity.

AIM

To examine gender differences in financial barriers to New Zealand primary health care.

METHODS

Data from SoFIE-health, an add-on to Statistics New Zealand-led Survey of Family, Income and Employment (SoFIE), analysed using logistic regression, controlling for demographic, socioeconomic, health behaviour and health variables. Access to primary health care includes general practitioner and dental care and prescription drugs.

RESULTS

Odds of deferring seeing their doctor(s), dentist and buying a prescription respectively at least once during preceding 12 months, because they could not afford the cost of a visit or prescription, were greater for women compared to men (Odds Ratio (OR) 1.82, 95% CI: 1.67-1.99; OR 2.05, 95% CI: 1.78-2.34; and OR 1.58, 95% CI: 1.47-1.71; respectively). Adjusting for demographic, socioeconomic, health behaviour and health status attenuated OR to 1.45 (1.31-1.61) for deferring medical visit, 1.47 (1.26-1.71) buying prescription, and 1.35 (1.24-1.46) for deferring dental visit, although confidence intervals still excluded the null.

DISCUSSION

Gender significantly associated with reporting cost barriers to primary health care, regardless of individual deprivation or income levels, suggesting that primary health care policies targeting gender-specific factors are warranted. Policy measures to reduce co-payments may improve access to care for both women and men, and may have positive health implications.

Development of New Zealand's deprivation index (NZDep) and its uptake as a national policy tool

OBJECTIVES

To outline the development and uses of the census-based New Zealand small-area index of relative socio-economic deprivation, NZDep.

METHODS

NZDep has been created from four 5-yearly censuses using theory developed from international deprivation research, a standard statistical procedure (principal component analysis) and both construct and criterion validation.

RESULTS

The latest index was based on nine socio-economic deprivation variables available for just over 4 million people. It was calculated from a basis of 24,000 small areas containing a median of approximately 90 people. The deprivation index has a value from 1 (low) to 10 (high). It is mapped to standard administrative areas and is available free of charge. The index is easy to visualize, and deprivation maps are widely used. The index is used in many applications in research and social epidemiology, and routinely by the country's Ministry of Health, both to explore health variations across the country and to allocate central government funds to local health care providers. Geographers in local government were quick to recognize the index as a good tool for visualizing the diversity and neediness of local communities, and hence as a tool for town and service planning.

CONCLUSION

The national NZDep index of small-area deprivation has been used widely in research on mortality, morbidity and determinants of ill health, and in needs assessment, resource allocation and advocacy.

Funding community medicines by exception: a descriptive epidemiological study from New Zealand

AIMS

To assess rates of approval and identify factors associated with successful applications for funding to the New Zealand Community Exceptional Circumstances (CEC) scheme.

METHOD

Descriptive quantitative analysis of data in CEC applications database. The main outcome was initial application approval rate. Analysis included calculation of unadjusted and adjusted associations between potential determinants (for example patient age, gender) and outcomes using logistic regression analysis. All CEC applications with a decision about approval or decline 1 October 2001 to 30 September 2008 were included.

RESULTS

Application numbers were high, but had reduced since 2001. A small number of medicines (11) and indications comprised about a third of the applications to the scheme. While some common applications were clearly outside the remit of the scheme, many applications were for patients who fitted the scheme's eligibility criteria. The overall initial application approval rate was 16% and the renewal application approval rate was 88%. Approval rates varied widely by type of medicine, therapeutic group and indication. After adjusting for other potential determinants there were no statistically significant differences in initial approval rates by gender, ethnicity or socioeconomic status of the patient. There were however, significant differences in initial application approval by age of the patient, type of applicant doctor and by geographical location of the applicant doctor.

CONCLUSIONS

There was no evidence that gender, ethnicity and socioeconomic status of patients were factors associated with successful applications. However, applications for younger patients, those made by specialists, and those made by applying clinicians from the Auckland District Health Board area were more likely to be successful. It is possible that this may to some degree be appropriate, but requires further research.

Measuring socioeconomic position in New Zealand

INTRODUCTION: Measures of socioeconomic position (SEP) are widely used in health research. AIM: To provide future researchers with empirically based guidance about the relative utility of five measures of SEP in predicting health outcomes. METHODS: Data from 12 488 adults were obtained from the 2006 New Zealand Health Survey. Seven health-related outcome measures with expected variations by SEP are modelled using five measures of SEP: a census-based small-area index of relative socioeconomic deprivation, NZDep2006; a questionnaire-based individual-level index of socioeconomic deprivation, NZiDep; an index of living standards, ELSI; education, measured by highest qualification; and equivalised household income. RESULTS: After including the individual measure of deprivation, the area-based measure of deprivation adds useful explanatory power, and, separately, the broader spectrum provided by the living standards index adds only a small amount of extra explanatory power. The education and household income variables add little extra explanatory power. DISCUSSION: Both NZiDep and ELSI are useful health-outcome predictors. NZiDep is the cheapest data to obtain and less prone to missing data. The area index, NZDep, is a useful addition to the arsenal of individual SEP indicators, and is a reasonable alternative to them where the use of individual measures is impracticable. Education and household income, using commonly used measurement tools, may be of limited use in research if more proximal indicators of SEP are available. NZDep and NZiDep are cost-effective measures of SEP in health research. Other or additional measures may be useful if costs allow and/or for topic-related hypothesis testing. KEYWORDS: Deprivation; inequalities; living standards; New Zealand; socioeconomic position

Gender differences in financial barriers to primary health care in New Zealand

INTRODUCTION: Gender differences in health status and use of health care services have been established in the developed world with less attention paid to gender differences in financial barriers to primary care. Such barriers represent potentially avoidable mortality and morbidity. AIM: To examine gender differences in financial barriers to New Zealand primary health care. METHODS: Data from SoFIE-health, an add-on to Statistics New Zealand–led Survey of Family, Income and Employment (SoFIE), analysed using logistic regression, controlling for demographic, socioeconomic, health behaviour and health variables. Access to primary health care includes general practitioner and dental care and prescription drugs. RESULTS: Odds of deferring seeing their doctor(s), dentist and buying a prescription respectively at least once during preceding 12 months, because they could not afford the cost of a visit or prescription, were greater for women compared to men (Odds Ratio (OR) 1.82, 95% CI: 1.67–1.99; OR 2.05, 95% CI: 1.78–2.34; and OR 1.58, 95% CI: 1.47–1.71; respectively). Adjusting for demographic, socioeconomic, health behaviour and health status attenuated OR to 1.45 (1.31–1.61) for deferring medical visit, 1.47 (1.26–1.71) buying prescription, and 1.35 (1.24–1.46) for deferring dental visit, although confidence intervals still excluded the null. DISCUSSION: Gender significantly associated with reporting cost barriers to primary health care, regardless of individual deprivation or income levels, suggesting that primary health care policies targeting gender-specific factors are warranted. Policy measures to reduce co-payments may improve access to care for both women and men, and may have positive health implications. KEYWORDS: Gender; primary health care; access barriers; New Zealand

Too much and too little? Prevalence and extent of antibiotic use in a New Zealand region

OBJECTIVES

Although antibiotic use in the community is a significant contributor to resistance, little is known about social patterns of use. This study aimed to explore the use of antibiotics by age, gender, ethnicity, socio-economic status and rurality.

METHODS

Data were obtained on all medicines dispensed to ambulatory patients in one isolated town for a year, and data on antibiotics are presented in this paper. Demographic details were obtained from pharmacy records or by matching to a national patient dataset.

RESULTS

During the study year, 51% of the population received a prescription for one or more antibiotics, and on average people in the region received 10.15 defined daily doses (DDDs). Prevalence of use was higher for females (ratio, 1.18), and for young people (under 25) and the elderly (75 and over), and the amount in DDDs/person/year broadly followed this pattern. Māori (indigenous New Zealanders) were less likely to receive a prescription (48% of the population) than non-Māori (55%) and received smaller quantities on average. Rural Māori, including rural Māori children, received few prescriptions and low quantities of antibiotics compared with other population groups.

CONCLUSIONS

The level of antibiotic use in the general population is high, despite campaigns to try to reduce unnecessary use. The prevalence of acute rheumatic fever is high amongst rural Māori, and consequently treatment guidelines recommend prophylactic use of antibiotics for sore throat in this population. This makes the comparatively very low level of use of antibiotics amongst rural Māori children very concerning.

Continuity of care with general practitioners in New Zealand: results from SoFIE-Primary Care

Continuity of care has been defined as seeing the same health care provider over time, and has been shown to be associated with positive health outcomes, high quality care, high patient satisfaction with care and with lowering health care costs. While the benefits of continuity of care with a primary care provider are well documented, relatively little is known about those patients who receive or do not receive continuity of care. Using data from SoFIE-health, which is an add-on to the Statistics New Zealand-led Survey of Family, Income and Employment, this paper aims to construct a summary measure of continuity of care and to contribute to an enhanced understanding of the prevalence of continuity of care in New Zealand. We used the Primary Care Assessment Tools (PCAT) to create a mean score of continuity of care. We found continuity of care is high in New Zealand. Overall, our data provide some support for the hypothesis that people with high health needs have higher mean continuity of care scores (e.g. the elderly, Pacific and Asian ethnic groups, those in the low income tertile, and those with one or more chronic conditions). The authors propose that continued incentives to develop and sustain affiliation with a primary care provider and continuity of care are important for maintaining the quality and cost-effectiveness of primary health care.