CD country case-study workshop 2013 Incorporating equity in epidemiological research: a brief introduction Cesar Victora Federal University of Pelotas, Brazil
Equity in epidemiology Inequities: disparities that are unfair and avoidable Why worry about equity? Moral reasons Practical reasons
Deaths per 1,000 Inequalities by gender, Pelotas, 1993 30 25 20 Higher death rates for boys than for girls 15 10 5 0 Late Early Infant Inequalities, not inequities fetal neonatal Boys Girls Source: Barros, Victora
Types of inequity Gender Socioeconomic status Geographic (provinces, districts, etc.) Urban / rural / slum Ethnic group Etc.
The different levels of inequities An association between socioeconomic deprivation and ill-health has been found wherever and whenever it has been looked for (Sir Douglas Black, 2001) and at whatever level of aggregation it has been investigated
Mosley-Chen analysis Mosley and Chen, 1983
Mosley-Chen model for child health Mosley and Chen, 1983
World s 10 most unequal countries Zimbabwe Colombia Chile Paraguay Gini s index for income concentration UNDP 2001 Bolivia Honduras Brazil South Africa Nicaragua Scandinavian countries Gini s index =0.25 Swaziland 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8
IMR and land tenure: Rio Grande do Sul state
The 1982 Pelotas Birth Cohort Study Population-based cohort of 6,000 individuals Follow up from birth to 30 years One of the longest and largest birth cohorts in LMICs
Field work in Pelotas, 1980 s
Before handing over to Aluisio for methods, a few thoughts about how countries may improve equity
Equity: what can countries do? Recognize that health services often contribute to increasing inequities Prioritize diseases of the poor Consider the pattern of inequity Deploy/improve services where the poor live Employ appropriate delivery channels Remove financial barriers (user fees, etc) Monitor implementation, coverage and impact with an equity lens
Bangladesh MOH and partners: slide by S Arifeen NAWABGANJ PANCHAGARH THAKURGAON NILPHAMARI LALMONIRHAT DINAJPUR NAOGAON * RANGPUR JOYPURHAT BOGRA KURIGRAM GAIBANDHA JAMALPUR Bangladesh: how equity can drive SHERPUR INDIA MYMENSINGH NETRAKONA program implementation SUNAMGANJ SYLHET 2002 2003 2004 2005 2006 RAJSHAHI NATORE SIRAJGANJ TANGAIL KISHOREGANJ HABIGANJ MAULVIBAZAR INDIA KUSHTIA MEHERPUR INDIA CHUADANGA JESSORE PABNA RAJBARI JHENAIDAH MAGURA MANIKGANJ FARIDPUR KHULNA SATKHIRA BAGERHAT JHALOKATI GAZIPUR Bay of Bengal DHAKA NARAYANGANJ SHARIATPUR CHANDPUR MADARIPUR NARAIL GOPALGANJ PIROJPUR BARISAL BARGUNA MUNSHIGANJ PATUAKHALI BHOLA NARSINGDI BRAHAMANBARIA LAKSHMIPUR COMILLA NOAKHALI INDIA FENI * KHAGRACHHARI CHITTAGONG RANGAMATI COX'S BAZAR * BANDARBAN By 2006, 148 of 159 sub-districts in the red areas had IMCI MYANMAR
Why is equity important? Human rights Practical reasons It is possible to improve equity in health by mainstreaming equity into health management, monitoring and evaluation
Incorporating equity in epidemiological studies Is always possible and useful Must be planned ahead of time Does not necessarily require large sample sizes May show effects or associations that would not be evident in the whole-sample analyses Findings must be interpreted in light of delivery channels Failure to incorporate equity is a missed opportunity