Successful Ageing Influence of socio-economic factors, gender and health service provision

1. CADENZA Symposium 2008 Successful AgeingInfluence of socio-economic factors, gender and health service provision Shah Ebrahim London School of Hygiene & Tropical Medicine

2. Outline • Socio-economic development and life expectancy • Social class, survival and disability • Gender, survival and disability • Life-course influences on disability • Health services

3. Successful ageing requires survival Socio-economic position Health services Survival Gender

4. Socio-economic development and ageing • Life expectancy: comparisons between countries by income levels

5. Life expectancy and GDP Lynch et al. BMJ 2000;320:1200

6. Preston’s curves: explanations for better health 1900’s Preston, S. H Int. J. Epidemiol. 2007 36:484-490; doi:10.1093/ije/dym075

7. Preston’s conclusion • Improvements in survival are not all explained by economic growth • Nutrition and education have had only a small role. • Global diffusion of medical and health technologies: • innovations in hygiene and sanitation • maternal and child services • specific vaccines and drugs for treatment of bacterial infections

8. Paradoxes of Costa Rica, Cuba, Sri Lanka: high life expectancy but low GDP Marmot M, Clinical Medicine, 2006

9. Social class (an English view) I’m upper class. I look down on both of them I’m middle class. I look up to him but I look down on him I know my place John Cleese Ronnie Barker Ronnie Corbett

10. Social class and life expectancy:age 65

11. Locomotor disability and social class: British Regional Heart Study men 12.3% 19.2% 21.5% 28.5% 33.7% 40.1% Source: Ebrahim et al, Int J Epidemiology (2000)

12. Social class and disability: possible explanations Social class Disability Chronic diseases: Arthritis, CVD Risk factors: inactivity, smoking, BMI etc

13. Locomotor disability and social class: British Regional Heart Study men Adjusted for smoking, BMI, activity and alcohol Excluding men with CVD, arthritis and respiratory disease 12.3% 19.2% 21.5% 28.5% 33.7% 40.1% Source: Ebrahim et al, Int J Epidemiology (2000)

14. Lack of health & social services Material and psycho-social models of causation Poverty MATERIAL CONDITIONS Inadequate diet Smoking Poor housing PSYCHO-SOCIAL CONDITIONS Lack of control Increased stress Low social capital Reduced survival

15. A metaphor: air travel: differences in a neo-material and psychosocial theory First class Cattle class Lynch & Davey Smith BMJ 2000;320;1200-1204

16. Material vs. psychosocial explanations Compare air travellers in firstand economy class. Travellers in economy have worse health becausethey sat in a cramped space and couldn't sleep not because theycould see the bigger seats in firstclass Lynch & Davey Smith. BMJ 2000;320:1200

17. Implications for intervention • psychosocial interpretation: health inequalities would be reduced by abolishing first class, or mass psychotherapy to alter perceptions of relative disadvantage. • neo­material viewpoint: health inequalities can be reduced by upgrading conditions in economy class Lynch & Davey Smith BMJ 2000;320;1200-1204

18. Social inequalities and survival • Growing wider • Not fully explained by smoking, diet, exercise • Potentially avoidable

19. Gender, survival and disability

20. Life expectancy at age 65 Office of National Statistics, UK

21. Percentage of life expectancy spent able to get outdoors, 1991 Men Women 8.6 4.8 11.2 6.1 Source: Bone et al Health Expectancy, 1995

24. Distribution of walking time Time to walk 6m. 2% increase per single year increase in age, p<0.001)

25. Adult social class, 2002/3 Time to walk 6m. 4.9% increase in walking time per category increase in social class, p=0.02 Adult occupational social class, 2002/3

26. Household income, 1937/9 and walking speed in 2002/3 Time to walk 6m. 3.2% reduction in walking time per category increase in income, p=0.04 high low Weekly household income, 1937/9

27. You need to walk at 0.8 m/s to cross a Hong Kong road The youngest participants (aged 64-66) only walked at 0.7 m/s!

28. Guardian 9 September 2004 Inner-Age? Pharmanex? Isolagen?

29. Health services for older people • Complex interventions - combinations of interdisciplinary teamwork for health and social problems • Do they work?

30. MRC trial of multidimensional assessment and management • 40,000 older people randomized to different care: death and institutional care • Comparisons of geriatric service vs. primary care service • Comparison of targeted service vs. universal service • After 10 years work – geriatric service slightly worse than primary care and universal no better than targeted service

31. Components of complex interventions • Assessment • Primary prevention Physical activity Environment, home safety Self care, immunisation Social network • Secondary prevention Treatment of chronic conditions • Tertiary prevention Medication review, rehabilitation

32. Meta-analysis of 45 trials Relative risk of not living in own home Favours intervention Favours control 0.87 (95% CI 0.79, 0.94) Beswick A et al, Lancet 2007

33. Health care and social support • Effective services • evidence base patchy in LMICs • Affordability • privatisation of long-term care • Accessibility • waiting lists, local treatment • Appropriateness • growing private anti-ageing sector

34. Number of admissions to hospitals in the three years before death, England, 1999-2000. Dixon, T. et al. BMJ 2004;328:1288

35. GDP 1.5% 1.6% 1.6% 1.8% Projections of long-term care costs £28.0 £19.9 £14.7 £ billions £11.1 With Respect to Old Age, Cm 4129, 1999

36. Summary • Socio-economic factors play a major role in determining survival and disability • Women do better than men in terms of survival but not in terms of disability • Health services do improve survival and reduce institutionalisation • But too much health service use is a problem for many