Validation of a deprivation index for public health: a complex exercise illustrated by the Quebec index.

INTRODUCTION: Despite the widespread use of deprivation indices in public health, they are rarely explicitly or extensively validated, owing to the complex nature of the exercise. METHODS: Based on the proposals of British researchers, we sought to validate Quebec's material and social deprivation index using criteria of validity (content, criterion and construct validity), reliability and responsiveness, as well as other properties relevant to public health (comprehensibility, objectivity and practicality). RESULTS: We reviewed the international literature on deprivation indices, as well as publications and uses of the Quebec index, to which we added factual data. CONCLUSION: Based on the review, it appears that the Quebec index responds favourably to the proposed validation criteria and properties. However, additional validations are required to better identify the contextual factors associated with the index.

TITRE: Valider un indice de défavorisation en santé publique : un exercice complexe, illustré par l'indice québécois. INTRODUCTION: Malgré l'usage répandu d'indices de défavorisation en santé publique, leur validation est rarement abordée de manière explicite ou élaborée, car il s'agit là d'un exercice complexe. MÉTHODOLOGIE: En nous fondant sur les propositions de chercheurs britanniques, nous avons cherché à valider l'indice québécois de défavorisation matérielle et sociale en utilisant des critères de validité (validité de contenu, validité sur critère et validité de construit), de fiabilité, de sensibilité et d'autres propriétés pertinentes en santé publique (intelligibilité, objectivité et praticabilité). RÉSULTATS: Nous avons passé en revue la littérature internationale sur les indices de défavorisation ainsi que les publications et les utilisations de l'indice québécois et nous avons ajouté des données factuelles. CONCLUSION: Après examen, il appert que l'indice québécois répond favorablement aux critères et propriétés de validation proposés. Des validations additionnelles s'imposent toutefois afin de mieux cerner les facteurs contextuels associés à cet indice.

Associations between disability prevalence and local-area characteristics in a general community-living population.

BACKGROUND: Disability is understood to arise from person-environment interactions. Hence, heterogeneity in local-area characteristics should be associated with local-area variation in disability prevalence. This study evaluated the associations of disability prevalence with local-area socioeconomic status and contextual features. METHODS: Disability prevalence was obtained from the Canada census of 2001 for the entire province of Québec at the level of dissemination areas (617 individuals on average) based on responses from 20% of the population. Data on local-area characteristics were urban-rural denomination, social and material deprivation, active and collective commuting, residential stability, and housing quality. Associations between local-area characteristics and disability prevalence were assessed using multilevel logistic regressions. RESULTS: Disability was associated with local-area socioeconomic status and contextual characteristics, and heterogeneity in these factors accounted for urban-rural differences in disability prevalence. Associations between contextual features and disability prevalence were confounded by local-area socioeconomic status. Some associations between local-area socioeconomic status and disability prevalence were moderated by contextual characteristics. The importance of this effect modification is greater when expressed in terms of the absolute magnitude of disability than in the relative likelihood of disability. CONCLUSION: Explanation of rural-urban differences by the contribution of other local-area characteristics is consistent with the conceptualization of urban-rural categories as the reflection of spatially varying ensembles of compositional and contextual factors. Although local-area socioeconomic status explains most variability in disability prevalence, this study shows that contextual characteristics are relevant to analyses of the spatial patterning of disability as they predict spatial variations of disability, sometimes in interaction with socioeconomic status. This study demonstrates that absolute and relative perspectives on effect modification may lead to differing conclusions.

A deprivation index for health planning in Canada.

Administrative databases in the Canadian health sector do not contain socio-economic information. To facilitate the monitoring of social inequalities for health planning, this study proposes a material and social deprivation index for Canada. After explaining the concept of deprivation, we describe the methodological aspects of the index and apply it to the example of premature mortality (i.e. death before the age of 75). We illustrate variations in deprivation and the links between deprivation and mortality nationwide and in different geographic areas including the census metropolitan areas (CMAs) of Toronto, Montréal and Vancouver; other CMAs; average-size cities, referred to as census agglomerations (CAs); small towns and rural communities; and five regions of Canada, namely Atlantic, Quebec, Ontario, the Prairies and British Columbia. Material and social deprivation and their links to mortality vary considerably by geographic area. We comment on the results as well as the limitations of the index and its advantages for health planning.

Material and social deprivation and health and social services utilisation in Québec: a local-scale evaluation system.

Very few studies have employed local-scale analyses to evaluate how well primary health care and social services reach the most socially and economically deprived individuals. This paper describes a project, conducted in close partnership with decision-makers and practitioners at selected local community service centres (in French, CLSCs) in Quebec, Canada, that developed a system for assessing primary care and social services utilisation by applying deprivation levels defined at the local scale (i.e., according to the distribution of deprivation in individual CLSC service areas). More than 25 years ago, Québec started setting up a province-wide network of publicly financed CLSCs whose mission was to offer first-line health and social services at the local level. Now approximately one Quebecer in four receives at least one service a year from a CLSC. The evaluation system presented in this article is built on deprivation profiles for each CLSC service area and comprises maps, relative indices of service utilisation, and an interpretation framework that facilitates the integration of new data into the decision-making and services planning processes. Study results show that deprivation levels, when defined using local perspectives, correspond more closely to decision-makers' perceptions, that relative indices are sensitive to key determinants of services provision and utilisation, and that the interpretation framework is useful for reassessing intervention strategies.

A deprivation index for health and welfare planning in Quebec.

Given that one of the goals of public health policy in Quebec and Canada is to reduce social inequalities in health and welfare, it is surprising, to say the least, that most information systems in this field make no mention of people's socio-economic characteristics. The present article proposes an index to reflect the material and social dimensions of deprivation as this concept has been developed by Peter Townsend and other authors. The article describes the method used to create the index, which uses census data and tools developed by Statistics Canada to match postal codes with enumeration areas. Examples are provided of the use of the index in information systems covering three aspects of health and welfare in Quebec: deaths, hospitalizations and births. The value of the information provided by this index in planning health and social services is demonstrated.

Geographies of health perception in Québec: a multilevel perspective.

Self perceived health is a widely used measure and, in Quebec, it has been shown to vary significantly between geographical areas. In the present study, these geographical variations are examined in a multilevel analysis in order to disentangle compositional (individual characteristics) and contextual (place) effects. The analysis recognizes four levels of variation: individual, household, local and regional. Similar analyses carried out in Britain, have considered only two levels: individual and local. Data come from the 1992-1993 Quebec Health and Social Survey, a general household survey using a stratified two-stage sampling design. Health perception (the response variable) is considered with a set of individual predictor characteristics reflecting gender, lifestyle, socio-economic conditions, marital status and social support. Results show the existence of significant local area variations in health perception after having allowed for individual characteristics and variations at the household level. At the regional level, however, no systematic and significant variations remain although some individual regions are found to have a significant impact on health perception.

[An indicator of needs for the regional allocation of public health resources in Quebec]. / Un indicateur de besoins pour l'allocation régionale des ressources en santé publique au Québec.

This paper proposes an indicator of needs for regional resource allocation in public health in Quebec. In the literature, the only reported measure of needs for regional resource allocation in public health has two parameters: size of population and Potential Years of Life Lost for preventable causes of death (APVP-EV). We verified whether APVP-EV were associated with various indices of socioeconomic conditions and lifestyle, preventive behaviours, satisfaction with social life, healthy life expectancy and some clienteles specific to public health. Our analysis indicates that the rate of Potential Years of Life Lost by avoidable causes is significantly related to all variables except satisfaction with social life. We therefore propose using size of population and its rate of APVP-EV to determine regional allocation of resources in public health.

The selection of needs indicators for regional resource allocation in the fields of health and social services in Québec.

In Québec, recent political statements have strengthened the necessity to allocate resources according to regional population needs. A regional-provincial working group was set up to propose needs indicators in 8 different fields-or client-oriented programs-which subdivide the entire spectrum of health and social services in Québec. These programs include physical health, mental health, public health, functionally impaired elderly people, physical deficiency, intellectual deficiency, alcoholism and drug abuse and problems (abuse, neglect, delinquency) among young people and their families. The following paper summarizes the main proposals of the working group. Some comments are made on the definition of client-oriented programs, basic concepts, research questions and methodological approaches. Concrete examples are given in order to illustrate the type of data and methods used. Furthermore, the indicators selected for resource allocation (in each of the 8 client-oriented programs) are presented on a regional basis (n = 18) and introduced in a principal component analysis. Their variations are discussed and recommendations to facilitate their use and promote their development are made. Finally, the actual utilization of these indicators is reported.

Avoidable mortality in Québec and its regions.

Avoidable mortality has been proposed as an outcome measure of health services and our aim, in this study, is to trace its general features and regional variations in Québec. For that purpose, comparisons are established between two time periods (1969-73 and 1982-90) and with several countries. Furthermore, regional SMRs (for the period 1982-90) are submitted to the Gail heterogeneity test and introduced in a stepwise regression with variables describing health services, socio-economic context and prevalence or incidence of related diseases. An analysis of proportional mortality is carried out in the two northern regions of Kativik and Baie-James. Avoidable mortality has dropped substantially in Québec, except in the case of asthma, and now displays excellent scores at the international level. Only three causes of death show significant regional variations: tuberculosis, hypertensive and cerebrovascular diseases and perinatal mortality. These variations are mainly associated with socio-economic factors but also with health services. Furthermore, the highest rates of avoidable death have been observed in Gaspésie, Saguenay/Lac St-Jean and in the two northern regions. These results are discussed through information already available on health services in Québec.

[Aging and functional limitations: a comparative analysis of data from the HALS survey of the metropolitan region of Montreal and the province of Quebec, 1986]. / Vieillissement et limitations fonctionnelles: analyse comparee des donnees de l'enquete ESLA entre la region metropolitaine de Montreal et la province de Quebec, 1986.

"In this article, an analysis of data from the Health and Activity Limitation Survey (HALS) for the metropolitan region of Montreal (MRM) and for the province of Quebec, conducted in 1986-87 by Statistics Canada, will show that the level of disabilities and the severity of handicaps are distinctly related to ageing. This raises central questions regarding the nature of the ageing process and on the pertinent policies to be adopted. Furthermore, significant spatial differences can be observed concerning the level of disabilities for various age groups. As such, the level of disabilities is generally lower in the MRM than in the rest of Quebec, except among those aged 75 and over and for the worst degree of disability." (SUMMARY IN ENG AND SPA)

Health discrepancies in rural areas in Québec.

Little information exists on health discrepancies within rural areas. Our research proposes to analyse the Québec Health Survey--a population health survey carried out in Québec in 1987--using a geographic grid which defines three different rural areas: that area bordering urban centers, a more remote area and the very remote hinterland. The analysis brings to light major, statistically significant, discrepancies between these areas in three sectors: health status determinants (physical activity and social support), the actual state of health (perceived health, a global health index and various pathologies) and the consequences that may be attributed to this state of health (disability and medication). It shows the difficult situation of inhabitants of the very remote hinterland.

[Development of a conversion table of dependence of the aged on home aide needs]. / Etablissement d'une table de passage de la dépendance des personnes âgées au besoin d'aide à domicile.

Planning home help for geographical areas requires information on disabilities and required needs. This paper proposes a methodology to estimate the amount of help required. The analysis is based on survey data from three French regions: Ile-de-France, Languedoc-Roussillon and Basse-Normandie and from a team of experts. The total need, whether covered by professionals or by the patient's social network is considered for three aspects: Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) and additional help resulting from home conditions. The required average number of hours per week varies from 49.9 for people confined to bed or chair, to 3.8 for people able to get out of their house without help (group 4). The need for IADL represents 44% of the total need for group 1 and 60% for group 4. Housing conditions generated an additional time representing 3 to 5% of total need, according to the group considered. The methodology allows to identified discrepancies between requirements and help provided by region and by disability group within each region. It appears to be a useful tool in planning home-help.

[The demand for health services: a geographic analysis in Quebec]. / Le recours aux services des professionnels de la santé: une analyse géographique au Québec.

Nearly one quarter of the people surveyed in Quebec have seen a health professional during the two previous weeks. One third of these visits have been to GPs. Females have paid more visits than males, widows more than married people, the elderly more than the young. Moreover, two groups have had a higher demand: the poor, wherever they are, and the rich in the big cities and metropolitan areas. When grouped into homogeneous areas, the growth of demand is correlated with available services and perceived illness or ailments. When a group increases its demand for services, which are nearly free of charge, the consumption level of the group goes beyond need, and the availability of services becomes increasingly the main determinant.