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Book Review
Measuring health equity in small areas: Findings from demographic surveillance systems
INDEPTH Network
ISBN: 0-7546-4494-4 201 pages Hampshire, England: Ashgate
Jeanettte Pope
Public Health Information Department Unit, University of Adelaide, SA
Measuring Health Equity in Small Areas: Findings From Demographic Surveillance Systems concerns the measurement of socio-economic health inequalities in ten, severely resource- constrained areas in countries of Asia and Africa. The book presents studies from the INDEPTH network of sentinel surveillance sites (33 across 18 countries), which have the goal to provide quantitative health information to help policy makers set health priorities and policies. Although a description of the network is not included in the book, it can be found on their website (www.indepth-network.org).
The book begins with a discussion of the difficulties of measuring wealth/poverty and the social relations associated with it (the ‘socio-’ of ‘socio-economic’ status). It argues that measures of income are particularly inadequate in these settings because of income irregularity, the difficulty in calculating income separate from business costs among the self employed, and problems establishing the number of people dependant on single incomes. The ten sites in the book instead try to conceptualise socio-economic status through varying composite indices of wealth that include aspects of material, human and social capital. All ten sites indices include measures of material assets, four include measures of human capital (education level), and two of social capital (social relationships). The different methods for creating the indices are discussed.
The book then provides a scientific paper from each of the ten sites reporting on what analysis using their index reveals about socio-economic inequalities in child mortality in small areas. The Bandim health surveillance system in West Africa, for example, describes how they developed an index of socio-economic status using principal components analysis of variables such as type of roof, electricity, television, type of toilet, number of rooms and mean number of people per bed. This surveillance system also has created measures level of mother’s education and a range of social capital and health beliefs factors such as favouritism and care taker vulnerability (husband’s interference, very young care takers and inability to get help from family when needed). The paper then examines the effect of these material, human and social capital factors on child mortality.
The studies as a whole demonstrate the persistent presence of geographically concentrated health inequalities in health status and health service use across the settings. They are a sobering reminder that in many places child death is still common – so common that some studies found it difficult to identify statistical risk factors because everyone had experienced child death and researchers had to construct outcome measures of multiple deaths per family. The studies importantly highlight the complex association between poverty, gender and ethnicity in those health inequalities. They show that socio-economic inequalities are not just related to wealth but to the complex social arrangements that go hand-in-hand with economic inequality. This information will undoubtedly help policy makers design better health interventions in local areas.
The real importance of this book, however, is not the findings, but the demonstration that small-area information and socio-economic factors can be successfully included in health surveillance systems. Indicators created by surveillance systems throw spotlights on issues. They frame the way the policy makers define problems and therefore conceive of solutions. In this case, the attempts to include a range of new measures in these surveillance systems will ensure that policy makers consider how social organisation affects the vectors of disease and the types of resources people draw on to deal with the consequences. They will also ensure authorities are reminded of the importance of the social relations within particular economic conditions, above and beyond simple understandings of having or not having wealth.
This book should be read by anyone involved in the management and design of surveillance systems, including the custodians of surveillance systems in developed country settings who could learn much from the INDEPTH endeavours. There are probably two audiences. One is people reviewing the technical aspects of measurement of socio-economic status, particularly in resource-poor settings. The second is more generally those interested in developing social theory frameworks that can underpin measurement in the real world. This book is a reminder of the importance of exploring new ways to monitor health issues and health service use that bring the role of social conditions to the fore. If surveillance systems do not engage in the challenge to find appropriate measures of socio-economic status, significant social conditions will be obscured in our reporting of disease problems, and therefore potentially in our thinking about solutions. The value of the book lies in the INDEPTH network’s attempt to try something different, and in the enormous amount of methodological effort undertaken. Hopefully it will inspire others to continue to develop this work within their own surveillance systems, both in Australia and elsewhere.
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