Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 https://doi.org/10.1186/s12939-021-01397-3 REVIEW Open Access Measuring health inequalities: a systematic review of widely used indicators and topics Sergi Albert-Ballestar1,2 and Anna García-Altés1,2,3* Abstract Background: According to many conceptual frameworks, the first step in the monitoring cycle of health inequalities is the selection of relevant topics and indicators. However, some difficulties may arise during this selection process due to a high variety of contextual factors that may influence this step. In order to help accomplish this task successfully, a comprehensive review of the most common topics and indicators for measuring and monitoring health inequalities in countries/regions with similar socioeconomic and political status as Catalonia was performed. Methods: We describe the processes and criteria used for selecting health indicators from reports, studies, and databases focusing on health inequalities. We also describe how they were grouped into well-known health topics. The topics were filtered and ranked by the number of indicators they accounted for. Results: We found 691 indicators used in the study of health inequalities. The indicators were grouped into 120 topics, 34 of which were selected for having five indicators or more. Most commonly found topics in the list include “Life expectancy”, “Infant mortality”, “Obesity and overweight (BMI)”, “Mortality rate”, “Regular smokers/ tobacco consumption”, “Self-perceived health”, “Unemployment”, “Mental well-being”, “Cardiovascular disease/ hypertension”, “Socioeconomic status (SES)/material deprivation”. Conclusions: A wide variety of indicators and topics for the study of health inequalities exist across different countries and organisations, although there are some clear commonalities. Reviewing the use of health indicators is a key step to know the current state of the study of health inequalities and may show how to lead the way in understanding how to overcome them. Keywords: Health inequalities, Health indicators, Review, Health policy Introduction the Spanish Public Health General Direction (Dirección Strong efforts to tackle health inequalities can be seen at General de Salud Pública) and the Foreign Health of international and national level since the 1980s. In early Health Ministry and Social Policy (Sanidad Exterior del 2008, the World Health Organization’s (WHO) Global Ministerio de Sanidad y Política Social) requested the Commission on Social Determinants of Health called for constitution of the Commission for the Reduction of action on the social determinants of health, the condi- Social and Health Inequalities (Comisión para Reducir tions in which persons are born, grow, work, live, and las Desigualdades Sociales en Salud en España (CRDSS- age, to “close the gap in a generation” [1]. In late 2008, E) [2]. The mission of CRDSS-E was to elaborate on a proposal of intervention measures to reduce health in- * Correspondence: agarciaaltes@gencat.cat equalities. The CRDSS-E published two documents: one 1 Catalan Health System Observatory, Agència de Qualitat i Avaluació analysing health inequalities in the Spanish context [3], Sanitàries de Catalunya (AQuAS), 81-95 (2a planta), 08005 Barcelona, Spain 2 CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain and another describing some policy proposals to tackle Full list of author information is available at the end of the article them [4]. In 2011, a total of 125 countries, Spain being © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. 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The of concrete regions, countries, or organisations were declaration recommended interventions from govern- added to these terms (i.e., “Andalucía health observa- ments and international organisations [6]. tory” or “Canada health inequalities”). The search was At a regional level in Catalonia, tackling health inequal- performed from March to June of 2019. Once finished, a ities is one of the main goals of both the Catalan Health set of inclusion criteria was applied; studies included in Plan 2016–2020 (led by the Health Department of the the review had to: Catalan Government) [7] and the Interdepartmental and Intersectorial Public Health Plan 2017–2020 (PINSAP) [8, 1. Include health inequalities indicators: All the 9]. During the past years, various reports and peer- reports that contained no health indicators were reviewed papers about the health effects of the economic automatically discarded (i.e., policy frameworks crisis on the population of Catalonia were published by [21]). the Catalan Health System Observatory [10–17]. 2. Have been carried out by a governmental Overall, much effort has been devoted to monitoring organisation or a related entity, whether at an and tackling health inequalities at regional, national, and international, national, or regional level: the international levels. Even so, OECD countries continue reports not published by governmental (or to present large disparities in health, including, for ex- government-related) organisations were discarded. ample, significant differences in life expectancy between 3. Have a socioeconomic and political status people with the highest and lowest levels of education similar (or highly related) to Catalonia: some [18]. The selection of topics represents the first step in reports were discarded due to significant differences monitoring health inequalities according to many con- in the socioeconomic profile of the countries they ceptual frameworks and is highly relevant, as these were studying in comparison to Catalonia or Spain. topics will potentially limit the detection of health in- equalities within the population, hence playing a key role Once the reports were selected, the authors performed in providing evidence for posterior decision-making [19, a quality control check of the indicators shown in the re- 20]. Yet some difficulties may arise during the selection ports and databases. The indicators had to match the of relevant topics, as well as their health indicators. A basic anatomy of an indicator as a minimum require- wide diversity of indicators for monitoring health in- ment to be considered an indicator. This basic anatomy equalities have been used across different countries and consists of containing data, i.e. the numerical data in- organisations; this is due to the high variety of context- put; and containing good metadata, like a title and an ual factors that may have an influence on it, such as the explanation of how an indicator is defined and calcu- study goals or the information resources available. lated [22]. In addition, the different reports found In order to help accomplish this task successfully, the were classified according to the geo-political region objective of this study is to perform a systematic review they were studying: 1. international, 2. national, and of the most common topics and indicators used for 3. regional (Table 1). measuring and monitoring health inequalities in the re- After this selection process, the indicators were ports, projects, and databases of international, national, grouped into topics by semantic matching of their and regional governmental organizations. definition as well as by the area of knowledge there The main purpose of this study is to provide a broad are intended to measure. Most of the topics were overview of health inequalities topics considered relevant supported by references of relevant organisations like by different public health organizations. Nevertheless, the WHO or the United Nations (UN) (see Table 2). the focus of this review is on countries/regions with Each topic was uniquely named in accordance with similar socioeconomic and political status to Catalonia. the area of knowledge that instruments were intended It may also be useful for other organizations who decide to measure. Indicators from different sources were to study or monitor health inequalities to accomplish its often merged due to high similarities between them very first step: topic selection. In addition, gaining some (most commonly, the only differences were stratifiers insights about which health issues are being prioritized, such as age, gender or region). Every topic had to be as well as which indicators were used, are considered formed by at least five indicators in order to be con- secondary goals. sidered relevant enough; the topics with less than five indicators were discarded. Material and methods The search was performed by the two researchers, and First, a bibliographic search was performed using the results shared in order to agree on any discrepancies. PubMed, Google Scholar, and Google search engine with All the data was organised in spreadsheets to identify the terms “health inequalities”, “health observatories” common indicators, and then sorted by the amount of Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 3 of 15 Table 1 Reports and datasets identified in the search Type Organisation/ Report or database title Number URL for website or PDF Reference Institution of indicators International WHO Regional Office Data Management Tool 6 http://dmt.euro.who.int/classifications/tree/ [28] for Europe B#B03 International European Commission Health inequalities in the EU 12 https://ec.europa.eu/health/sites/health/files/ [25] social_determinants/docs/ healthinequalitiesineu_2013_en.pdf International Social Protection Portfolio of EU Social Indicators for the 12 https://ec.europa.eu/social/ [26] Committee Indicators Monitoring of Progress Towards the EU BlobServlet?docId=14239&langId=en Sub-group (European Objectives for Social Protection and Commission) Social Inclusion International Various organisations I2SARE 37 https://www.sergas.es/Saude-publica/-I2 [27] (European SARE-Galicia Commission funded project) International European Commission European Core Health Indicators 64 https://ec.europa.eu/health/indicators/echi/ [24] (ECHI)* list_en#id3 International European Commission Eurostat (SDG) 13 https://ec.europa.eu/eurostat/web/sdi/good- [23] health-and-well-being International The World Bank World Bank Open Data (Indicators 52 https://data.worldbank.org/indicator/ [30] section) International WHO 100 Core Health Indicators (plus health- 100 https://www.who.int/healthinfo/indicators/1 [29] related SDGs) 2018 00CoreHealthIndicators_2018_infographic. pdf?ua=1 National Institute of Health Marmot Indicators Release 2017 10 http://www.instituteofhealthequity.org/ [35] Equity about-our-work/marmot-indicators-release-2 017 National Canadian Institute for Health Inequalities Map 105 https://infobase.phac-aspc.gc.ca/health- [34] Health Information inequalities/docs/health-inequalities-map-en. pdf National Public Health Agency Key Health Inequalities in Canada: A 22 https://www.canada.ca/en/public-health/ [33] of Canada (PHAC) National Portrait – Executive Summary services/publications/science-research-data/ key-health-inequalities-canada-national- portrait-executive-summary.html National Government of Long-term monitoring of health 14 https://www2.gov.scot/Publications/201 [37] Scotland inequalities: December 2018 report 8/12/8085 National National Health England Analysis: NHS Outcome 30 https://www.england.nhs.uk/wp-content/ [36] Service (England) Framework Health Inequalities uploads/2017/07/nhs-outcome-framework- Indicators 2016/17 health-inequalities-indicators-2016-17.pdf National Institut d’Estadística Observatori Social d’Andorra 13 https://observatorisocial.ad/ [31] d’Andorra National Australian Institute of Health inequalities in Australia: 20 https://www.aihw.gov.au/getmedia/0cbc6 [32] Health and Welfare morbidity, health behaviours, risk c45-b97a-44f7-ad1f-2517a1f0378c/ factors, and health service use hiamhbrfhsu.pdf National WHO Regional Office Health Inequalities in Slovenia 32 http://www.euro.who.int/__data/assets/pdf_ [38] for Europe file/0008/131759/Health_inequalities_in_ Slovenia.pdf National Instituto Nacional de Indicadores Sociais - 2011 16 https://censos.ine.pt/xportal/xmain?xpid= [40] Estadística (Portugal) INE&xpgid=ine_ publicacoes&PUBLICACOESpub_boui=1492 79938&PUBLICACOEStema=5553 8&PUBLICACOESmodo=2 National Ministry of Health and Moving Dorward Equity in Health: 30 https://www.mscbs.gob.es/profesionales/ [39] Social Policy of Spain Monitoring Social Determinants of saludPublica/prevPromocion/promocion/ Health and the Reduction of Health desigualdadSalud/PresidenciaUE_2010/ Inequalities conferenciaExpertos/docs/ haciaLaEquidadEnSalud_en.pdf Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 4 of 15 Table 1 Reports and datasets identified in the search (Continued) Type Organisation/ Report or database title Number URL for website or PDF Reference Institution of indicators Regional Observatorio Desigualdades en Salud en la 26 https://www.sp.san.gva.es/DgspPortal/ [43] Valenciano de la Salud Comunidad Valenciana docs/20180301_Desigualdades_Salud_OVS2 018.pdf Regional Ajuntament de Desigualtats en salut, respostes a nivell 22 http://www.consorci.org/media/upload/ [42] Barcelona local: Polítiques per reduir les desigualtats arxius/coneixement/salut-publica/2017/ en salut a la ciutat de Barcelona D_%20Malmusi_Desigualtats_28-09-2017.pdf Regional Escuela Andaluza de Guía de indicadores para medir las 55 https://www.easp.es/project/guia-de- [41] Salud Pública desigualdades de género en salud y sus indicadores-para-medir-las-desigualdades- determinantes de-genero-en-salud-y-sus-determinantes/ indicators they included. The names of the indicators in governments of countries such as Andorra [31], the spreadsheets were those given in the original reports Australia [32], Canada [33, 34], England [35, 36], or their metadata information. Scotland [37], Slovenia [38], Spain [39] or Portugal [40]. In the last category, regional, some reports pub- Results lished by Spanish regions were included (Andalucía In total, 21 reports, projects, and databases were iden- [41], Barcelona [42], Valencia [43]). A total of 691 tified and classified into three categories: 1. inter- health indicators were identified (Table 1). national [8], 2. national [10], and 3. regional [3]. In Following an iterative process of evaluation, we identi- the first category, international, all the projects se- fied a core set of 120 candidate topics, of which 34 were lected were carried out or funded by the European finally selected (Fig. 1). Table 2 describes a complete list Commission [23–27], the WHO [28, 29] or the of 34 topics with the corresponding definition of each World Bank [30]. In the following category, national, topic. The ten most commonly used were: “Life expect- studies were conducted by health agencies or ancy”, “Infant mortality”, “Obesity and overweight Fig. 1 Flowchart of the processes undertaken to review the most common topics in the study of health inequalities Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 5 of 15 Table 2 List of topics ranked by the number of health indicators grouped within Topic Description of measured topics Reference Life expectancy Time that a concrete population is expected to live. [23–30, 33–39, 41–43] Infant mortality Death of young children under the age of 1 in a population. [24–30, 33, 34, 36, 38–42] Obesity and overweight (BMI) Measurement of people having more body fat than is optimally healthy, [22, 24, 25, 27, 29–33, 36, 38, to an extent that it may have a negative effect on health. 42, 43] Mortality rate Measurement of the number of deaths in a particular population, scaled [25–27, 29, 30, 34, 37, 38, 40– to the size of that population, per unit of time. 43] Regular smokers/ tobacco Measurement of the number of people consuming tobacco (smoking) [23–25, 27, 29, 31–34, 38, 42, consumption in a population. 43] Self-perceived health Measurement of the expression of subjective assessment by the [23–26, 31, 32, 34, 36–38, 42, respondent of his/her health. 43] Unemployment Measurement of people above a specified age that are not in paid [24, 25, 27, 28, 30, 34, 36, 38, employment or self-employment and are currently available for work 39, 41, 42], during the reference period. Mental well-being Level of psychological well-being or an absence of mental illness. [24, 29, 33, 34, 36–39, 41–43] Cardiovascular disease/ hypertension Measurement of the number of people affected by cardiovascular [24, 27, 29, 32, 34, 36–38, 41, disease (CVD) or hypertension in a population. 43] Socioeconomic status (SES)/ material Measurement of the social standing or class of individuals in a population, [24, 25, 28, 33–35, 38, 39, 42], deprivation as well as the state of economic strain and durables. Diabetes/ insulin resistance Measurement of people affected by diabetes (a chronic, metabolic disease [24, 25, 29, 30, 32–34, 38, 41], characterised by elevated levels of blood glucose) or insulin resistance in a population. Physical activity Measurement of physical activity (any bodily movement produced by [24, 29, 31, 32, 34, 38, 39, 42], skeletal muscles that requires energy expenditure) in a population. Cancer Measurement of people affected by cancer (group of diseases that can start [24, 25, 27, 33, 34, 36, 37, 43] in almost any organ or tissue of the body when abnormal cells grow uncontrollably, go beyond their usual boundaries to invade adjoining parts of the body and/or spread to other organs) in a population. HIV Measurement of people affected by HIV (an infection that attacks the body’s [23, 24, 27, 29, 30, 34, 40, 41], immune system, specifically the white blood cells, called CD4 cells) in a population. Long-term limitations/ chronic Measurement of people affected by diseases or conditions that are persistent [23–26, 31, 34, 36, 37] illnesses or long-lasting. Tuberculosis Measurement of people with health issues caused by the infection of the [23, 29, 30, 33, 34, 40, 42, 43] bacteria Mycobacterium tuberculosis in a population. Hazardous alcohol consumption Measurement of hazardous alcohol consumption in a population. [24, 29, 32–34, 37, 38] Low birthweight Measurement of birth weights of infants of 2499 g or less in a population. [27, 29, 34, 37, 38, 41, 42], Perinatal, neonatal and stillbirths Measurement of foetus or neonate deaths in a population. [24, 27, 29, 30, 36, 38, 43] mortality General practitioner (GP) utilisation Measurement of the utilisation of general practitioners (medical doctors) in [24, 26, 31, 32, 34, 36, 39] a population. Suicide/self-harm Measurement of the number of intentionally self-caused deaths and/or [25, 29, 33, 34, 36, 38, 43] other intentional self-harm injuries in a population. Healthcare resources Measurement of resources such as materials, personnel or facilities that can [24, 27, 30, 38–40, 43] be used to provide healthcare. Alcohol consumption Measurement of people consuming alcohol (a toxic and psychoactive [24, 25, 31, 32, 37, 38] substance with dependence-producing properties) regularly in a population. Road traffic accidents (injuries and Measurement of deaths and injuries due to road traffic accidents (crashes) [23, 24, 27, 29, 30, 38], deaths) in a population. Food consumption (vegetables, fruit, Measurement of people ingesting solid foods in a population. [24, 29, 32, 34, 38, 39] salt) Primary studies/ illiteracy Measurement of people with primary studies (first stage of [24, 28, 32, 35, 39, 42] formal education) or illiterate (not able to read) in a population. Child well-being Indicators to measure the general health, proper growth, and well-being [31, 33, 35, 39–41], of children. Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 6 of 15 Table 2 List of topics ranked by the number of health indicators grouped within (Continued) Topic Description of measured topics Reference Respiratory disease Measurement of people affected by a disease affecting the organs and [24, 29, 32, 36, 38, 41], tissues that make gas exchange in a population. Work-related health risks Measurements of risks and/or diseases as a result of an exposure to risk [23, 24, 29, 36, 39, 43] factors from work activity in a population. Dental care/ oral health Measurement of people with oral diseases or provided with dental health [26, 32–34, 36, 38], services in a population. Policy and legislation Indicators measuring policy-making initiatives. [24, 28, 29, 36, 39, 40] Perceived mental health Measurement of the expression of subjective assessment by the respondent [24, 30, 33, 34, 36] of his/her mental health and/or psychological well-being. Unintentional injuries Measurement of people affected by any injury that is not caused on [24, 33, 36, 38, 41], purpose or with intention to harm in a population. Pregnancy care/ breastfeeding Indicators measuring the care provided during pregnancy or other [24, 32, 34, 39, 41], pregnancy-related issues, such as breastfeeding, in a population. Hip fractures and surgical procedures Measurement of the amount of surgical procedures and/or relevant fractures [24, 30, 36, 41, 43] that will likely require surgical procedures (i.e. hip fractures) in a population. (BMI)”, “Mortality rate”, “Regular smokers/tobacco con- found among the health indicators. Indicators are focused sumption”, “Self-perceived health”, “Unemployment”, on different aspects, such as prevalence and incidence, mor- “Mental well-being”, “Cardiovascular disease/hyperten- tality, preventive measures, or treatments. For example, for sion”, “Socioeconomic status (SES)/material deprivation”. the topic “HIV”: “HIV incidence” [23, 26, 28, 33, 40], However, some topics that ranked below these were “Prevalence of HIV, male/female, by ages” [29, 39] and closely related with some of the most common topics; “AIDS-related mortality rate” [28, 39] are the most com- for example, “Perinatal, neonatal and stillbirths mortal- mon, yet “Antiretroviral therapy (ART) coverage” [28] and ity” might be considered as a subtype of “Infant mortal- “HIV test results for TB patients (positive results)” [28] can ity”; and “Perceived mental health” is similar to both also be relevant. “Mental well-being” and “Self-perceived health”. Further- The results of the study show that the most common more, some indicators may represent antithetically the topics are related to: same area of knowledge; that is the case for the indica- tors in the topic “Long-term limitations/chronic ill- – Mortality/life expectancy: “Life expectancy” [44, 45], nesses” and the indicator “Healthy Life Years (HLY)” “Infant mortality” [46] or “Mortality rate” [47] are [within the topic “Life expectancy”], where the former widely used to study health inequalities. (long-term limitations or chronic illnesses) is used to de- – Incidence/mortality rates of specific diseases: termine the latter (the end of a healthy life condition). “Cardiovascular disease/hypertension”, “Cancer Nevertheless, the metadata of the health indicators (incidence or mortality)” [48], “Diabetes/insulin within each topic was highly homogeneous: they all had resistance” [49], “HIV” [50], “Tuberculosis (TB)” [51] similar definitions and methodology. or “Respiratory diseases”. In general, the indicators within each topic were very – Social determinants of health [52]: similar. In fact, often the differences among them were re- ◦ “Living and working conditions” where this lated to the different stratifiers (such as sex, age or region) could be studied at an individual level, was highly used for their calculation. For example, in the first topic ranked: “Unemployment” [53] and “Primary “Life expectancy”, indicators have different variations: studies/illiteracy”. Otherwise, these indicators were “Life expectancy at birth” [23–25, 27–29, 32, 33, 37, 40– at the bottom of the list. 42], “Life expectancy at birth by sex” [22, 24–27, 33, 34], ◦ This was similar for “Individual lifestyle factors “Life expectancy at a certain age” [25, 33, 35, 40], “Life ex- and social and community networks” topics, which pectancy by educational attainment level” [25], and “Life can also be studied at an individual level: “Obesity expectancy at birth by socioeconomic status” [25]. Com- and overweight (BMI)” [54, 55], “Regular smokers/ plex measures of inequality, such as “Slope index of in- tobacco consumption” [56], “Alcohol consumption” equality (SII) for male and female life expectancy” [34] [57], “Hazardous alcohol consumption”, “Physical may be considered another (more advanced) variation. activity” [58], and “Food consumption (vegetables, Furthermore, in the case of a health outcomes or diag- fruit, salt)”. nostics (such as mortality or cancer) the concrete disease or ◦ Socioeconomic level: “Socioeconomic status cause may also play an important role in the heterogeneity (SES)/material deprivation” [59, 60]. Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 7 of 15 ◦ Healthcare system: “Healthcare resources” and the need of knowing how particular regions of inter- “Policy and Legislation”. est were dealing with health inequalities. Interest in regions was mainly based on previous knowledge of Discussion concrete public health organizations studying those Main results of the study regions, as well as interest in looking for other orga- The results of the study showed that the most com- nizations in charge of tackling health inequalities in mon topics were related to mortality/life expectancy, regions similar to Catalonia. Nevertheless, as in any incidence/mortality rates of specific diseases (i.e., TB review, it is not possible to ensure that absolutely all or HIV), and social determinants of health, such as the reports suitable for this study were found during living and working conditions, and individual lifestyle the search, nor that they were selected after applying factors and social and community networks, according the selection criteria. to Dahlgren and Whitehead’s model of the social de- terminants of health [52]. The indicators that can be Grouping health indicators into topics studied at an individual level tended to be highly As stated above, the most frequent health indicators ranked, in comparison to those that are studied at were grouped into topics according to the health domain different levels (such as hospital or region), which they were measuring (with each indicator related to only tended to be at the bottom. Many methodological dif- one topic). For example, although “Percentage of 15- ferences between indicators were due to stratifiers in year-olds who were overweight in 2009–10, EU Member their calculation. States by sex” [25] and “Obesity rate by body mass index (BMI) (sdg_02_10)” [23, 66] are different indicators per Study selection criteria se, they are both intended to measure the same health To include health inequalities indicators was a funda- issue and, hence, were grouped under the same topic mental requirement for any report in order to be in- “Obesity and overweight (BMI)” under the indicator cluded in the review. Hence, although some reports name “Obesity and/or overweight (total, by sex, age, or provided in-depth insights about tackling health inequal- educational level)”. ities (i.e., [21, 61]) they were not selected due to lack of Most of the selected health indicators were taken health indicators monitoring. from the official statistics of different countries or In addition, to be carried out by a governmental or international organisations, whose development and a government-related organisation was also an import- methodology has been closely consolidated over many ant requirement, as many academic and/or private in- years and respond to international standards. In stitutions carry out studies and reviews of health addition, most of these indicators are related to rele- inequalities, but their policy-making influence is lim- vant knowledge areas for the study of health inequal- ited. Their reports tend to be focused on concrete ities, such as lifestyle habits, deprivation, and knowledge fields, such as gender influence [62], the mortality. effects of economic crises [63], or access to healthcare To prioritise the most relevant topics, all the groups [64]; which are also relevant for the study of health with less than five health indicators were deleted. inequalities but whose authorship does not fit the se- This meant that, unfortunately, interesting topics such lection criteria, as the main interest of this paper is as the “Years of potential life lost” [34, 36, 42], “Un- identifying the health inequalities indicators used by met health needs” [23, 26, 39] and “Passive smokers” health agencies or similar government-related entities. [33, 34] were not taken into consideration. Neverthe- The reports not produced by this kind of organisation less, this selection does not imply per se a periodic were rejected. monitoring of the selected health indicators, as spe- Lastly, to have a socioeconomic and politic status simi- cific topics not present in this list may be studied ac- lar or highly related to Catalonia criteria was intended cording to ultimate needs. to exclude reports whose health indicators were adapted to least developed/developing countries where, for ex- ample, access to treatments of diarrhea for infants may Relevance of the most common topics still be an issue [65]. Hence, some reports were dis- All the topics aim to measure and study the relation carded due to significant differences in the socioeco- between determinants of health and health outcomes. nomic profile of the countries they are studying in Interestingly, three of the top five topics in the list comparison to Catalonia or Spain. (see Table 2) are related to mortality: life expectancy, These criteria were applied to all the reports and infant mortality, and mortality rate. Life expectancy at studies found after an extensive search. The addition birth is an indicator of mortality conditions and, by of country/region names in the search responded to proxy, of health conditions [44]. Hence, life Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 8 of 15 expectancy as well as other mortality-related topics indicators try to measure every relevant (and measur- are widely used in the study of health inequalities. able) aspect of the topic. Living and working conditions, such as BMI or smok- Common stratifiers are sex, age, and studied region, ing, are also key factors in the study of health inequal- something that is coherent with the determinants of ities as both share a strong socioeconomic gradient [54, health perspective and the focus on inequalities. How- 56]. Therefore, as may be expected, they appeared ever, the stratifiers found are highly heterogeneous among the top 10 positions in the list of topics (see and may also include socioeconomic status, educa- Table 2). According to our review, the most common tional level, or nationality/country of origin, among way to measure socioeconomic status is to analyse the many others. unemployment rates and material deprivation level of the population. Research fitted to monitor health inequalities In Spain, some regions use less common health in- This comprehensive review was carried out to help dicators for studying health inequalities that may be accomplish the first step in the process for tackling interesting for particular knowledge areas. For ex- and monitoring health inequalities: selecting high- ample, the Valencian Observatory of Health uses the impact issues and health indicators [19, 20]. The “Caregiver profile”, which they report to be mostly next steps in the analysis will be to carefully take women, without primary studies, 57-years-old on into account stratifiers such as area of residence, average, and reporting bad self-perceived health. In gender, age, and nationality. Lastly, after the identifi- addition, they also use “Reasons why contraceptive cation of key health inequalities, decision-making methods are not used by age and nationality of stakeholders will need to play a role during the last women” as well as a “Sexual-health information re- steps: determining priorities of action and imple- sources (school, parents, friends, etc.)”, which may menting changes. The time variable will play a key help to understand possible sexual health inequalities role in the monitoring, as it will indicate the pos- [43]. In the Andalusian School of Public Health, the sible health consequences of policy-making decisions indicator “Psychosis and mental illnesses due to drugs [19, 20]. or alcohol abuse” may be helpful to estimate various negative health outcomes of alcohol and substance abuse that the healthcare system will need to address Conclusions [41]. Even so, more than a half of topics in Table 2 Reviewing the most common health indicators and appear in their reports. topics used in the study of health inequalities may As may be expected, the health indicators used in help research teams in different ways. First, having other reports produced by the Catalan Health System an overview of what is being done by their neigh- Observatory, such as the “Community Health Indica- bouring countries or regions may highlight issues tors”, match the implicit measurement concept be- that should not be missed when selecting relevant hind many of the topics: obesity and overweight, health topics to study. Second, even if some topics mortality by age (including infant), self-perceived might not ultimately be chosen as a priority of ac- health, and population with primary studies are some tion, having a complete list of key issues will provide of them [67]. an overview of what is relevant in the study of health inequalities, as well as some interesting insights. Health indicators Lastly, knowing what other research institutions are As can be seen in Table 3, health indicators were com- working on will promote potential collaborations be- bined within each topic if stratifiers such as population tween organizations, creating synergies and bonds sex, age, or region were the only difference in their cal- that may lead to better understanding and monitor- culation methodologies. Some indicators were also ing of health inequalities. merged if they were formerly different in the way they At a regional level, these results are highly valuable expressed the same data (i.e., raw number, rate per 1000 for the first stages of health inequalities monitoring or 100,000). cycles in Catalonia. This study provided the basis for The health indicators within each topic often cover choosing health topics to study as well as helped gain a different aspect relevant to health inequalities. For insights about which indicators should be used. In example, in the topic “Tuberculosis” [23, 29, 33, 34, addition, regions with similar socioeconomic status 40, 42, 43] indicators about incidence, prevalence, or and goals in tackling health inequalities may benefit mortality can be observed. In addition, health indica- from this research. Similarly, at a national and inter- tors about treatment coverage or vaccination are also national level these results may help organizations included in this topic. Overall, in most topics, shift the focus towards undermined health inequalities Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 9 of 15 Table 3 List of indicators by topic Topics Indicators Reference Life expectancy Life expectancy at birth or at certain age (total, by sex, educational level [23–30, 33–36, 38, 41–43] and/or socioeconomic status) Health-adjusted life expectancy [33, 34] Inequality in life expectancy, slope index of inequality (SII) for male and [35, 39] female life expectancy Healthy life years (total, by sex, region and/or socioeconomic status) [25, 26, 36, 37, 39, 43] Slope index of inequality for male and female disability-free life expectancy [35] Infant mortality Infant mortality (total, by sex, by socioeconomic status, deprivation or [24–30, 33, 34, 36, 38, 40–42] disposable family income) Infant mortality of newborns weighting at least 500 g [34] Inequality in infant mortality [39] Highest and lowest infant mortality rates per 1000 live births and measures [25] of inequality between EU Member States, 2000–2010 Obesity and overweight (BMI) Obesity and/or overweight (total, by sex, age, or educational level) [22, 24, 25, 27, 29–33, 36, 38, 42, 43] Body mass index [24] Mortality rate All-cause mortality (total, by sex, age, or region) [25, 27, 29, 34, 37, 38, 41–43] Death rates by cause of death [26, 29, 40, 42] % completeness of death registration with cause-of-death information [30] Regular smokers /tobacco consumption Smoking/tobacco consumption (total, by frequency of consumption, age, [23–25, 27, 29, 31–34, 38, 42] sex, employment and occupational status and/or by difficulties experienced in paying bills) Tobacco and alcohol consumption [43] Pregnant women smoking [24] Self-perceived health Self-perceived health (total, by age and/or sex) [23–26, 31, 32, 34, 37, 38, 42, 43] Total health gain as assessed by patients for elective procedures: physical [36] health related procedures/psychological therapies Unemployment Unemployment (total, by duration/long-term) [24, 25, 27, 28, 30, 38, 42] Employment of people with long-term conditions/mental illness/ [36, 41] disabilities Eligibility for employment insurance (aged 15–69) [34] Age dependency ratio (% working-age population) [30] Population living in jobless households [39] Employment gap [39] Mental well-being Risk of psychological suffering [42] Health-related quality of life for people with mental illness [36] (eventual or recovery) Psychological well-being or discomfort (by age, by using GHQ-12) [24, 37, 43] Mental disorders or illness (ICD9MC: 290–319 / including addictions) [39, 41] Morbidity: neurotic, personality, and other non-psychotic mental disorders [41] (except drugs or alcohol) (ICD9MC: 300–302, 306–319) Depression (mental health) [38] Mental illness hospitalisation rate (total, by age) [33, 34] Coverage of services for severe mental health disorders [29] Cardiovascular disease/ hypertension Mortality due to cardiovascular causes, including heart diseases [27, 34, 36, 37, 43] (total, by sex and/or age) Arterial hypertension [32, 38, 41] Blood pressure [24, 29] Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 10 of 15 Table 3 List of indicators by topic (Continued) Topics Indicators Reference Proportion of stroke patients reporting an improvement in activity [36] Cardiovascular and heart diseases (including heart attacks, angina pectoris, [38] and heart failure) First ever hospital admission for heart attack (aged under 75 years) [37] 30-day in-hospital case-fatality AMI and stroke [24] Socioeconomic status (SES)/ material Working poor [33, 34, 39] deprivation Disposable family income/family SES [39, 42] Income tax base [38] People in households in receipt of means-tested benefits [35] Slope index of inequality for people in households in receipt of [35] means-tested benefits % at risk of poverty – with less than 60% of the median income/% at [39] persistent risk of poverty (by intensity of poverty) % who own a house and car [39] % areas with > 20% population poor [39] Age-standardised percentage of people aged 25 and over by severity of [25] material deprivation SII Income/SII Deprivation (by perceived health)/inequality relative index/ [25, 28, 39] Gini coefficient (income distribution)/salary gap/income inequality (S80/S20) within and across local areas Population below poverty line and income inequality [24] Diabetes / Insulin resistance Age-standardised prevalence rate of anti-diabetic drug recipients [38] Diabetes (excluding gestational) (by region, age) [25, 30, 32–34, 41] Raised blood glucose/diabetes among adults [29] Diabetes control [24] Physical activity Physical activity, active or moderately active (total or during free time, by [24, 31, 34, 38] sex and/or age) Sedentarism/insufficient physical activity [29, 32, 42] % children by the number of hours of physical activity during a week [38] Little social or recreational activity [39] Cancer Cancer mortality (total, by sex, age) [27, 36, 37] Cancer incidence (total, by age) [25, 34, 37] Lung cancer incidence or mortality [33, 34, 43] Survival rates cancer (1–5 years from all cancers/diagnosed at stages 1 and [24, 36] 2) Colorectal cancer screening, past 5 years (aged 50–74) [34] HIV HIV incidence / prevalence (total, by sex, age) [24, 27, 29, 30, 34, 40, 41] AIDS-related mortality rate [29, 40] People living with HIV who know their status [29] Antiretroviral therapy coverage [29] Prevention of mother-to-child transmission [29] HIV test results for TB patients (positive results) [29] Death rate due to TB, HIV, and hepatitis by sex [23] Long-term limitations/ chronic illnesses Health-related quality of life for people with long-term conditions [36] Long-term/chronic conditions, limitations, or illness (total, by age, sex) [24, 25, 31, 34, 37] Self-reported chronic morbidity or limitations in daily activities [24, 26] Physical and sensory functional limitations [24] Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 11 of 15 Table 3 List of indicators by topic (Continued) Topics Indicators Reference Death rate due to chronic diseases by sex [23] Tuberculosis Incidence/prevalence of TB (by country of origin, nationality, age, and sex) [29, 30, 33, 34, 40, 42, 43] Evolution of anti-TB vaccination (BCG) [40] TB notification rate [29] Coverage for TB treatment/drug susceptibility testing (for active, latent [29] infection or drug-resistant) Death rate due to TB, HIV, and hepatitis by sex [23] Hazardous alcohol consumption Hazardous alcohol consumption/heavy drinking (total, by age) [24, 33, 34, 38] Alcohol-related deaths (aged 45–74 years) [37] High-risk alcohol consumption [32] Harmful use of alcohol, defined according to the national context as [29] alcohol per capita consumption (aged 15 years and older) within a calendar year in litres of pure alcohol Low birthweight Low birthweight [27, 29, 34, 37, 38, 42] Preterm delivery [29, 38] Hospital discharges due to delayed intrauterine growth, foetal malnutrition, [41] shortened pregnancy and low birth weight, caesarean sections, and low birth weight infants (by province) Small for gestational age [34] Perinatal, neonatal, and stillbirths/foetal Perinatal mortality [24, 27, 43] mortality Neonatal mortality rate [29, 30, 36] Under-5 mortality rate [29, 30] Stillbirth mortality [29, 36] Foetal mortality by nationality [43] Stillbirths, perinatal mortality, and infant mortality [38] General practitioner (GP) utilisation Health professionals (including doctor/GP/specialist) consultations [31, 32, 34] (by time period) Care utilisation (including GP) [24, 26] Experience of GP services/Out of Hours service [36] % without a GP [39] Suicide/self-harm Suicide mortality [25, 29, 33, 34, 38] Suicide and mortality from injury of undetermined intent among people [36] with recent contact from NHS Suicides and self-injuries [43] Healthcare resources Hospital beds [24, 27, 30] Health facilities [40] % areas understaffed in health & education [39] Physicians employed (total or rate, by region) [24, 27, 38, 40] Specialist surgical workforce (per 100,000 population) [30] Nurses employed including/excluding midwives (total and rate) [24, 27, 40] Alcohol consumption Alcohol consumption (total, by sex) [24, 31, 38] Alcohol first hospital admissions (aged under 75 years) [37] Alcohol risk [32] Patterns of alcohol consumption [25] Road traffic accidents (injuries and Mortality caused by road traffic injury (per 100,000 people) [29, 30] deaths) Healthy life years lost by traffic accidents and falls [38] Road injuries and deaths (register-based and self-reported) [23, 24, 27] Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 12 of 15 Table 3 List of indicators by topic (Continued) Topics Indicators Reference Food consumption (vegetables, fruit, Fruit/vegetable consumption (total, by times a day, by age) [24, 34, 38] salt) Salt intake [29, 32] Low access to healthy food [39] Primary studies/ illiteracy Population by education (including early school leavers) [24, 28, 39, 42] Young people who are not in education, employment or training [35] Days away from study or work [32] Results in math and literacy or years of education [39] % illiterate or does not know the language well [39] Child well-being Hospital discharges in girls and boys by age [41] Children well-being/achieving a good level of development at age 5 [35, 39] Early childhood development [33] Incidence of one of the 17 most common disorders in children, by sex [31] and age Respiratory disease Mortality rate from respiratory disease (including COPD, total, by age) [36, 38] COPD and associated diseases (ICD9MC: 490-496) [24, 41] Bronchitis and acute bronchiolitis including emphysema (ICD9MC: 466) [32, 41] Care-seeking for symptoms of pneumonia [29] Work-related health risks Health-related quality of life for carers [36] Occupational diseases [43] Work accidents [39] Health worker density and distribution [29] Work-related health risks [24] People killed in accidents at work [23] Dental care/ oral health Dental consultations [26, 32, 34] Tooth extractions in secondary care for children under 10 [36] Dental care (regular brushing of teeth, regular visits to the dentist, proper [38] diet, and the use of protective agents) Dental disease (caries and periodontal disease)] [36, 38] Dental pain or discomfort, past month (aged 18+) [34] Inability to chew [33, 34] Decay-missing-filled teeth index (aged 6–17) [34] Policy and legislation A measure of the effectiveness of post-diagnostic care in sustaining [36] independence and improving quality of life New cases of International Health Regulations (IHR)-notifiable diseases and [29] other notifiable diseases Total net official development assistance to medical research and basic [29] health sectors prepared International health regulations capacity and health emergency [29] preparedness Integrated programmes in settings, including workplace, schools, hospital [24] Expenditure on public health administrations [40] Legislation, plans and funds to fight discrimination and structural health [28, 39] inequalities Prevention of HIV in key populations [29] Policies and practices on healthy lifestyles including nutrition [24] Perceived mental health Psychological distress (total or by place, by age) [24, 30, 34] Excess under 75 mortality rates in adults with common mental illness [36] Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 13 of 15 Table 3 List of indicators by topic (Continued) Topics Indicators Reference Perceived mental health (fair or poor) [33, 34] Pregnancy care/ breastfeeding Breastfeeding (total, having ever breastfed, initiation, exclusive, by age) [24, 32, 34] Recommended duration of breastfeeding [32] Hospital discharge for giving birth (ICD9MC: 650) [41] % pregnant women receiving prenatal care [39] Hip fractures and surgical procedures Proportion of patients with hip fractures recovering to their previous [36] levels of mobility/walking ability at 30 days Fractures including hip, vertebral and forearm fractures [41, 43] (ICD9MC: 800–829) (by province, sex, age) Number of surgical procedures including PTCA, hip, cataract [24, 30] (per 100,000 population) topics or explore new areas of knowledge (yet unstud- Author details 1 ied or with a different perspective). Catalan Health System Observatory, Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), 81-95 (2a planta), 08005 Barcelona, Spain. 2 CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain. Abbreviations 3 Institut d’Investigació Biomèdica (IIB Sant Pau), Barcelona, Spain. AIDS: Acquired immune deficiency syndrome; AMI: Acute myocardial infarction; BCG: Bacillus Calmette-Guérin; BMI: Body mass index; Received: 6 October 2020 Accepted: 28 January 2021 COPD: Chronic obstructive pulmonary disease; CRDSS-E: Comisión para Reducir las Desigualdades Sociales en Salud en España; CVD: Cardiovascular disease; ECHI: European Core Health Indicators; GHQ-12: 12-Item General Health Questionnaire; GP: General practitioner; HI: Health indicators; HIV: Human Immunodeficiency Virus; HLY: Healthy Life Years; References ICD9MC: International Classification of Diseases, Clinical Modification; 1. World health organization (WHO). 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