Monitoring privilege for health equity: building consensus on indicators to monitor socioeconomic advantage through a modified Delphi survey

Abstract

The World Health Organization's Commission on Social Determinants of Health highlighted the need to measure and monitor the inequitable distribution of power, money, and resources across society. Efforts to monitor health inequity focus on disadvantage rather than advantage or privilege, and on proximal health outcomes rather than distal social and structural determinants of health. This study aimed to identify a comprehensive set of key indicators to measure and monitor socioeconomic advantage. Following a literature review to establish an initial set of indicators (n = 79), we used a three-round, online Delphi survey to build consensus among a panel of participants with diverse disciplinary backgrounds and with expertise related to socioeconomic inequity. Participants rated indicators for relevance to the concept of socioeconomic advantage using a seven-point Likert scale and ranked priority indicators among selected indicator categories. Thirty-one, 21 and 15 experts—predominantly from Australia— participated in the first, second and third round, respectively. Sixty-four of 76 indicators reached consensus, including all indicators within the ‘Wealth’ and ‘Income/wealth inequality’ categories. Priority rankings of economic indicators were clear: gross income and disposable income were the highest ranked income indicators; net wealth was the highest ranked wealth indicator. Ranking of ‘Connections and signalling indicators’ was less distinct; however, elite secondary schooling, and attendance at exclusive events received the highest mean ranks. Monitoring of these socioeconomic advantage indicators is crucial for identifying whether policy and governance is ultimately shifting the dial on equitably distributing resources for improving health equity outcomes.