Exploring the worst life expectancy gap in England A Longitudinal Study of Health Inequalities in Stockton on Tees.

Dr Jon Warren

Kate Mattheys

Prof Clare Bambra

∂

Prospective cohort study of health inequalities

Aim:

• To gather information about examine health inequalities in

Stockton on Tees .

• Evaluate competing theories of health inequalities and enhance

understanding of the causal factors involved.

• Try to assess the impact of government austerity policies and

welfare reform upon health inequalities.

∂

Why Stockton? Stockton on Tees and Health Inequalities

• Data from Public Health England in 2012 showed that the life

expectancy gap in for men in Stockton was the second largest in

England at 15.3 years.

• The highest was Westminster with a gap for men of 16.9

years. Middlesbrough came in 3rd with 14.8 years

• For women Stockton was the second largest gap in England 11.3

years, the same gap is evident in Bolton and Middlesbrough.

• The highest gap was in Darlington 11.6 years. The third highest gap for

women was in Newcastle upon Tyne 10.8 years.

∂

Why Stockton? Stockton on Tees and Health Inequalities

• New figures from 2014 show……Things are now worse

• The gap for men is now 16.4 years the worst in England

• For women the gap is now 11 years the worst in England

• High health inequality and getting worse

∂

How to do it ? (method)

• A four year longitudinal survey incorporating 375 households from the

most deprived areas in area and 375 households from the least

deprived areas of the borough.

• Individuals would be initially identified via households. The initial

interview would be done face to face.

• There a further four telephone follow ups with one individual from each

household. After 6 months, 12 months, 24 months and 36 months.

∂

How to do it ? – Key Issues

• Who to ask ? (sample frame and sampling strategy)

• What to ask ? (questionnaire development)

• Getting response ? (data collection)

∂

Who to ask ? (sample frame and sampling strategy)

• Idea to compare the most deprived 20% of the population with the least

deprived 20%

• Problem…… finding them.

• Postcode areas?

• Council Wards.?

• Lower Super Output Areas.?

∂

Stockton on Tees -LSOAs

∂

Stockton on Tees -LSOAs

∂

Stockton Town Centre

∂

Hartburn

∂

Who to ask ? (2) (sample frame and sampling strategy)

•Lower Super Output Areas. 20 with the lowest IMD score. 20 with the

highest IMD scores. Range 1.54-74.5

•The addresses within each LSOA were provided by the most recent ONS

(Office for National Statistics) postcode lookup tables

•In total there were 20,013 addresses in the 40 study LSOAs, ranging from

313 to 1380 addresses per LSOA.

•200 addresses from each LSOA were then randomly chosen using simple

random sampling technique in the “ R” statistical software program.

∂

Who to ask ? (3) (sample frame and sampling strategy)

•Identify an contact via household at base line .

•Tracking individuals at the 4 follow ups

•How to choose an individual ?

•Household selection grid …..

∂

Household selection grid Hoinville et al :1977

Total Number of Eligible Persons

Assigned

Number of

Address

1

2

3

4

5

6 or more

1 or 2

3

1

1

1

2

2

3

2

3

3

3

3

5

4 or 5

6

1

1

2

1

3

1

4

1

5

2

6

2

7 or 8

9

1

1

1

2

1

3

1

4

1

5

1

5

10 or 11

12

1

1

2

1

2

1

3

2

4

2

4

2

∂

What to ask ? (questionnaire development)

•Baseline- face to face questionnaire -not more than an hour long (Follow

up- telephone questionnaire- not more than 30 minutes long)

•To collect information on health determinants

•Social/Material- Work, Income , Housing

•Behaviourial-Smoking, Drinking, Exercise

•Psychosocial- Loneliness, Happiness, Job satisfaction.

•Health to be measured using validated health measures namely EQ5D,

EQ5D VAS and SF8, Warwick Edinburgh mental health scale

∂

What to ask ? (questionnaire development) 2

•Based upon experience of previous surveys. (County Durham

worklessness study 2009-2011)

•Questions derived from well established surveys including:

•Health Survey for England 2011

•General Lifestyle Survey 2010

•Poverty and Social Exclusion in the UK 2012

•English Longitudinal Survey 2010

•European Social Survey 2013

•Tested within the team

•Pilot Study…….

∂

Pilot Study

•December 2013- January 2014

•Invitation letter sent out in advance.

•£10 shopping voucher (love to shop offered as a thank you).

•21st least deprived LSOA – 24 addresses – 26% response rate.

•21st most deprived LSOA- 24 addresses -35.3% response rate.

•Challenging, but …questionnaire worked , (minor changes to phrasing.)

∂

Getting response (data collection)

•Need for help collecting data….

•March 2013 initial discussions , 3 potential providers to help with data

collection.

•1 Not interested (too small)

•1 Too expensive (not that impressive either)

•1 Excellent attitude and the right price

•But …August 2013- January 2014 University tendering process….

•3 providers approached 2 tendered.

•1 Too expensive (not that impressive either)

•1 Excellent attitude and the right price

∂

Getting response (data collection)

•January- March 2014 preparatory meetings with QA

•Issues sampling strategy, selection grids etc.

•Briefing QA interviewers.

•200 target addresses per LSOA= 8000 invitation letters to be sent out.

•Labelling , folding, stuffing ,licking

•1000 per week April- May 2014

•Field period April-may extended to June.

∂

Getting response (data collection) baseline

•Final score

•June 2014- 836 surveys complete

• 397 most deprived areas and

• 439 least deprived areas.

•Thank you letters and shopping vouchers were sent out at the start of

June more Labelling , folding, stuffing ,licking

∂

Baseline results….

Table 1: Baseline Characteristics of Stockton Health Inequalities Survey

Most deprived N=397

Least deprived N=439

Gender

Male 161 (40.6%) 181 (41.2%)

Female 236 (59.4%) 258 (58.8%)

Age

Mean and range, years 50.9 range=75 54.6 range=69

≤ 65 years (Working Age) 72.5% 67.2%

Marital Status

Married 104 (26.2%) 266 (60.6%)

Divorced 62 (15.6%) 41 (9.3%)

Single Separated Widowed

155 (39.0%) 18 (4.5%) 49 (12.3%)

76 (17.3%) 12 (2.7%) 43 (9.8%)

∂

Baseline results….Material/Social

Tenure

Own outright Buying via mortgage/loan Renting

67 (16.9%) 40 (10.1%) 286 (72.0%)

223 (50.8%) 163 (37.1%) 51 (11.6%)

Renting (Social Housing) Renting (other)

222 (76.3%) 69 (23.7%)

9 (17.6%) 42 (82.4%)

Transport

No motor vehicle access 228 (57.4%) 26 (5.9%)

Occupational Class (currently working)

Professional 10 (10.5%) 51 (24.9%)

Intermediate 7 (7.4%) 35 (17.1%)

Skilled Non Manual 12 (12.6%) 38 (18.5%)

Skilled Manual 11 (11.6%) 30 (14.6%)

Semi Skilled 11 (11.6%) 20 (9.8%)

Unskilled 44 (46.3%) 31 (15.1%)

Not currently working 302 (76.1%) 233 (53.1%)

Benefits

HH currently receiving 350 (88.2%) 309 (70.4%)

∂

Baseline results….Health issues

Primary Health Problem

% reporting Health problem Musculo-Skeletal

234 (58.9%) 63 (26.9%)

197 (44.9%) 59 (29.9%)

Mental Health 29 (12.4%) 20 (10.2%)

Digestive/Gastric 36 (15.4%) 34 (17.3%)

Cardiovascular 48 (20.5%) 36 (18.3%)

Respiratory Neurological

28 (12.0%) 14 (6.0%)

10 (8.1%) 20 (10.2%)

Other 16 (6.8%) 12 (6.1%)

Multiple (≥3) health problems 75 (18.9%) 43 (9.8%)

Seen clinician in past 30 days Ever used Foodbank

226 (56.9%) 30 (7.6%)

226 (51.5%) 2 (0.5%)

Smoking and Drinking

Regular Smokers 146 (36.8%) 43 (9.8%)

Cigarettes per day (in smokers) 10.2 0.27

Drinking Alcohol 227 (57.2%) 333 (75.9%)

Units per week (in drinkers) 11.9 9.7

∂

Baseline results -Environmental Factors

Baseline Characteristics of Stockton Health Inequalities Survey

Most deprived N=397

Least deprived N=439

Environmental factors

Housing suffers from damp Housing is too dark Housing is not warm enough Noise from neighbours/street Area has pollution/grime Area has crime/vandalism Feel safe walking after dark

101 (25.4%) 72 (18.1%) 78 (19.7%) 91 (22.9%) 52 (13.1%) 111 (28.0%) 252 (63.5%)

10 (2.3%) 41 (9.3%) 29 (6.6%) 46 (10.5%) 15 (3.4%) 28 (6.4%)

406 (92.5%)

∂

Baseline results- Health Behaviours

Baseline Characteristics of Stockton Health Inequalities Survey

Most deprived N=397

Least deprived N=439

Health Behaviours

Regular Smokers 146 (36.8%) 43 (9.8%)

Cigarettes per day (in smokers) 10.2 0.27

Drinking Alcohol 227 (57.2%) 333 (75.9%)

Units per week (in drinkers) Fruit and Veg Portions per day Take weekly or more exercise Weekly exercise (minutes) Body mass index (BMI)

11.9 2.9

252 (63.5%) 469

27.34

9.7 4.0

312 (71.1%) 309

25.74

∂

Baseline results -Validated health measures

Health Scores

Most Deprived

Least Deprived

EQ5D

(UK Norm =0.86)

0.749 0.868

EQ-VAS

(UK Norm = 82.48)

63.5 74.1

WEDMHS

(UK Norm =51.6)

49.67 54.65

SF8- PCS

(UK Norm = 52.1)

45.49 50.03

SF-8 MCS

(UK Norm= 50.9)

49.5 53.46

BMI

(25-30 = overweight)

27.34 25.74

∂

What is the gap in mental wellbeing?

5 point

difference

between the

two areas

∂

Social Determinants of Mental

Wellbeing – Model

Material – Socioeconomic Material – Physical

environment

Psychosocial Behavioural

Housing Tenure Are there problems with damp in

the home

How often does the

participant meet socially with

friends, family or work

colleagues

Does the

participant smoke

Is anyone in the household in

receipt of benefits

Is the home too dark, not

enough light

How safe would the

participant feel walking alone

after dark

Does the

participant drink

alcohol

Is the household in receipt of

housing benefit

Is the household warm enough

in winter

How often does the

participant feel they lack

companionship

Weekly alcohol

consumption

Is the participant in paid

employment

Are there problems with noise in

the neighbourhood

How often does the

participant feel left out

Daily portions of

fruit and

vegetables

Is this a workless household Is there pollution, grime or

environmental problems in the

neighbourhood

How often does the

participant feel isolated from

others

Frequency of

physical exercise

Household income Is there crime in the

neighbourhood

Happiness scale

Highest educational level

∂

Housing Tenure WEMWBS Score and Housing Tenure Most or least deprived

area

In which way do you

occupy your home

Mean N Std. Deviation

Least Deprived Own outright 56.02 195 8.714

Buy with help of

mortgage or loan

53.78 138 10.570

Rent it 55.30 44 12.132

Live there rent free 65.00 2 7.071

Total 55.17 379 9.896

Most Deprived Own outright 52.38 61 9.134

Buy with help of

mortgage or loan

53.57 37 13.152

Rent it 49.03 255 12.628

Live there rent free 48.75 4 10.996

Total 50.07 357 12.220

∂

Causes?

• Housing benefit

• Housing tenure

• Household income

• Pollution/environmental problems

Material

• Alcohol Use

• Frequency of physical exercise Behavioural

• How often the person feels ‘left out’

• Happiness PsychoSocial

∂

Baseline Causal ModelWEMWBS

Warwick Edinburgh Mental Wellbeing Scale Baseline Causal Model

Model Estimate Lower Cl Upper

CI

Percentage

Change

1. Age and Gender Adjusted 5.04 3.42 6.66

5. Psychosocial + Behavioural 1.91 0.59 3.23 62.0

6. Material and Behavioural 0.46 -1.66 2.57 90.9

7. Material and Psychosocial 0.15 -1.59 1.90 96.9

8. FULL MODEL (Material and

Psychosocial and Behavioural) 0.07 -1.64 1.79 98.6

Direct Effects of Material % 36.51

(Material Physical 4.56%, Material Socioeconomic 32%)

Direct Effects of Psychosocial % 7.61

Direct Effects of Behavioural % 1.61

Indirect Effects % 52.81

∂

Conclusions

• Material (socioeconomic) factors have the largest direct effects on the

gap in mental wellbeing in Stockton-on-Tees.

• However there are very large indirect effects.

• The presence of psychosocial and behavioural determinants will

aggravate the impact of material factors on the gap in mental wellbeing.

∂

Getting response (data collection) 1st Follow up baseline plus 6 months

Final score

• January 2015- 515 surveys complete; a follow up rate of 61.8%

• 229 most deprived areas; a follow up rate 57.7%

• 286 least deprived areas; a follow up rate 65.2%

∂

Getting response (data collection) 2nd Follow up baseline plus 12 months

Final score

• July 2015- 478 surveys complete; a follow up rate of 92.8%

• 218 most deprived areas; a follow up rate of 95.2%

• 260 least deprived areas; a follow up rate of 91%

∂

Next Steps……

•We digitised our data….SPSS- labour intensive process

•We developed a telephone questionnaire

•First follow-up wave telephone interviews took place Oct-Dec 2014

•Second follow-up wave telephone interviews began in May 2015

•Analysis of baseline data- health outcomes and health determinants

(ongoing)