a longitudinal study of health inequalities in stockton on ... · why stockton? stockton on tees...
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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)