Deprivation Category Research Articles

Pre-notification Increases Uptake of Colorectal Cancer Screening in All Demographic Groups: A Randomized Controlled Trial

To assess whether pre-notification is effective in increasing uptake of colorectal cancer screening for all demographic groups. Scottish national colorectal cancer screening programme. Males and females aged 50-74 years received a faecal occult blood test by post to complete at home. They were randomized to receive in addition: the pre-notification letter, the pre-notification letter + information booklet, or the usual invitation. Overall, 59,953 subjects were included in the trial between 13/04/09 and 29/05/09 and followed to 27/11/09. Pre-notification letters were posted two weeks ahead of the screening test kit. Uptake was defined as the return of a screening test and chi-squared tests compared uptake between the trial arms. Logistic regression assessed the impact of the letter and letter + booklet on uptake independently of gender, age, deprivation and screening round. Uptake was higher with both the letter (59.0%) and the letter + booklet (58.5%) compared with the usual invitation (53.9%, p < 0.0001). This increased uptake was seen for males, females, all age groups and all deprivation categories including least deprived females (letter 69.9%, usual invitation 66.6%) and most deprived males (42.6% vs. 36.1%), the groups with the highest and lowest levels of uptake respectively in the pilot screening rounds conducted prior to the roll out of the programme. Uptake with the pre-notification letter compared with the usual invitation was higher both unadjusted and adjusted for demographic factors (odds ratio 1.24, 95% CI 1.193-1.294). Pre-notification is an effective method of increasing uptake in colorectal cancer screening for both genders and all age and deprivation groups.

Quality of Life in People with Type 2 Diabetes in Relation to Deprivation, Gender, and Age in a New Community-Based Model of Care

Objectives. To evaluate changes in health related quality of life (HRQL) for individuals with Type 2 diabetes following the introduction of a new community-based model of care. Methods. A survey method was used in which HRQL, Problems Areas In Diabetes (PAID) and demographics were assessed before and 18 months after introducing the new service. Results. Overall HRQL and PAID scores were lower than published levels in individuals with diabetes but remained stable during the transition to the new model of care except for the bodily pain domain and deteriorating PAID scores for older patients. Four domains of SF36 health showed deterioration in the highest socio-economic groups. Deterioration was also observed in males, most notably mental health, in patients aged 54 years or less, 75 years or more and patients from socio-economic groups 1 and 2. HRQL was lowest at baseline and follow-up in socio-economic groups 6 & 7. Low levels of distress in patients across all deprivation categories was observed but remained stable over the transition. Conclusions. HRQL and distress associated with diabetes remained stable following the introduction of the new community-based model of care except for deterioration in the bodily pain domain and deteriorating PAID scores for older patients. Relevance for Practice. (i) Health related quality of life assessment is practical and acceptable to patients. (ii) In clinical governance terms it is good practice to monitor the impact of change in service delivery on the health of the patients in your care. (iii) Screening with health related quality of life tools such as generic and disease specific tools could help identify health problems otherwise undetected within current clinical care. Systematic identification of the most vulnerable groups with Type 2 diabetes should allow care to be better targeted.

036 Socio-economic inequalities in cancer survival in England after the NHS cancer plan

ObjectivesSocio-economic inequalities in survival have been reported for most adult cancers in England. The NHS Cancer Plan (2000) aimed to improve cancer patient survival, and tackle inequalities in survival between...

063 Population ageing in Scotland: an analysis of the implications for healthcare expenditure using the Renfrew/Paisley study

ObjectiveIt is important for health policy and expenditure projections to fully understand the relationship between age, death and expenditure for health care (HC). Evidence shows that older age groups incur...

039 Regional disparities in cancer survival following the NHS National Cancer Plan for England: an analysis by cancer network

ObjectiveReducing geographic inequalities in survival from cancer in England was a key aim of the Calman-Hine Report (1995) and the NHS Cancer Plan (2000). In this paper we assess whether...

P36 Distribution of physical activity amenities in Scotland by small area measures of deprivation and urbanicity

ObjectiveObesity and physical activity are associated with aspects of the physical environment where people live, but the precise mechanisms of these associations are not well understood. Knowledge of the extent...

Inequalities in cancer survival and the NHS cancer plan: evidence of progress?

Inequalities in cancer survival and the NHS cancer plan: evidence of progress?

A Small-area Ecologic Study of Myocardial Infarction, Neighborhood Deprivation, and Sex

Socioeconomic inequalities in the risk of coronary heart disease (CHD) are well documented for men and women. CHD incidence is greater for men but its association with socioeconomic status is usually found to be stronger among women. We explored the sex-specific association between neighborhood deprivation level and the risk of myocardial infarction (MI) at a small-area scale. We studied 1193 myocardial infarction events in people aged 35-74 years in the Strasbourg metropolitan area, France (2000-2003). We used a deprivation index to assess the neighborhood deprivation level. To take into account spatial dependence and the variability of MI rates due to the small number of events, we used a hierarchical Bayesian modeling approach. We fitted hierarchical Bayesian models to estimate sex-specific relative and absolute MI risks across deprivation categories. We tested departure from additive joint effects of deprivation and sex. The risk of MI increased with the deprivation level for both sexes, but was higher for men for all deprivation classes. Relative rates increased along the deprivation scale more steadily for women and followed a different pattern: linear for men and nonlinear for women. Our data provide evidence of effect modification, with departure from an additive joint effect of deprivation and sex. We document sex differences in the socioeconomic gradient of MI risk in Strasbourg. Women appear more susceptible at levels of extreme deprivation; this result is not a chance finding, given the large difference in event rates between men and women.

Effect of Gender, Age and Deprivation on Key Performance Indicators in a Fobt-based Colorectal Screening Programme

To assess the effect of gender, age and deprivation on key performance indicators in a colorectal cancer screening programme. Between March 2000 and May 2006 a demonstration pilot of biennial guaiac faecal occult blood test (gFOBT) colorectal screening was carried out in North-East Scotland for all individuals aged 50-69 years. The relevant populations were subdivided, by gender, into four age groups and into five deprivation categories according to the Scottish Index of Multiple Deprivation (SIMD), and key performance indicators analysed within these groups. In all rounds, uptake of the gFOBT increased with age (P < 0.001), decreased with increasing deprivation in both genders (P < 0.001), and was consistently higher in women than in men in all age and all SIMD groups. In addition, increasing deprivation was negatively associated with uptake of colonoscopy in men with a positive gFOBT (P < 0.001) although this effect was not observed in women. Positivity rates increased with age (P < 0.001) and increasing deprivation (P < 0.001) in both genders in all rounds, although they were higher in men than in women for all age and SIMD categories. Cancer detection rates increased with age (P < 0.001), were higher in men than in women in all age and SIMD categories, but were not consistently related to deprivation. In both genders, the positive predictive value (PPV) for cancer increased with age (P < 0.001) and decreased with increasing deprivation (P < 0.001) in all rounds and was consistently higher in men than in women in all age and SIMD categories. In this population-based colorectal screening programme gender, age, and deprivation had marked effects on key performance indicators, and this has implications both for the evaluation of screening programmes and for strategies designed to reduce inequalities.

Trends in skin cancer incidence by socioeconomic position in Scotland, 1978–2004

Background:Non-melanoma skin cancer has been little studied in relation to deprivation.Methods:Incident cases diagnosed in 1978–2004 were extracted from the Scottish Cancer Register and assigned to quintiles of Carstairs deprivation scores. Age-standardised incidence rates (ASRs) (European standard population) were calculated by deprivation quintile, sex, period of diagnosis, for the three main types of skin cancer.Results and conclusion:As age-standardised incidence of each skin cancer increased significantly over time across all deprivation categories, rates were consistently highest in the least deprived quintile.

Institutional Design and Ethnic Violence: Do Grievances Help to Explain Ethnopolitical Instability?

Recent research on the motives of civil war has been dominated by the juxtaposition of greed versus grievance factors. This academic debate has generated a vast amount of empirical evidence to assess the explanatory power of the grievance concept but neglected its non-empirical limitations. In an attempt to direct attention back to the theoretical and methodological issues surrounding the grievance concept, the purpose of this analysis is twofold: first, I outline a grievance-based explanation of ethnic violence which argues that political institutions that provide low chances of political representation are likely to increase the odds of ethnic violence due to the intrinsic worth of political representation, its impact on the distribution of resources and powers, and its effects on perceptions of security. This explanation then serves, second, as a reference point to highlight three non-empirical limitations of the grievance concept, namely the lack of direct measures for grievances, the failure to identify clear reference categories of relative deprivation and the questionable assumption that all ethnic groups share common values. I conclude that due to these limitations, scholars working with the grievance concept inevitably remain in the realm of conjectures without being able to test the causal mechanisms they stipulate properly.

Non-fatal injuries in three Central and Eastern European urban population samples: the HAPIEE study

Background: Despite high mortality from injuries and accidents, data on rates and distribution of non-fatal injuries in Central and Eastern European populations are scarce. Methods: Cross-sectional study of random population samples of 45–69-year-old men and women (n = 28 600) from Novosibirsk (Russia), Krakow (Poland) and six Czech towns, participating in the Health, Alcohol and Psychosocial factors In Eastern Europe (HAPIEE) study. Participants provided information on non-fatal injuries in the past 12 months, socio-economic characteristics, alcohol consumption and other covariates. Results: The period prevalence of non-fatal injuries in the last year among Czech, Russian and Polish men was 12.5, 9.4 and 5.3%, respectively; among women, the respective proportions were 9.9, 9.8 and 6.4%. Injury prevalence declined with age in men and increased with age in women. Higher injury prevalence was associated with being unmarried, material deprivation, higher drinking frequency and problem drinking. In the pooled data, the adjusted odds ratio (OR) for the highest versus lowest material deprivation category was 1.57 [95% confidence interval (CI) 1.38–1.79]; for problem drinking, the OR was 1.44 (95% CI 1.23–1.69). Alcohol did not mediate the link between socio-economic status and injury. Conclusion: Non-fatal injuries were associated with material deprivation, other socio-economic characteristics and with alcohol. These results not only underscore the universality of the inequality phenomenon, but also suggest that the mediating role of alcohol in social differentials in non-fatal injury remains an unresolved issue.

Proximity to Industrial Polluting Sources and Socioeconomic Status-An Environmental Equity Study on A Small-Area Scale

ISEE-0466 Background & Objective: Territorial disparities in exposure to environmental hazards according to socioeconomic status (SES) contradict the principle of environmental justice, which states that no population group should suffer a disproportionate burden of exposure. In this work, which is the first phase of an epidemiological study on environmental risk factors of perinatal mortality, we investigated the association between proximity to industrial pollution sources and SES at small-area level and assessed the impact of different proximity indicators on the measure of the association. Methods: An ecological study was conducted in the Lille Metropolitan Area (LMA). We used a validated deprivation index, constructed from 1999 census data, to estimate SES at the French census block level (n = 453; 1,100,000 inhabitants). Information on industrial air emissions in 2006 was drawn from the French database of the European Pollutants Emission Register. Several industrial proximity indicators were estimated and sensitivity analysis was performed to investigate their influence on the association with SES while controlling for spatial autocorrelation in the data. We present here results using a Multi-Site Proximity Index (MSPI), a cumulative distance measure between census block centroids and each facility. Results: Significant spatial autocorrelation was detected in SES and location of industries. Spatial distributions of industries show a clear pattern, with a higher number located in the most deprived areas, near the LMA center. The MSPI differ significantly between deprivation categories (P < 0.001), with the lowest MPSI in the most disadvantaged blocks (geometric mean: 499,286 km [95%CI = 482,959-516,166] in category 5) and the greatest in the wealthiest ones (559,083 km [95%CI = 533,197; 588,225] in category 1). Inclusion of emission levels in the MSPI sharpens the contrasts. Conclusion: Deprived populations experience a greater exposure to industrial pollution. Substantial exposure misclassification may result from a poor choice of proximity metrics in environmental equity analyses and may lead to erroneous conclusions.

Assessing the Role of Individual and Neighbourhood Characteristics in HIV Testing: Evidence from a Population Based Survey

Objectives:Individuals living in deprived neighbourhoods have poor health outcomes, including human immunodeficiency virus (HIV) infection mortality. We assessed the association between individual and neighbourhood characteristics, and HIV testing across Canada.Methods:We used logistic regression modelling to evaluate this association in 2219 men and 2815 women, aged 18-54 years, in Canada, using data from the National Population Health Survey (1996/7),. Socio-economic characteristics and presence of a sexually transmitted infection (STI) were the individual level characteristics. Small area of residence was classified according to categories of material and social deprivation; these were the ’neighbourhood’ variables in the model.Results:Ethnic minority women were less likely to report an HIV test than white women (OR 0.44, 95% CI: 0.23 to 0.86). Women without a regular doctor were significantly less likely to report ever having had an HIV test (OR 0.57, 95% CI: 0.35 to 0.93). Adjusting for individual level characteristics, we found that men and women living in the most materially deprived neighbourhoods were slightly less likely to report HIV testing than those living in the least deprived neighbourhoods (Men - OR 0.61, 95% CI: 0.34 to 1.08; Women - OR 0.62, 95% CI: 0.38 to 1.00).Discussion:Thus, living in poor neighbourhoods was associated with poor uptake of an HIV test. These economic disparities should be taken in account while designing future prevention strategies. Ethnic minority women were less likely to go for HIV testing and culturally appropriate messages may be required for prevention in ethnic minorities.

The risk factors for unexplained antepartum stillbirths in Scotland, 1994 to 2003

Objective:To determine the factors contributing to unexplained antepartum stillbirth in Scotland.Study Design:A 10-year birth database in Scotland was used to compare the unexplained antepartum stillbirth with other birth outcomes. The sample unit was a pregnant mother with a gestational age of 20 weeks and above and with a fetal birth weight of 200 g and above.Result:Maternal age of 35 years and above, lower deprivation category, inaccessible area of residence, maternal smoking, maternal height of <160 cm and gestational age of above 39 weeks were significantly associated with unexplained antepartum stillbirth. In multivariable analysis only maternal age (adjusted odds ratio (OR): 1.8, confidence interval (CI): 1.1 to 3.0, P=0.02), smoking during pregnancy (adjusted OR: 2.0, CI: 1.1 to 3.5, P=0.02), and maternal height (adjusted OR: 1.4, CI: 1.1 to 1.8, P=0.01), remain significant. Screening of pregnancies based on these three risk factors had 4.2% sensitivity and 99.4% specificity. The prevalence of stillbirth for this population was 0.2%. A positive predictive value of only 1.2% implies that only 1 in 83 women with these three risk factors will have antepartum stillbirth. The remaining 82 will suffer needless anxiety and potentially diagnostic procedures.Conclusion:Advanced maternal age, maternal smoking, and shorter maternal height were associated risk for unexplained antepartum stillbirth but screening based on these factors would be of limited value.

A multiple indicator, multiple cause method for representing social capital with an application to psychological distress

This paper describes a structural equation methodology for obtaining social capital scores for survey subjects from multiple indicators of social support, neighbourhood and trust perceptions, and memberships of organizations. It adjusts for variation that is likely to occur in levels of social capital according to geographic context (e.g. level of area deprivation, geographic region, level of urbanity) and demographic group. Social capital is used as an explanatory factor for psychological distress using data from the 2006 Health Survey for England. A highly significant effect of social capital in reducing the chance of psychiatric caseness is obtained after controlling for other individual and geographic risk factors. Allowing for social capital has considerable effects on the impacts on psychiatric health of other risk factors. In particular, the impact of area deprivation category is much reduced. There is also evidence of significant differentiation in social capital between population categories and geographic contexts.

Does deprivation index modify the acute effect of black smoke on cardiorespiratory mortality?

ObjectivesTo investigate whether deprivation index modifies the acute effect of black smoke on cardiorespiratory mortality.MethodsGeneralised linear Poisson regression models were used to investigate whether deprivation index (as measured by the...

Increasing socioeconomic inequalities in first acute myocardial infarction in Scotland, 1990–92 and 2000–02

BackgroundDespite substantial declines, Ischaemic Heart Disease (IHD) remains the largest cause of death in Scotland and mortality rates are among the worst in Europe. There is evidence of strong, persisting regional and socioeconomic inequalities in IHD mortality, with the majority of such deaths being due to Acute Myocardial Infarction (AMI). We examine the changes in socioeconomic and geographic inequalities in first AMI events in Scotland and their interactions with age and gender.MethodsWe used linked hospital discharge and death records covering the Scottish Population (5.1 million). Risk ratios (RR) of AMI incidence by area deprivation and age for men and women were estimated using multilevel Poisson modelling. Directly standardised rates were presented within these stratifications.ResultsDuring 1990–92 74,213 people had a first AMI event and 56,995 in 2000–02. Adjusting for area deprivation accounted for 59% of the geographic variability in AMI incidence rates in 1990–92 and 33% in 2000–02. Geographic inequalities in male incidence reduced; RR for smaller areas (comparing area on 97.5th centile to 2.5th) reduced from 1.42 to 1.19. This was not true for women; RR increased from 1.45 to 1.59. The socioeconomic gradient in AMI incidence increased over time (p-value < 0.001) but this varied by age and gender. The gradient across deprivation categories for male incidence in 1990–92 was most pronounced at younger ages; RR of AMI in the most deprived areas compared to the least was 2.6 (95% CI: 1.6–4.3) for those aged 45–59 years and 1.6 (1.1–2.5) at 60–74 years. This association was also evident in women with even stronger socioeconomic gradients; RRs for these age groups were 4.4 (3.4–5.5), and 1.9 (1.7–2.2). Inequalities increased by 2000–02 for both sexes; RR for men aged 45–59 years was 3.3 (3.0–3.6) and for women was 5.6 (4.1–7.7)ConclusionRelative socioeconomic inequalities in AMI incidence have increased and gradients are steepest in young women. The geographical patterning of AMI incidence cannot be fully explained by socioeconomic deprivation. The reduction of inequalities in AMI incidence is key to reducing overall inequalities in mortality and must be a priority if Scotland is to achieve its health potential.

Population-based cancer survival trends in England and Wales up to 2007: an assessment of the NHS cancer plan for England

The National Health Service (NHS) cancer plan for England was published in 2000, with the aim of improving the survival of patients with cancer. By contrast, a formal cancer strategy was not implemented in Wales until late 2006. National data on cancer patient survival in England and Wales up to 2007 thus offer the opportunity for a first formal assessment of the cancer plan in England, by comparing survival trends in England with those in Wales before, during, and after the implementation of the plan. We analysed population-based survival in 2.2 million adults diagnosed with one of 21 common cancers in England and Wales during 1996-2006 and followed up to Dec 31, 2007. We defined three calendar periods: 1996-2000 (before the cancer plan), 2001-03 (initialisation), and 2004-06 (implementation). We estimated year-on-year trends in 1-year relative survival for patients diagnosed during each period, and changes in those trends between successive periods in England and separately in Wales. Changes between successive periods in mean survival up to 5 years after diagnosis were analysed by country and by government office region of England. Life tables for single year of age, sex, calendar year, deprivation category, and government office region were used to control for background mortality in all analyses. 1-year survival in England and Wales improved for most cancers in men and women diagnosed during 1996-2006 and followed until 2007, although not all trends were significant. Annual trends were generally higher in Wales than in England during 1996-2000 and 2001-03, but higher in England than in Wales during 2004-06. 1-year survival for patients diagnosed in 2006 was over 60% for 12 of 17 cancers in men and 13 of 18 cancers in women. Differences in 3-year survival trends between England and Wales were less marked than the differences in 1-year survival. North-South differences in survival trends for the four most common cancers were not striking, but the North West region and Wales showed the smallest improvements during 2001-03 and 2004-06. The findings indicate slightly faster improvement in 1-year survival in England than in Wales during 2004-06, whereas the opposite was true during 2001-03. This reversal of survival trends in 2001-03 and 2004-06 between England and Wales is much less obvious for 3-year survival. These different patterns of survival suggest some beneficial effect of the NHS cancer plan for England, although the data do not so far provide a definitive assessment of the effectiveness of the plan.

Fluoride rinsing and dental health inequalities in 11‐year‐old children: an evaluation of a supervised school‐based fluoride rinsing programme in Edinburgh

Previous studies have shown that fluoride mouthrinsing programmes are effective in reducing caries among children and adolescents. National surveys of child dental health in the UK confirm that there is variation in oral health. In particular, children of low socioeconomic status in Scotland have a disproportionately high share of dental disease. This study aimed to evaluate an existing school-based fluoride mouthrinsing programme on dental caries in populations stratified by socioeconomic status. A random sample of 1333 children surveyed by the National Dental Inspection Programme with average age 11.4 years was included in the study. Caries prevalence data were collected for the 661 rinsers and 672 nonrinsers. Chi-squared tests and t-tests were carried out to test differences in proportion and in mean D(3)MFT, respectively. The data were modelled using multilevel logistic regression, adjusting for age, sex, deprivation and rinse status. There is a strong negative association between deprivation and prevalence of D(3)MFT = 0. There is no significant difference in prevalence of D(3)MFT between rinsers and nonrinsers, however, mean D(3)MFT is greater for nonrinsers within each deprivation category. After adjusting for age, sex and deprivation, the odds of a tooth being decayed missing or filled for a child who rinsed are 0.79 (0.64, 0.98) compared with those of a child who did not. Fluoride rinsing can be effectively targeted at children from deprived areas through school-based initiatives. There are some difficulties in recruiting all children from the more deprived backgrounds, but overall reductions in D(3)MFT were observed.