Deprived Individuals Research Articles

Digital financial inclusion and inclusive development in lower-middle-income countries: the enabling role of institutional quality

PurposeThis study aims to explore how institutional quality links digital financial inclusion to inclusive development in lower-middle-income countries, considering heterogeneities.Design/methodology/approachThe study uses dynamic generalized method of moments to analyze a balanced panel data set of 48 lower-middle- income countries (LMICs) from 2004 to 2022, sourced from various databases. It assesses four variables and conducts checks for study robustness.FindingsThe study reveals a positive link between digital financial inclusion and inclusive development in LMICs, confirming theoretical predictions. Empirically, nations with quality institutions exhibit greater financial and developmental inclusion than those with weak institutions, emphasizing the substantial positive impact of institutional quality on the connection between digital financial inclusion and inclusive development in LMICs. For instance, the interaction effect reveals a substantial increase of 0.123 in inclusive development for every unit increase in digital financial inclusion in the presence of strong institutions. The findings provide robust empirical evidence that the presence of quality institutions is a key catalyst for the benefits of digital finance in inclusive development.Originality/valueThis study offers significant insights into digital financial inclusion and inclusive development in LMICs. It confirms a positive relationship between digital financial inclusion and inclusive development, highlighting the pivotal role of institutional quality in amplifying these benefits. Strong institutions benefit deprived individuals, families, communities and businesses, enabling full access to digital financial inclusion benefits. This facilitates engagement in development processes, aiding LMICs in achieving Sustainable Development Goals.

Deprivation as a fundamental cause of morbidity and reduced life expectancy: an observational study using German statutory health insurance data.

Across all developed countries, there is a steep life expectancy gradient with respect to deprivation. This paper provides a theoretical underpinning for this gradient in line with the Grossman model, indicating that deprivation affects morbidity and, consequently, life expectancy in three ways: directly from deprivation to morbidity, and indirectly through lower income and a trade-off between investments in health and social status. Using rich German claims data covering 6.3 million insured people over four years, this paper illustrates that deprivation increases morbidity and reduces life expectancy. It was estimated that highly deprived individuals had approximately two more chronic diseases and a life expectancy reduced by 15years compared to the least deprived individuals. This mechanism of deprivation is identified as fundamental, as deprived people remain trapped in their social status, and this status results in health investment decisions that affect long-term morbidity. However, in the German setting, the income and investment paths of the effects of deprivation were of minor relevance due to the broad national coverage of its SHI system. The most important aspects of deprivation were direct effects on morbidity, which accumulate over the lifespan. In this respect, personal aspects, such as social status, were found to be three times more important than spatial aspects, such as area deprivation.

Risk of winter hospitalisation and death from acute respiratory infections in Scotland: national retrospective cohort study.

We undertook a national analysis to characterise and identify risk factors for acute respiratory infections (ARIs) resulting in hospitalisation during the winter period in Scotland. A population-based retrospective cohort analysis. Scotland. The study involved 5.4 million residents in Scotland. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for the association between risk factors and ARI hospitalisation. Between 1 September 2022 and 31 January 2023, there were 22,284 (10.9% of 203,549 with any emergency hospitalisation) ARI hospitalisations (1759 in children and 20,525 in adults) in Scotland. Compared with the reference group of children aged 6-17 years, the risk of ARI hospitalisation was higher in children aged 3-5 years (aHR = 4.55; 95% CI: 4.11-5.04). Compared with those aged 25-29 years, the risk of ARI hospitalisation was highest among the oldest adults aged ≥80 years (aHR = 7.86; 95% CI: 7.06-8.76). Adults from more deprived areas (most deprived vs. least deprived, aHR = 1.64; 95% CI: 1.57-1.72), with existing health conditions (≥5 vs. 0 health conditions, aHR = 4.84; 95% CI: 4.53-5.18) or with history of all-cause emergency admissions (≥6 vs. 0 previous emergency admissions, aHR = 7.53; 95% CI: 5.48-10.35) were at a higher risk of ARI hospitalisations. The risk increased by the number of existing health conditions and previous emergency admission. Similar associations were seen in children. Younger children, older adults, those from more deprived backgrounds and individuals with greater numbers of pre-existing conditions and previous emergency admission were at increased risk for winter hospitalisations for ARI.

Pravo na povahu do pryvatnoho i simeinoho zhyttia dlia zasudzhenykh do dovichnoho pozbavlennia voli u svitli praktyky Yevropeiskoho sudu z prav liudyny shchodo Ukrainy: stan doslidzhennia problemy v ukrainskii naukovii literaturi

Guaranteed by the Constitution of Ukraine and Article 8 of the Convention for the Protection of Human Rights and Fundamental Freedoms of 1950, the right to respect for private and family life for those sentenced to life imprisonment, in terms of its implementation and scope, differs from this right for free individuals. But it is undeniable that those sentenced to life imprisonment are not deprived of this right in full. This is consistently emphasized in its practice by the European Court of Human Rights. In addition to private and family life being a natural need of every individual, its realization, particularly in forms such as maintaining and supporting connections with the outside world, is a means of re-socialization for individuals undergoing punishment in the form of life imprisonment. The benchmark for the development of Ukrainian legislation and law enforcement practice is the practice of the European Court of Human Rights. Therefore, the legal positions of the European Court of Human Rights regarding the right to respect for private and family life for those sentenced to life imprisonment should be studied and generalized. The precondition for the further development of any scientific direction is the comprehension of what has already been done by previous researchers. The conducted research has shown that Ukrainian scientific literature has addressed the legal positions of the European Court of Human Rights regarding various aspects of the right to respect for the private and family life of prisoners, broadly understood (including those in custody, sentenced to a certain term of imprisonment, and those sentenced to life imprisonment): 1) the conclusion that the restriction of the right to respect for private and family life for persons deprived of liberty, provided it is lawful, is not incompatible with the Convention; 2) the conditions/criteria for the legality of such restriction, implemented by national authorities; 3) the systematic identification of the main types of violations of the right to respect for family life recorded in the decisions of the European Court of Human Rights regarding convicted persons and persons in custody; 4) special protection of correspondence between an inmate and their lawyer; 5) differentiation of the spheres of application of Article 8 with other articles of the Convention, primarily Article 3; 6) determination of the main trend in the practice of the European Court of Human Rights «in the penitentiary sphere and in the criminal justice system as a whole,» which consists of constantly raising the standards of human rights by the Court; 7) ignoring the need for an individual approach in applying restrictions on the rights of persons deprived of liberty. The analysis of the existing body of scientific literature shows that existing studies are mainly based on the analysis of the European Court of Human Rights practice regarding foreign states and, with one exception, do not distinguish the legal status of those sentenced to life imprisonment among other deprived individuals. Since the publication of the analyzed monographs, 9–10 years have passed. During this time, the European Court of Human Rights has developed a significant body of practice regarding Ukraine, taking into account the Ukrainian context. Therefore, the analysis of the European Court of Human Rights decisions specifically regarding Ukraine should be a priority. Additionally, they should be analyzed in full. Such an analysis will allow, in conjunction with demonstrating the Convention’s standards regarding the right of those sentenced to life imprisonment to respect for their private and family life, to show the systematic and partial problems in this area identified by the European Court of Human Rights in its practice regarding Ukraine.

Association of neighbourhood-level material deprivation with adverse outcomes and processes of care among patients with heart failure in a single-payer healthcare system: A population-based cohort study.

We studied the association between neighbourhood material deprivation, a metric estimating inability to attain basic material needs, with outcomes and processes of care among incident heart failure patients in a universal healthcare system. In a population-based retrospective study (2007-2019), we examined the association of material deprivation with 1-year all-cause mortality, cause-specific hospitalization, and 90-day processes of care. Using cause-specific hazards regression, we quantified the relative rate of events after multiple covariate adjustment, stratifying by age ≤65 or ≥66 years. Among 395 763 patients (median age 76 [interquartile range 66-84] years, 47% women), there was significant interaction between age and deprivation quintile for mortality/hospitalization outcomes (p ≤ 0.001). Younger residents (age ≤65 years) of the most versus least deprived neighbourhoods had higher hazards of all-cause death (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.10-1.29]) and cardiovascular hospitalization (HR 1.29 [95% CI 1.19-1.39]). Older individuals (≥66 years) in the most deprived neighbourhoods had significantly higher hazard of death (HR 1.11 [95% CI 1.08-1.14]) and cardiovascular hospitalization (HR 1.13 [95% CI 1.09-1.18]) compared to the least deprived. The magnitude of the association between deprivation and outcomes was amplified in the younger compared to the older age group. More deprived individuals in both age groups had a lower hazard of cardiology visits and advanced cardiac imaging (all p < 0.001), while the most deprived of younger ages were less likely to undergo implantable cardioverter-defibrillator/cardiac resynchronization therapy-pacemaker implantation (p = 0.023), compared to the least deprived. Patients with newly-diagnosed heart failure residing in the most deprived neighbourhoods had worse outcomes and reduced access to care than those less deprived.

Temporal trends and patterns in cause-specific mortality and hospitalisations after incident atrial fibrillation in England from 2001 to 2017

Abstract Background Atrial fibrillation (AF) incidence is increasing, and in high income countries outstrips that of many cancers.(1) Following AF diagnosis reports of temporal trends of mortality are conflicting,(2-7) whilst reports of hospitalisation provide an incomplete picture of drivers of admission.(4,8) Purpose To investigate trends in cause-specific mortality and hospitalisation for patients with incident AF, including by age, sex, socioeconomic status and diagnostic care setting. Methods We used linked primary and secondary care records of 72 412 patients in England aged ≥16 years with incident AF between Jan 1, 2001 and Dec 31, 2017. The primary outcomes were all-cause and cause-specific mortality and hospitalisation at 1 year following diagnosis. Poisson regression estimated rate ratios (RRs) with 95% confidence intervals (CIs) comparing 2001/02 and 2016/17, adjusted for age, sex, region, socioeconomic status and 18 major comorbidities. Results Mean age at diagnosis was 75·6 years (SD 12·4), and 44 762 (61·8%) had ≥3 comorbidities. One-year mortality following incident AF was 20·0% and declined over the study period (RR 2016/17 vs. 2001/02, 0·72; 95% CI, 0·65–0·80) with larger declines for cardiovascular (RR 0·46; 95% CI, 0·37-0·58) and cerebrovascular mortality (RR 0·41; 95% CI, 0·29–0·60) than other causes of death (Figure 1). By 2016/17 dementia (67, 8·0%) accounted for more deaths than myocardial infarction, heart failure and acute stroke combined (56, 6·7%), and for patients aged ≥80 years death from non-cardio/cerebrovascular causes did not decline (RR 1·05; 95% CI 0·88–1·25). Mortality was higher for patients in the most deprived socioeconomic quintile compared with those in the least deprived quintile (RR 1·22; 95% CI 1·15–1·29), and for those diagnosed in hospital compared with primary care (RR 2·58; 95% CI 2·48-2·68), but similar between men and women. Hospitalisation within the first year after AF diagnosis was high (1·72 hospitalisations per patient-year at risk), with infection the most common cause and cardio/cerebrovascular diseases representing less than a fifth of all admissions (Figure 2). Hospitalisations increased (RR 1·17; 95% CI 1·13-1·22), driven by admissions for non-cardio/cerebrovascular causes (RR 1·42; 95% CI 1·39-1·45). Individuals aged ≥80 years experienced a greater increase in hospitalisation compared with younger individuals (RR 1·39, 95% CI 1·30-1·48) particularly for non-cardio/cerebrovascular causes (RR 1·54, 95% CI 1·44-1·65). Patterns for hospital admissions by sex and diagnostic setting were similar to those observed for mortality, but frequency of hospitalisation was similar between most and least deprived individuals. Conclusion For patients newly diagnosed with AF, cardiovascular and cerebrovascular mortality has declined, and hospitalisations for non-cardio/cerebrovascular diseases increased. The changing outcomes of AF require new strategies to reduce its health burden.Figure 1:Temporal trends in mortalityFigure 2:Temporal trends in admission

Personal relative deprivation impairs the ability to inhibit impulsive responses: an exploratory ERP study.

Evidence indicates that personal relative deprivation (PRD) can lead to various impulsive behaviors. Given that impulsive behaviors are usually caused by a failure to exert cognitive control, the purpose of this study was to explore whether PRD affects the ability to exert cognitive control on behavior. Forty-six healthy participants were randomly assigned to PRD or non-PRD group. Participants of the PRD group were told their income would lie below the Chinese average. While their electrophysiological responses were recorded, they underwent a Go/No-Go task simultaneously assessing the ability to detect response conflict and inhibit the predominant response. We found that the individuals with induced PRD show diminished ability to inhibit predominant response. We suggest this is because PRD-related concerns consume cognitive resources, leaving less for other tasks. However, we also found that individuals with induced PRD show enhanced ability to detect conflict. This might be because that individuals with induced PRD were sensitive to potentially threatening information (high-conflict No-Go trials) and they can detect conflict with less cognitive resources. These findings may facilitate future attempts to design interventions for relatively deprived individuals to manage their impulsive behavior.

Differences in white matter hyperintensities in socioeconomically deprived groups: results of the population-based LIFE Adult Study.

Previous studies have shown that socioeconomically deprived groups exhibit higher lesion load of the white matter (WM) in aging. The aim of this study was to (i) investigate to what extent education and income may contribute to differences in white matter hyperintensities (WMHs) and (ii) identify risk profiles related to a higher prevalence of age-associated WMH. Population-based adult study of the Leipzig Research Centre for Civilization Diseases (LIFE) in Leipzig, Germany. Dementia-free sample aged 40-80 years (n = 1,185) derived from the population registry. Information was obtained in standardized interviews. WMH (including the derived Fazekas scores) were assessed using automated segmentation of high-resolution T1-weighted anatomical and fluid-attenuated inversion recovery (FLAIR) MRI acquired at 3T. Despite a significant association between income and WMH in univariate analyses, results from adjusted models (age, gender, arterial hypertension, heart disease, and APOE e4 allele) indicated no association between income and WMH. Education was associated with Fazekas scores, but not with WMH and not after Bonferroni correction. Prevalence of some health-related risk factors was significantly higher among low-income/education groups. After combining risk factors in a factor analysis, results from adjusted models indicated significant associations between higher distress and more WMH as well as between obesity and more deep WMH. Previously observed differences in WMH between socioeconomically deprived groups might stem from differences in health-related risk factors. These risk factors should be targeted in prevention programs tailored to socioeconomically deprived individuals.

Factors influencing influenza, pneumococcal and shingles vaccine uptake and refusal in older adults: a population-based cross-sectional study in England

ObjectivesUptake of influenza, pneumococcal and shingles vaccines in older adults vary across regions and socioeconomic backgrounds. In this study, we study the coverage and factors associated with vaccination uptake, as...

How well do area-based deprivation indices identify income- and employment-deprived individuals across Great Britain today?

BackgroundArea-based deprivation indices are used in many countries to target interventions and policies to populations with the greatest needs. Analyses of the Carstairs deprivation index applied to postcode sectors in 2001 identified that less than half of all deprived individuals lived in the most deprived areas. ObjectiveThis article examines the specificity and sensitivity of deprivation indices across Great Britain in identifying individuals claiming income- and employment-related social security benefits. Study designThis was a descriptive analysis of cross-sectional administrative data. MethodsThe data sets for the 2020 Scottish Index of Multiple Deprivation, Scottish Income and Employment Index, the 2019 English Index of Multiple Deprivation and the 2019 Welsh Index of Multiple Deprivation were obtained. For each data set, small areas were ranked by increasing overall deprivation, and the cumulative proportions of individuals who were income and employment deprived were calculated. Receiver operating characteristic curves were plotted to show the sensitivity and specificity of each index, and the percentages of income- and employment-deprived individuals captured at different overall deprivation thresholds were calculated. ResultsAcross all indices, the sensitivity and specificity for detecting income- and employment-deprived individuals were low, with less than half living in the most deprived 20% of areas. Between 55% and 62% of income-deprived people and between 56% and 63% of employment-deprived people were missed across the indices at the 20% deprivation threshold. The sensitivity and specificity were slightly higher for income deprivation than employment deprivation across indices and slightly higher for the Scottish Index of Multiple Deprivation and Scottish Income and Employment Index than for the English Index of Multiple Deprivation and Welsh Index of Multiple Deprivation. ConclusionArea-based deprivation measures in Great Britain have limited sensitivity and specificity for identifying individuals who are income or employment deprived. Place-based policies and interventions are unlikely to be effective at reducing inequalities as a result. Creation of individually linked data sets and interventions that recognise the social and economic relationships between social groups are likely to be more effective.

How well does the Scottish Index of Multiple Deprivation identify income and employment deprived individuals across the urban-rural spectrum and between local authorities?

BackgroundArea-based indices of deprivation are used to identify populations at need, to inform service planning and policy, to rank populations for monitoring trends in inequalities, and to evaluate the impacts of interventions. There is scepticism of the utility of area deprivation indices in rural areas because of the spatial heterogeneity of their populations. ObjectiveTo compare the sensitivity of the Scottish Index of Multiple Deprivation (SIMD) for detecting income and employment deprived individuals by urban-rural classification and across local authorities. Study designDescriptive analysis of cross-sectional data. MethodsData from the 2020 Scottish Index of Multiple Deprivation (SIMD) were used to calculate the number and percentage of income and employment deprived people missed within each of the six-fold urban-rural classification strata and each local authority using areas ranked by the national SIMD, within local authority rankings, and within urban-rural strata rankings, for deprivation thresholds between the 5% most deprived areas and the 30% most deprived areas. The Slope Index of Inequality (SII) and Relative Index of Inequality (RII) were calculated within local authorities and urban-rural classification strata to estimate the concentration of deprivation within ranked data zones. ResultsThe number and percentage of income and employment deprived people is higher in urban than rural areas. However, using the national, local authority, and within urban-rural classification strata rankings of SIMD, and under all deprivation thresholds (from the 5%–30% most deprived areas), the percentage of income and employment deprived people missed by targeting the most deprived areas within urban-rural strata is higher in more remote and rural areas, and in island local authorities. The absolute number of income and employment deprived individuals is greater in urban areas across rankings and thresholds. ConclusionThe SIMD misses a higher percentage of income and employment deprived people in remote, rural and island areas across deprivation thresholds and irrespective of whether national, local or within urban-rural classification strata are used. However, the absolute number of people missed is higher in urban areas.

Are ethnic employment penalties mitigated in deprived neighbourhoods and in ethnically dense neighbourhoods?

AbstractExisting research has extensively documented that those living in the most deprived neighbourhoods and individuals from some ethnic minority groups have low rates of labour market participation in the United Kingdom. This paper brings together these two established areas of research to ask whether ethnic minority groups have better employment participation when living in more deprived neighbourhoods. We hypothesise that this could be due to different socialisation processes enabling ethnic minorities to secure employment more easily in deprived neighbourhoods as well as in neighbourhoods where there is greater ethnic density. Data from the United Kingdom Household Longitudinal Study in England are linked to the Index of Multiple Deprivation 2014 and the 2011 Census to model unemployment and economic inactivity between 2009 and 2019 separately for women and men. The results show that some ethnic minority groups face disadvantage in the labour market, especially Pakistani and Bangladeshi women. There is little support to suggest that these penalties are lessened in more deprived neighbourhoods or in more ethnically dense neighbourhoods. There is some suggestion that groups who do not face ethnic penalties compared with the White British group have lower rates of unemployment and economic inactivity in more deprived neighbourhoods. We suggest policies aimed at improving labour market outcomes for disadvantaged ethnic minorities should target them wherever they live.

A Study on Socio-Economic Problems Faced by the Transgender: The Evidence from Dera Ghazi Khan, Pakistan

Transgender community have been facing socioeconomic problems in Pakistan for long. It is imperative to identify such issues to resolve these problems for the betterment of the transgender community. This study is primarily focused on theidentification and evaluation of socioeconomic problems faced by the transgender individuals in the Dera Ghazi Khan division, Punjab, Pakistan. The study shows that the transgender individuals lack the access to better healthcare facilities, haveno access to education, and have no employment opportunities. Consequently&#x0D; transgender community have to live in severe economic conditions with meagreincome levels. Moreover, they do not have any social recognition and status. Thefindings of the study draws attention of the government and policymakers topromulgate policies to ensure the provision of better healthcare, educational, andemployment opportunities to the deprived transgender individuals.

Comparing Material and Social Deprivation Indicators: Identification of Deprived Populations

The new indicator for material and social deprivation validated in 2014 by the European Commission enlarged the scope of measuring social exclusion, which entails both material hardship of individuals and households, and a relevant social dimension. Using EU-SILC data, this paper compares the standard measure of material deprivation and the new indicator in terms of the sub-population they identify as suffering deprivation across Europe. In 2019, only 57% of the deprived individuals according at least one of the two indicators were so according to both, while 23% was deprived only according to the new measure and 20% was deprived only under the old indicator. We compare the micro-level determinants of inclusion into these different deprived populations, both at the aggregated level and separately for each of the 21 countries included in our sample.

Trends, barriers and enablers to measles immunisation coverage in Saskatchewan, Canada: A mixed methods study.

Many social, cultural, and systemic challenges affect the uptake of measles immunisation services. Prior studies have looked at the caregivers' perspectives, but little is known about the perspectives of the health care providers on the barriers of measles immunisation services in Canada. This study examined measles immunisation coverage trends across the regional health authorities in Saskatchewan and explored the barriers and enablers to measles immunisation coverage from providers' perspectives. The study adopted an explanatory sequential mixed method. We utilized the entire population of 16,582 children under two years of age available in the Saskatchewan Immunisation Management System (SIMS) registry for 2002 and 2013 in aggregate format and interviewed 18 key informants in pre-determined two-stages in 2016 and 2017. The quantitative analysis was done with Joinpoint regression modelling, while the qualitative interview data was analyzed using hybrid inductive and deductive thematic approaches. There was a 16.89%-point increase in measles immunisation coverage in the province from 56.32% to 73.21% between 2002 and 2013. There was also a persistently higher coverage among the affluent (66.95% - 82.37%) than the most deprived individuals (45.79% - 62.60%) in the study period. The annual rate of coverage change was marginally higher among the most deprived (16.81%; and average annual percentage change (AAPC) 2.0, 95% CI 1.7-2.2) than among the affluent group (15.42% and AAPC 3.0; 95% CI 2.0-4.0). While access-related issues, caregivers' fears, hesitancy, anti-vaccination challenges, and resource limitations were barriers to immunisation, improving community engagement, service delivery flexibility, targeted social responses and increasing media role were found useful to address the uptake of measles and other vaccine-preventable diseases immunisation. There is low coverage and inequity in measles immunisation uptake in Saskatchewan from social and institutional barriers. Even though there is evidence of disparity reduction among the different groups, the barriers to increasing measles immunisation coverage have implications for the health of the socio-economically deprived groups, the healthcare system and other vaccination programs. There is a need to improve policy framework for community engagement, targeted programs, and public health discourse.

Relative Deprivation Leads to the Endorsement of "Anti-Chicken Soup" in China.

"Anti-chicken soup" (ACS) persuades people to yield to reality and give up rather than encouraging people to work hard as "chicken soup" does. The current study explored whether people with a higher level of relative deprivation (RD) would be more likely to endorse ACS. We found that people with high-measured (Study 1) and manipulated (Study 2) RD were more likely to endorse ACS. Study 2 also suggested that the effect was mediated by self-handicapping. It seems that relatively deprived individuals may adopt the strategy of self-handicapping so that they could attribute their failure to external causes, which in turn leads to lower motivation to try their best and ultimately the endorsement of ACS.

Socioeconomic deprivation: an important largely unrecognized risk factor in primary prevention of cardiovascular disease

Abstract Background Socioeconomic deprivation is associated with higher cardiovascular morbidity and mortality. Whether deprivation status should be incorporated in more cardiovascular risk estimation scores remains unclear. Purpose This study evaluates how socioeconomic deprivation status affects the performance of three primary prevention cardiovascular risk scores. Methods The Generation Scotland Scottish Family Health Study was used to evaluate the performance of three cardiovascular risk scores with (ASSIGN) and without (SCORE2, PCE) socioeconomic deprivation as a covariate in the risk prediction model. Deprivation was defined by Scottish Index of Multiple Deprivation score. The predicted 10-year risk was evaluated against the observed event rate for the cardiovascular outcome of each risk score. The comparison was made across three groups defined by the deprivation index score consisting of group 1 defined as most deprived, group 3 defined as least deprived and group 2 which consisted of individuals in the middle deprivation categories. Results The study population consisted of 15,506 individuals (60.0% female, median age of 51). Across the population 1,808 (12%) individuals were assigned to group 1 (most deprived), 8,119 (55%) to group 2, and 4,708 (32%) to group 3 (least deprived). Risk scores based on models that did not include deprivation status significantly under predicted risk in the most deprived (6.4% observed versus 4.6% predicted for SCORE2 and 6.7% observed versus 4.7% predicted for PCE, p&amp;lt;0.001 for both). Both risk scores also significantly overpredicted the risk in the least deprived group (4.0% observed versus 4.7% predicted for SCORE2, p=0.007 and 4.2% observed versus 4.9% predicted for PCE, p=0.028). In contrast, no significant difference was demonstrated in the observed versus predicted risk when using the ASSIGN risk score, which included socioeconomic deprivation status in the risk model. Conclusions Socioeconomic status is a largely unrecognized risk factor in primary prevention of cardiovascular disease. Risk scores that exclude socioeconomic deprivation as a covariate under- and overestimate the risk in the most and least deprived individuals, respectively. This study highlights the importance of incorporating socioeconomic deprivation status in risk estimation systems to ultimately reduce inequalities in health care provision for cardiovascular disease. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The British Heart Foundation.Health Data Research UK which receives its funding from HDR UK Ltd (HDR-5012) funded by the UK Medical Research Council, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Department of Health and Social Care (England), Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Health and Social Care Research and Development Division (Welsh Government), Public Health Agency (Northern Ireland), British Heart Foundation and the Wellcome Trust.

Temporal trends and patterns in atrial fibrillation incidence: a population-based study of 3.4 million individuals

Abstract Background Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide; confers an increased risk of adverse outcomes and once diagnosed most patients will require lifelong-treatment. Population-based studies of AF incidence are needed to inform health-service planning. However, few reports refer to a standard population and estimates of incidence in high income countries vary by over 12-fold. Purpose We aimed to assess trends in the crude and standardised atrial fibrillation incidence by sex, age, socioeconomic status and region in a large general population cohort from England. We also investigated the comorbidity profile of patients over almost two decades. Methods We used linked primary and secondary electronic health records of 3.4 million individuals from the Clinical Practice Research Datalink (CPRD). The CPRD database contains anonymised patient data from approximately 7% of the UK population and is broadly representative in terms of age, sex, and ethnicity. Eligible patients aged 16 years and older contributed data between Jan 1 1998 and Dec 31 2017. We defined incident AF diagnosis as the first record of AF in primary care or hospital admission records from any diagnostic position. For incidence calculations, we excluded all individuals who had a diagnosis of AF before the study start date, or within the first 12 months of registration with their general practice. For patients with incident AF, we extracted baseline characteristics, comorbidities, socioeconomic status and geographic region. We calculated standardised rates by applying direct age and sex standardisation to the 2013 European Standard Population. We inferred crude rates by applying year-specific, age-specific and sex-specific incidence to UK census mid-year population estimates. Results From 1998 to 2017 AF incidence (standardised by age and sex) increased by 30% (from 247 to 322 per 100,000 person-years; adjusted incidence ratio [IRR] 1.30, 95% CI 1.27–1.33) (Figure 1). Absolute number of incident AF increased by 72% (from 117,880 in 1998 to 202,333 in 2017), due to an increasing number of older people. Comorbidity burden at diagnosis of AF increased (2.58 [SD 1.83] vs 3.74 [2.29] conditions; adjusted difference 1.26, 95% CI 1.14–1.39). Age-standardised incidence was higher in men than women (IRR 1.49; 95% CI 1.46–1.52), and men were younger at diagnosis (adjusted difference 5.53 years; 95% CI 5.36–5.69). Socioeconomically deprived individuals had more comorbidities and were more likely to develop AF than the most affluent individuals (IRR 1.20; 95% CI 1.15–1.24). Over time, the age of AF diagnosis declined disproportionately in the most deprived individuals (Figure 2). Conclusion In England AF incidence has increased, and the socioeconomic gradient in age at diagnosis and comorbidity burden widened. This changing burden of AF requires policy-based interventions to prevent associated morbidity and mortality. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): British Heart Foundation, National Institute of Health Research

Socioeconomic inequality in access to timely and appropriate care in emergency departments

In publicly-funded healthcare systems, waiting times for care should be based on need rather than ability to pay. Studies have shown that individuals with lower socioeconomic status face longer waits for planned inpatient care, but there is little evidence on inequalities in waiting times for emergency care. We study waiting times in emergency departments (EDs) following arrival by ambulance, where health consequences of extended waits may be severe. Using data from all major EDs in England during the 2016/17 financial year, we find patients from more deprived areas face longer waits during some parts of the ED care pathway. Inequalities in waits are small, but more deprived individuals also receive less complex ED care, are less likely to be admitted for inpatient care, and are more likely to re-attend ED or die shortly after attendance. Patient-physician interactions and unconscious bias towards more deprived patients may be important sources of inequalities.

Socioeconomic Deprivation: An Important, Largely Unrecognized Risk Factor in Primary Prevention of Cardiovascular Disease.

Background:Socioeconomic deprivation is associated with higher cardiovascular morbidity and mortality. Whether deprivation status should be incorporated in more cardiovascular risk estimation scores remains unclear. This study evaluates how socioeconomic deprivation status affects the performance of 3 primary prevention cardiovascular risk scores.Methods:The Generation Scotland Scottish Family Health Study was used to evaluate the performance of 3 cardiovascular risk scores with (ASSIGN [Assessing cardiovascular risk using SIGN (Scottish Intercollegiate Guidelines Network) guidelines to ASSIGN preventive treatment]) and without (SCORE2 [Systematic Coronary Risk Evaluation 2 algorithm], Pooled Cohort Equations) socioeconomic deprivation as a covariate in the risk prediction model. Deprivation was defined by Scottish Index of Multiple Deprivation score. The predicted 10-year risk was evaluated against the observed event rate for the cardiovascular outcome of each risk score. The comparison was made across 3 groups defined by the deprivation index score consisting of group 1 defined as most deprived, group 3 defined as least deprived, and group 2, which consisted of individuals in the middle deprivation categories.Results:The study population consisted of 15 506 individuals (60.0% female, median age of 51). Across the population, 1808 (12%) individuals were assigned to group 1 (most deprived), 8119 (52%) to group 2, and 4708 (30%) to group 3 (least deprived), and 871 (6%) individuals had a missing deprivation score. Risk scores based on models that did not include deprivation status significantly under predicted risk in the most deprived (6.43% observed versus 4.63% predicted for SCORE2 [P=0.001] and 6.69% observed versus 4.66% predicted for Pooled Cohort Equations [P<0.001]). Both risk scores also significantly overpredicted the risk in the least deprived group (3.97% observed versus 4.72% predicted for SCORE2 [P=0.007] and 4.22% observed versus 4.85% predicted for Pooled Cohort Equations [P=0.028]). In contrast, no significant difference was demonstrated in the observed versus predicted risk when using the ASSIGN risk score, which included socioeconomic deprivation status in the risk model.Conclusions:Socioeconomic status is a largely unrecognized risk factor in primary prevention of cardiovascular disease. Risk scores that exclude socioeconomic deprivation as a covariate under- and overestimate the risk in the most and least deprived individuals, respectively. This study highlights the importance of incorporating socioeconomic deprivation status in risk estimation systems to ultimately reduce inequalities in health care provision for cardiovascular disease.