Townsend Score Research Articles

The relationship between use of NHS Direct and deprivation in southeast London: an ecological analysis

Little is known about the utilization of NHS Direct by disadvantaged groups, in spite of the service aiming to be 'accessible to all'. This study investigates the relationship between use of NHS Direct and deprivation in one predominantly disadvantaged area. Ward-level call rates to NHS Direct South East London over a 6 month period were calculated using postcode data. Jarman and Townsend scores were used as a proxy of deprivation in each ward. We performed negative binomial regression to investigate the relationship between deprivation score and rate of calls to NHS Direct. There was a significant, non-linear (quadratic) effect of deprivation score on call rates; call rates were lower in both the most affluent and most deprived wards. Calls to NHS Direct rise with increasing deprivation until, at extreme levels of deprivation, they subsequently decline. This challenges assumptions that NHS Direct is not utilized in deprived areas.

The influences on preventive care provided to children who frequently attend the UK General Dental Service.

To identify the relationship between the preventive and restorative care provided to children who frequently attend the General Dental Service in the UK after taking into account socio-economic status, gender and dental caries experience. General dental practices in the North West of England. The study design involved a retrospective investigation of case notes of 677 children who regularly attended 50 general dental practitioners. The complete history of the dental care received by each child during the primary dentition period was recorded. Analyses took place at the patient level. Information was recorded on the total number of carious teeth and restorative and preventive care provided to the children. Preventive care was categorised as dietary advice, oral hygiene instruction, prescription of fluoride tablets and application of fluoride varnish. Socio-economic status was measured using the Townsend score of the electoral ward of residence of each subject. Logistic regression models, taking into account the clustering of the subjects within dental practices were fitted to identify whether or not socio-economic status was significantly associated with provision of each category of preventive care, after controlling for gender, the total number of teeth affected by caries and the proportion of carious teeth which were restored. Children from poorer backgrounds were significantly more likely to receive oral hygiene instruction than their more affluent peers. Socio-economic status did not influence dentists' decisions to prescribe fluoride tablets, but children from affluent backgrounds were significantly more likely to have fluoride varnish applied to their teeth than children from deprived backgrounds after controlling for other factors. The more teeth affected by decay significantly increased the odds of giving dietary advice, prescription of fluoride tablets and application of fluoride varnish, but had no effect on whether or not oral hygiene instruction was given. As the percentage of decayed but filled teeth decreased the odds of giving dietary advice or applying fluoride varnish increased significantly. Conclusion It would appear that dentists are providing appropriate preventive care according to the aetiological causes of dental disease. They also look to be providing preventive care in compensation for decisions not to restore carious primary teeth. However the preventive care provided seems to be reactive to disease patterns, and in this high risk group of patients does not seem to be particularly effective.

Preventive or restorative care for children?

Objectives To identify the relationship between the preventive and restorative care provided to children who frequently attend the General Dental Service in the UK after taking into account socio-economic status, gender and dental caries experience. Setting General dental practices in the North West of England. Subjects and materials The study design involved a retrospective investigation of case notes of 677 children who regularly attended 50 general dental practitioners. The complete history of the dental care received by each child during the primary dentition period was recorded. Analyses took place at the patient level. Information was recorded on the total number of carious teeth and restorative and preventive care provided to the children. Preventive care was categorised as dietary advice, oral hygiene instruction, prescription of fluoride tablets and application of fluoride varnish. Socio-economic status was measured using the Townsend score of the electoral ward of residence of each subject. Logistic regression models, taking into account the clustering of the subjects within dental practices were fitted to identify whether or not socio-economic status was significantly associated with provision of each category of preventive care, after controlling for gender, the total number of teeth affected by caries and the proportion of carious teeth which were restored. Results Children from poorer backgrounds were significantly more likely to receive oral hygiene instruction than their more affluent peers. Socio-economic status did not influence dentists' decisions to prescribe fluoride tablets, but children from affluent backgrounds were significantly more likely to have fluoride varnish applied to their teeth than children from deprived backgrounds after controlling for other factors. The more teeth affected by decay significantly increased the odds of giving dietary advice, prescription of fluoride tablets and application of fluoride varnish, but had no effect on whether or not oral hygiene instruction was given. As the percentage of decayed but filled teeth decreased the odds of giving dietary advice or applying fluoride varnish increased significantly. Conclusion It would appear that dentists are providing appropriate preventive care according to the aetiological causes of dental disease. They also look to be providing preventive care in compensation for decisions not to restore carious primary teeth. However the preventive care provided seems to be reactive to disease patterns, and in this high risk group of patients does not seem to be particularly effective.

Meningococcal disease and social deprivation: a small area geographical study in Gwent, UK

Although meningococcal disease is known to be linked to characteristics of individuals associated with social deprivation, there is only limited evidence of a relation with area-based measures of deprivation. In a small area geographical study, we ascertained 295 confirmed or probable cases occurring between 1996 and 1999 in the socially diverse resident population of Gwent Health Authority, equating to an average annual rate of 13.2 per 100,000. Incidence rates of meningococcal disease increased from 8.1 per 100,000 in the least deprived fifth of enumeration districts to 19.8 per 100,000 in the most deprived fifth, a relative risk of 2.4 (95% CI 1.7-3.6). In Poisson regression, the percentage change in the incidence rate arising from a unit change in the enumeration district Townsend score, was 9.4% (95% CI 6.2-12.6%). Strongest associations were found for the under 5 age group, serogroup B disease and with the overcrowding variable component of the Townsend index. Our study quantifies the strength of the relation between meningococcal disease and social deprivation at small area level and provides further evidence of the need for action to reduce health inequalities.

The effects of smoking on birthweight-for-gestational-age curves in teenage and adult primigravidae

Objectives. To compare the effect of smoking on the birthweight-for-gestational-age curves of teenage and adult primigravidae. Methods. A retrospective analysis of the perinatal database at the Liverpool Women's Hospital for the years 1997–1999 for teenage and adult primigravidae. Results. Records on 1157 primigravidae were available. There were no significant differences between the mean birthweight (3220 g±666 vs 3244 g±680, P=0.43) and the proportion with low birthweight (LBW) babies (8.9% vs 10.6%, P=0.39) between teenage and adult primigravidae, respectively. The percentage of women who smoked increased from the middle class (Townsend score −6–−3) to the working class group (Townsend score +4–+12) for both teenagers (33.3–51.3%) and adults (6.9–29.6%). The mean birthweight of babies of smoking mothers was significantly lower than for non-smoking mothers (3112 g±639 vs 3327 g±663, P=0.00002). The birthweight-for-gestational-age pattern was lower at all gestational ages for smoking mothers in both the teenage and adult groups. Risk of LBW was significantly increased in teenagers who smoked (10.8% vs 3.9%, P<0.01), but not in adult smokers. Conclusion. Lower birthweights at all gestational ages were observed in babies of teenage and adult mothers who smoked.

The relationship between mean birth weight and poverty using the Townsend deprivation score and the Super Profile classification system

Super Profiles have been used as alternative methods of characterising the deprivation of an area. Some reports suggest that Super Profiles are as accurate as established indices such as the Townsend score (TS). This was a test of this assertion. A total of 138 696 live born singleton births to Birmingham residents born between 1986 and 1996 (inclusive) were allocated to enumeration districts (EDs) by linkage from the postcode. We allocated the TS of the individual's ED. We allocated a Lifestyle and Target Market ( TM) from Super Profiles by linkage to the ED. We examined the gradient between mean birth weight and the 10 Super Profile Lifestyles and compared this to the gradient between 10 Townsend groups and mean birth weight. We repeated this approach using the 40 TMs and 40 Townsend groups. We used both the median income and a census-derived deprivation measure to rank Lifestyles and TMs. The gradient between mean birth weight and area deprivation was linear for Townsend groups but not linear using either Lifestyles or TMs whichever method of ranking Lifestyles or TMs was used. Where Lifestyles or TMs were out of line with their neighbours, the TS of that group mostly explained this. As Super Profiles are generated using nationally representative data, applying the affluence ranking to small areas can lead to inaccuracies, as shown in this data. We conclude that Super Profiles are probably unsuitable as measures of deprivation of small areas. Public Health (2002) 116, 308–314.

Adjusted mortality rates: a tool for creating more meaningful league tables for stillbirth and infant mortality rates

A number of problems associated with league tables of performance indicators have been discussed in the literature. This paper attempts to address these problems for stillbirth and infant mortality rates in order to produce meaningful and useful information for the government, general public and health professionals. Composite stillbirth and infant mortality rates, low birth-weight and very low birth-weight rates were determined for the 100 English Health Authorities for 1996–1997. Townsend deprivation scores for these districts were also obtained. The mortality rates were adjusted by multiple regression for very low birth-weight and Townsend score separately and together. Confidence intervals were calculated for the dual-adjusted rates. Almost 60% of the variability in mortality rates were explained by Townsend score and very low birth-weight rates together. Adjusted league tables showed how the individual and combined predictors affect the individual mortality rates for each Health Authority. There was considerable overlap in the confidence intervals for the adjusted rates although there were a few Health Authorities whose mortality rates were clearly below most others. We conclude that fairer and more useful information is provided by geographically based league tables which give both crude rates and rates adjusted for single and multiple predictor variables. The inclusion of confidence intervals aids interpretation of annual random variations and knowledge of differences in the effects of the individual predictors enables better resource targeting. Public Health (2002) 116, 315–321.

Adjusted mortality rates a tool for creating more meaningful league tables for stillbirth and infant mortality rates

A number of problems associated with league tables of performance indicators have been discussed in the literature. This paper attempts to address these problems for stillbirth and infant mortality rates in order to produce meaningful and useful information for the government, general public and health professionals. Composite stillbirth and infant mortality rates, low birth-weight and very low birth-weight rates were determined for the 100 English Health Authorities for 1996–1997. Townsend deprivation scores for these districts were also obtained. The mortality rates were adjusted by multiple regression for very low birth-weight and Townsend score separately and together. Confidence intervals were calculated for the dual-adjusted rates. Almost 60% of the variability in mortality rates were explained by Townsend score and very low birth-weight rates together. Adjusted league tables showed how the individual and combined predictors affect the individual mortality rates for each Health Authority. There was considerable overlap in the confidence intervals for the adjusted rates although there were a few Health Authorities whose mortality rates were clearly below most others. We conclude that fairer and more useful information is provided by geographically based league tables which give both crude rates and rates adjusted for single and multiple predictor variables. The inclusion of confidence intervals aids interpretation of annual random variations and knowledge of differences in the effects of the individual predictors enables better resource targeting. Public Health (2002) 116, 315–321.

Affluence is not related to delay in diagnosis of Type 2 diabetes as judged by the development of diabetic retinopathy.

To determine the relationship between affluence and the presence of diabetic retinopathy at time of diagnosis of Type 2 diabetes. Records of patients held by Southampton Retinal Screening Programme were examined. Patients (n = 1844) newly diagnosed with Type 2 diabetes and subsequently receiving photographic retinal screening within 24 months were selected. Townsend scores for social deprivation were calculated and the patients with and without retinopathy at first screening were then compared. No significant difference was found in the median Townsend score of those people with (-0.2, interquartile range (IQR) -3.7 to 3.8) and those without (-0.5, IQR -3.3 to 3.6) diabetic retinopathy at first screening after diagnosis of Type 2 diabetes (P = 0.6). The relative affluence of the area in which a person lives, as judged by postcode, does not appear to predict likelihood of diabetic retinopathy at diagnosis of Type 2 diabetes.

Inequalities in the dental treatment provided to children: an example from the UK.

To identify the relationship between the socioeconomic status of frequently attending children and the dental care of their primary dentition provided by dentists working in the General Dental Service (GDS) of the UK National Health Service (NHS). The study design involved a retrospective investigation of the case notes of 658 children who were regularly attending patients of 50 General Dental Practitioners (GDPs) working in the North West of England. The socioeconomic status of each subject was measured using the Townsend score of their electoral ward of residence. Logistic regression models, taking into account the clustering of the subjects within dental practices, were fitted to identify whether or not socioeconomic status was significantly associated with the proportion of carious teeth that were restored, all dental extractions, dental extractions for pain or sepsis alone and courses of antibiotics prescribed after controlling other variables. A significant association between socioeconomic status and caries experience could not be found. There was also no association between socioeconomic status and the proportion of carious teeth filled or courses of antibiotics prescribed. Disadvantaged children were significantly more likely to have teeth extracted than their more affluent peers, but there was no association between deprivation and extractions for pain or sepsis alone. Children from deprived backgrounds who regularly attended this group of UK dentists were more likely to have extractions than their more affluent peers, irrespective of their caries experience.

Diagnostic and treatment behaviour in children with chronic respiratory symptoms: relationship with socioeconomic factors

Background: The prevalence and severity of asthma is believed to increase with increasing socioeconomic deprivation. The relationship between asthma diagnosis, symptoms, diagnostic accuracy, and socioeconomic deprivation as determined by Townsend...

Are socio-economic inequalities in mortality decreasing in Trent Region, UK? An observational study, 1988-1998.

There is substantial national interest in the widening gap in socio-economic inequalities. The aim of this study was to examine time trends in age-specific mortality in Trent Region comparing rates by socio-economic deprivation from 1988 to 1998. Mortality rates from 1988 to 1998 were calculated for each of five deprivation categories (derived using 1991-based enumeration district level Townsend scores) for men and women aged 45-54, 55-64, 65-74 and 75-84 years. Rate ratios (95 per cent confidence intervals) were calculated for the years 1988-1990 and 1996-1998, comparing the most deprived with the least deprived categories. For men aged 45-54, the rate ratio for the most deprived relative to the least deprived category was 2.42 (2.2-2.67) in 1988-1990 and 2.4 (2.17-2.65) in 1996-1998. Amongst women the ratio fell from 2.14 (1.88-2.42) to 1.67 (1.47-1.88). For men aged 55-64, the rate ratio fell from 2.07 (1.95-2.19) to 1.79 (1.67-1.91). For women the fall was from 1.99 (1.84-2.14) to 1.59 (1.46-1.73). For those aged 65-74, the fall was from 1.65 (1.58-1.72) to 1.33 (1.28-1.39) for men and from 1.55 (1.47-1.63) to 1.37 (1.30-1.45) for women. For people aged 75-84, no clear convergence in rates was seen. There appear to be decreases in socio-economic inequalities in mortality between 1988 and 1998 in Trent Region. These trends run counter to those described in the majority of recent literature.

Cross sectional survey of socioeconomic variations in severity and mechanism of childhood injuries in Trent 1992-7

Objective: To determine the relation between morbidity from injury and deprivation for different levels of injury severity and for different injury mechanisms for children aged 0-14 years.Design: Cross sectional survey...

Is clinical practice variability the major reason for differences in pathology requesting patterns in general practice?

To examine whether variations in pathology test requesting between different general practices can be accounted for by sociodemographic or other descriptive indicators of the practice. This was a comparative analysis of requesting patterns across a range of pathology tests representing 95% of those requested in general practice, in 22 general practices in a single district, serving a population of 165 000. Spearman correlation coefficients were calculated and both the top and bottom fifths of activity were displayed graphically to detect trends at the extremes of the ranges. The proportion of women of childbearing age, median practice Townsend scores, or the existence of specialist miniclinics within the practice did not have a demonstrable impact on requesting patterns. A weak correlation was found between the proportion of elderly patients and creatinine/electrolyte testing but not for the other two tests examined for this patient group. The large differences observed in general practice pathology requesting probably result mostly from individual variation in clinical practice and are therefore potentially amenable to change.

Do single handed practices offer poorer care? Cross sectional survey of processes and outcomes

Objectives: To determine whether there are important differences in performance between group practices and singlehanded general practitioners and the extent to which any differences are explained by practice characteristics such...

South Asian ethnicity and material deprivation increase the risk of Epstein-Barr virus infection in childhood Hodgkin's disease.

In order to further define the factors associated with the observed variations in the Epstein-Barr virus-positive rate in childhood Hodgkin's disease, we have studied the effect of material deprivation (measured by the Townsend score) and ethnic origin on the frequency of Epstein-Barr virus-positivity in 55 cases of childhood Hodgkin's disease, diagnosed between 1981 and 1999, from a multi-ethnic region of the United Kingdom. Epstein-Barr virus status was determined by immunohistochemistry for the Epstein-Barr virus-encoded latent membrane protein-1. 62% of cases were Epstein-Barr virus-positive. Ethnic group was the strongest predictor of Epstein-Barr virus-positivity, with South Asians having a more than 20-fold risk of being Epstein-Barr virus-positive compared with non-South Asians. An increased risk was still present after adjusting for deprivation. Townsend scores were significantly higher (indicating more deprivation) in the Epstein-Barr virus-positive group, particularly in males. The relative risk of Epstein-Barr virus-positivity showed a gradient with increasing Townsend score; the risk being 7-times higher in the most deprived quartile compared with the least deprived group. Although the association between Townsend score and Epstein-Barr virus-positivity was reduced after adjusting for ethnic group, the risk of Epstein-Barr virus-positivity was still 3-times higher in the most deprived compared with the least deprived quartile. In addition, cases having 2 or more siblings were 5-times as likely to be Epstein-Barr virus-positive as those from smaller families. These results provide the first evidence of a strong association between Epstein-Barr virus-positive Hodgkin's disease and South Asian children from the United Kingdom. In addition, deprivation may increase the likelihood of Epstein-Barr virus-positive disease independently of ethnicity. © 2001 Cancer Research Campaign http://www.bjcancer.com

Geographical distribution of cardiac arrest in Nottinghamshire

Background: to analyse the incidence of out-of-hospital cardiac arrest in Nottinghamshire; to ascertain its geographical distribution; and to determine whether the geography of coronary heart disease mortality and out-of-hospital cardiac arrest are the same. Methods and results: population based, retrospective study in the County of Nottinghamshire with a total population of 993 914 in an area of 2183 km 2 divided into 191 electoral areas. In the 4 years from 1 January, 1991 to 31 December, 1994, 1634 patients sustained a cardiac arrest attributed to a cardiac cause (International Classification of Diseases codes 390–414 and 420–429) and were attended by the Nottinghamshire Ambulance Service. The overall crude mean incidence rate of community cardiac arrest per electoral area was 40.2 per 100 000 population (range 0–121.2). Thirteen electoral areas, relatively deprived according to the Townsend score, had a significantly greater than expected incidence rate of cardiac arrest (median of 75.6/100 000 per electoral area; interquartile range (IQR) 65.3, 83.8). Twelve relatively affluent electoral areas had a significantly lower than expected incidence rate (median of 18.5/100 000 per area (IQR 13.0, 28.7). After adjusting for deprivation index, there were no differences in coronary heart disease (CHD) mortality and community cardiac arrest in urban and rural electoral areas. Apart from response times by ambulance crews, the events that follow the cardiac arrest such as bystander resuscitation, ventricular fibrillation found as the presenting rhythm and survival were similar in all electoral areas. Conclusions: increasing level of deprivation is associated with areas of increased incidence of out-of-hospital cardiac arrest in Nottinghamshire, and the effect is apparently different from that on CHD mortality. There is scope for reducing incidence rates of community cardiac arrest and to introduce strategies to improve survival in areas identified as having high rates of community cardiac arrest.

Does the multidimensional nature of Super Profiles help district health authorities understand the way social capital affects health?

Social capital describes the notion that the social processes in an area can lead to benefits in health. As Super Profiles describe the social character of an area and they are easy for health authorities to use, they could provide a simple method for local assessment of how social organization affects health. We calculated the expected mean birthweight for the enumeration districts of Birmingham based upon marital status, registration details of the child, year of birth, the mother's country of birth, fetal sex and deprivation as judged by the Townsend score using data from 138,696 live-born singleton births for the years 1986-1996 inclusive. We classified enumeration districts into Target Markets, derived from Super Profiles. For each Target Market, we calculated the observed mean birthweight and the difference and 95 per cent confidence interval between the observed and expected birthweights. We used information in Super Profiles to speculate about the social processes that led to some Target Markets having mean birthweights that were significantly different from those expected. Fifteen of the 40 Target Markets had significant differences between predicted and observed mean birthweight, but these differences were less than 50 g. There were no common characteristics of Target Markets that were consistently advantageous for birthweight and none that were disadvantageous. The information in the Super Profiles does not illuminate the way that social processes affect health, and the variation in mean birthweight between areas explained by social processes as measured by Super Profiles is small.

Water fluoridation, poverty and tooth decay in 12-year-old children

Aim: To examine the influence of water fluoridation, and socio-economic deprivation on tooth decay in the permanent dentition of 12 year old children. Setting: The North of England, fluoridated Newcastle and non-fluoridated Liverpool. A total of 6,638 children were examined. Outcome Measures: Multiple Regression analysis of fluoride status, mean electoral ward DMFT in 1992/93 and ward Townsend Scores from the 1991 census. Results: Social deprivation and tooth decay were significantly correlated in areas with and without water fluoridation. Multiple linear regression showed a statistically significant interaction between ward Townsend score, mean DMFT and water fluoridation, showing that the more deprived the area the greater the reduction in tooth decay. At a Townsend score of zero (the English average) there was a predicted 37% reduction in decay in 12-year-olds in fluoridated wards. Conclusions: Tooth decay is strongly associated with social deprivation. The findings confirm that the implementation of water fluoridation has markedly reduced tooth decay in 12-year-old children and that socio-economic dental health inequalities are reduced.

Use of statins in general practices, 1996-8: cross sectional study

The rationale for prescribing statins is well established.1 Recently there has been an increase in the rate of prescribing of lipid lowering drugs, although large variations remain between practices.2 Fewer...