Measuring Neighbourhood Deprivation: A Critique of the Index of Multiple Deprivation

Trends in inequalities in childhood overweight and obesity prevalence: a repeat cross-sectional analysis of the Health Survey for England

OBJECTIVE

To examine trends in socio-economic and ethnic inequalities in childhood overweight and obesity in the England between 1995 and 2019 in survey data and to compare these to administrative data.

DESIGN

Observational repeated cross-sectional study using the Health Survey for England (HSE) and National Child Measurement Programme (NCMP).

OUTCOME

Age and sex standardised overweight, obesity and overweight including obesity.

ANALYSIS

Inequalities assessed by parental education, family structure, ethnicity (binary non-white vs white) and area-level Index of Multiple Deprivation. Estimates stratified by age and sex. Trends compared against NCMP data (age 4-5 and 10-11 years).

RESULTS

Prevalence of childhood overweight including obesity increased from 26.0% in 1995 to 31.7% in 2019, with the highest and fastest growing levels in those aged 11-15 years, rising from 29.7% to 38.0%. Despite a plateau in overall childhood obesity since 2004, differences between groups demonstrated widening inequalities over time. Inequalities widened by area-level deprivation, household educational attainment, household structure and ethnicity driven primarily by increased prevalence among socioeconomically disadvantaged children. For example, the gap between children from households with no qualifications versus degree-level qualifications increased from -1.1% to 13.2%, and the gap between single-parent households and couple households increased from 0.5% to 5.3%. HSE trends in prevalence of childhood overweight and obesity by deprivation quintile were consistent with those in NCMP.

CONCLUSION

Overall levels of child overweight and obesity increased between 1995 and 2004. Since then, increases in prevalence among less advantaged groups have driven widening of inequalities.

Making ends meet - relating a self-reported indicator of financial hardship to health status

BACKGROUND

Area-based index of multiple deprivation (IMD) indicators of financial hardship lack individual specificity and sensitivity. This study compared self-reports of hardship with area measures in relation to health status.

METHODS

Interviews in one London Borough, reported financial hardship and health status. Associations of health status with most and least deprived quintiles of the IMD 2015 were compared with self-reported hardship; always or sometimes 'having difficulty making ends meet at the end of the month' in relation to never.

RESULTS

1024 interviews reported hardship status in 1001 (98%). 392 people (39%) reported they 'always' or 'sometimes' had hardship. In multivariate analysis, self-reported hardship was more strongly associated with smoking; odds ratio = 5.4 (95% CI: 2.8-10.4) compared with IMD, odds ratio = 1.9 (95% CI: 1.2-3.2). Health impairment was also more likely with self-reported hardship, odds ratio = 11.1 (95% CI: 4.9-25.4) compared with IMD; odds ratio = 2.7 (95% CI: 1.4-5.3). Depression was similarly related; odds ratio = 2.4 (95% CI: 1.0-5.6) and 2.7 (95% CI: 1.2-6.6), respectively.

CONCLUSIONS

Self-reported hardship was more strongly related to health status than area-based indicators. Validity and implementation in routine health care settings remains to be established.

Estimating individualized treatment rules in longitudinal studies with covariate-driven observation times

The sequential treatment decisions made by physicians to treat chronic diseases are formalized in the statistical literature as dynamic treatment regimes. To date, methods for dynamic treatment regimes have been developed under the assumption that observation times, that is, treatment and outcome monitoring times, are determined by study investigators. That assumption is often not satisfied in electronic health records data in which the outcome, the observation times, and the treatment mechanism are associated with patients' characteristics. The treatment and observation processes can lead to spurious associations between the treatment of interest and the outcome to be optimized under the dynamic treatment regime if not adequately considered in the analysis. We address these associations by incorporating two inverse weights that are functions of a patient's covariates into dynamic weighted ordinary least squares to develop optimal single stage dynamic treatment regimes, known as individualized treatment rules. We show empirically that our methodology yields consistent, multiply robust estimators. In a cohort of new users of antidepressant drugs from the United Kingdom's Clinical Practice Research Datalink, the proposed method is used to develop an optimal treatment rule that chooses between two antidepressants to optimize a utility function related to the change in body mass index.

Assessing the risk of endogeneity bias in health and mortality inequalities research using composite measures of multiple deprivation which include health-related indicators: A case study using the Scottish Index of Multiple Deprivation and population health and mortality data

The inclusion of health-related indicators in composite measures of multiple deprivation introduces a risk of endogeneity bias when using the latter in health inequalities research. This bias may ultimately result in the inappropriate allocation of healthcare resources and maintenance of preventable health inequalities. Mitigation strategies to avoid this bias include removing the health-related indicators or using single constituent domains (such as income or employment class) in isolation. These strategies have not been widely validated. This study used population-level health and mortality data with a contemporary composite measure of multiple deprivation (Scottish Index of Multiple Deprivation; SIMD) to assess these mitigation strategies. The differences between deprivation methods (original, health excluded, and income domain) were negligible. The results of quantitative research on health inequalities are unlikely to be affected by endogeneity bias.

Privacy-preserving estimation of an optimal individualized treatment rule: a case study in maximizing time to severe depression-related outcomes

Estimating individualized treatment rules-particularly in the context of right-censored outcomes-is challenging because the treatment effect heterogeneity of interest is often small, thus difficult to detect. While this motivates the use of very large datasets such as those from multiple health systems or centres, data privacy may be of concern with participating data centres reluctant to share individual-level data. In this case study on the treatment of depression, we demonstrate an application of distributed regression for privacy protection used in combination with dynamic weighted survival modelling (DWSurv) to estimate an optimal individualized treatment rule whilst obscuring individual-level data. In simulations, we demonstrate the flexibility of this approach to address local treatment practices that may affect confounding, and show that DWSurv retains its double robustness even when performed through a (weighted) distributed regression approach. The work is motivated by, and illustrated with, an analysis of treatment for unipolar depression using the United Kingdom's Clinical Practice Research Datalink.

Estimating uncertainty in a socioeconomic index derived from the American community survey

Socioeconomic indexes are widely used in public health to facilitate neighborhood-scale analyses. Although they are calculated with high levels of precision, they are rarely reported with accompanying measures of uncertainty (e.g., 90% confidence intervals). Here we use the variance replicate tables that accompany the United States Census Bureau's American Community Survey to report confidence intervals around the Yost Index, a socioeconomic index comprising seven variables that is frequently used in cancer surveillance. The Yost Index is reported as a percentile score from 1 (most affluent) to 100 (most deprived). We find that the average uncertainty for a census tract in the United States is plus or minus 8 percentiles, with the uncertainty a function of the value of the index itself. Scores at the extremes of the distribution are more precise and scores near the center are less precise. Less-affluent tracts have greater uncertainty than corresponding more-affluent tracts. Fewer than 50 census tracts of 72,793 nationally have unusual distributions of socioeconomic conditions that render the index uninformative. We demonstrate that the uncertainty in a census-based socioeconomic index is calculable and can be incorporated into any analysis using such an index.

The Incorporation of the 2030 Agenda in the Design of Local Policies for Social Transformation in Disadvantaged Urban Areas

According to the United Nations, the current COVID-19 crisis is threatening decades of development gains. This situation is aggravated in disadvantaged urban areas where 25% of the world’s population lives. Such concentration has aggravated the multidimensional problem that requires an integrated policy approach. Internationally, this approach has materialized in the formulation of global policies such as the 2030 Agenda. However, many doubts remain about the extent to which global policy such as the 2030 Agenda is able to inspire the formulation of local policies from the multidimensional perspective proposed by the Sustainable Development Goals (SDGs). To answer this question, in this contribution we rely on a comparative case study of two public policies aimed at promoting the social inclusion of the most vulnerable groups in the urban context: the “Andalusian Regional Strategy for Social Cohesion and Inclusion. Intervention in disadvantaged areas” (ERACIS) and the “Barcelona Strategy for Inclusion and Reduction of Social Inequalities 2017–2027”. The results show how the government sphere, the logic of intervention, and other aspects of policy design influence the incorporation of the principles of the 2030 Agenda in local policies, highlighting both risks and potentials of such policy transfer, crucial to the effective achievement of the SDGs.

Can the Risk of Severe Depression-Related Outcomes Be Reduced by Tailoring the Antidepressant Therapy to Patient Characteristics?

Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for patients with unipolar depression, yet there is little guidance on which SSRI provides the most benefit to a patient, based on personal characteristics. In this work, we explore whether an individualized treatment strategy can be used by health-care providers to adapt their prescription pattern to reduce the risk of a severe depression-related outcome (SDO) when choosing between citalopram and fluoxetine, 2 commonly prescribed SSRIs. Our population-based cohort study used data from the Clinical Practice Research Datalink, the Hospital Episode Statistics repository, and the Office for National Statistics database in the United Kingdom to create a cohort of individuals diagnosed with depression who were prescribed citalopram or fluoxetine between April 1998 and December 2017. Patients were followed from treatment initiation until occurrence of the SDO outcome, treatment discontinuation, or end of study. To find an optimal treatment strategy, we used dynamic weighted survival modeling, considering patient features such as age, sex, body mass index, previous psychiatric diagnoses, and medications. Our findings suggest that using patient characteristics to tailor the antidepressant drug therapy is associated with an increase of 4 days in the median time to SDO (95% confidence interval: 2, 10 days).

Association Between Atopic Eczema and Cancer in England and Denmark

Question

Is atopic eczema associated with increased cancer risk?

Findings

In 2 large cohort studies conducted in England (471 970 and 2 239 775 individuals with and without atopic eczema, respectively) and Denmark (44 945 and 445 673 individuals with and without atopic eczema, respectively), no evidence was found of an increased risk of most cancers among people with atopic eczema compared with those without eczema. However, atopic eczema was associated with an increased risk of lymphoma, particularly non-Hodgkin lymphoma, with risk increasing with greater eczema severity.

Meaning

The findings in this study did not support an association between atopic eczema and most cancers; however, there was evidence of higher lymphoma risk with increasing eczema severity.

Importance

Associations between atopic eczema and cancer are unclear, with competing theories that increased immune surveillance decreases cancer risk and that immune stimulation increases cancer risk. Establishing baseline cancer risk in people with atopic eczema is important before exploring the association between new biologic drugs for atopic eczema and cancer risk.

Objective

To investigate whether atopic eczema is associated with cancer.

Design, Setting, and Participants

Matched cohort studies were conducted from January 2, 1998, to March 31, 2016, in England and from January 1, 1982, to June 30, 2016, in Denmark. We conducted our analyses between July 2018 and July 2019. The setting was English primary care and nationwide Danish data. Participants with atopic eczema (adults only in England and any age in Denmark) were matched on age, sex, and calendar period (as well as primary care practice in England only) to those without atopic eczema.

Exposure

Atopic eczema.

Main Outcomes and Measures

Overall cancer risk and risk of specific cancers were compared in people with and without atopic eczema.

Results

In England, matched cohorts included 471 970 individuals with atopic eczema (median [IQR] age, 41.1 [24.9-60.7] years; 276 510 [58.6%] female) and 2 239 775 individuals without atopic eczema (median [IQR] age, 39.8 [25.9-58.4] years; 1 301 074 [58.1%] female). In Denmark, matched cohorts included 44 945 individuals with atopic eczema (median [IQR] age, 13.7 [1.7-21.1] years; 22 826 [50.8%] female) and 445 673 individuals without atopic eczema (median [IQR] age, 13.5 [1.7-20.8] years; 226 323 [50.8%] female). Little evidence was found of associations between atopic eczema and overall cancer (adjusted hazard ratio [HR], 1.04; 99% CI, 1.02-1.06 in England and 1.05; 99% CI, 0.95-1.16 in Denmark) or for most specific cancers. However, noncutaneous lymphoma risk was increased in people with atopic eczema in England (adjusted HR, 1.19; 99% CI, 1.07-1.34 for non-Hodgkin lymphoma [NHL] and 1.48; 99% CI, 1.07-2.04 for Hodgkin lymphoma). Lymphoma risk was increased in people with greater eczema severity vs those without atopic eczema (NHL adjusted HR, 1.06; 99% CI, 0.90-1.25 for mild eczema; 1.24; 99% CI, 1.04-1.48 for moderate eczema; and 2.08; 99% CI, 1.42-3.04 for severe eczema). Danish point estimates also showed increased lymphoma risk in people with moderate to severe eczema compared with those without atopic eczema (minimally adjusted HR, 1.31; 99% CI, 0.76-2.26 for NHL and 1.35; 99% CI, 0.65-2.82 for Hodgkin lymphoma), but the 99% CIs were wide.

Conclusions and Relevance

The findings from 2 large population-based studies performed in different settings do not support associations between atopic eczema and most cancers. However, an association was observed between atopic eczema and lymphoma, particularly NHL, that increased with eczema severity. This finding warrants further study as new immunomodulatory systemic therapeutics are brought to market that may alter cancer risk.

Evaluating Outwards Regeneration Effects (OREs) in Neighborhood-Based Projects: A Reversal of Perspective and the Proposal for a New Tool

This paper proposes a reversal of perspective in the evaluation of Regeneration projects. Until now, attention has been mainly focused on project “internal effectiveness”, in reference to the environment and life quality improvement of the areas directly affected by the interventions. The effects induced in the wider urban context are rarely sufficiently analyzed. This aspect instead opens an important field of investigation, useful for a broader assessment of regeneration initiatives, especially with regards to Public Housing Neighborhoods where the long-term project success also depends on the positive effects it generates in the surroundings. Therefore, the aim of this research is to develop a conceptualization of “Outwards Regeneration Effects” (OREs), based on an extensive literature review, and to make it operational through a conceptual framework for the qualitative analysis. The results of this study, on the one hand, highlight several critical issues raised by the interventions implemented so far, and, on the other hand, provide a more effective assessment framework, useful in the evaluation of future projects. Further developments of such an approach could lead to the development of operational evaluation models, combining both qualitative and quantitative indicators, starting from the implementation of the proposed analytic framework.

Hormone replacement therapy and asthma onset in menopausal women: National cohort study

BACKGROUND

There is uncertainty about the role of hormonal replacement therapy (HRT) in the development of asthma.

OBJECTIVE

We investigated whether use of HRT and duration of use was associated with risk of development of asthma in perimenopausal and postmenopausal women.

METHODS

We constructed a 17-year (from January 1, 2000, to December 31, 2016) open cohort of 353,173 women (aged 46-70 years) from the Optimum Patient Care Database, a longitudinal primary care database from across the United Kingdom. HRT use, subtypes, and duration of use; confounding variables; and asthma onset were defined by using the Read Clinical Classification System. We fitted multilevel Cox regression models to estimate hazard ratios (HRs) with 95% CIs.

RESULTS

During the 17-year follow-up (1,340,423 person years), 7,614 new asthma cases occurred, giving an incidence rate of 5.7 (95% CI = 5.5-5.8) per 1,000 person years. Compared with nonuse of HRT, previous use of any (HR = 0.83; 95% CI = 0.76-0.88), estrogen-only (HR = 0.89; 95% CI = 0.84-0.95), or combined estrogen and progestogen (HR = 0.82; 95% CI = 0.76-0.88) HRT was associated with a reduced risk of asthma onset. This was also the case with current use of any (HR = 0.79; 95% CI = 0.74-0.85), estrogen-only (HR = 0.80; 95% CI = 0.73-0.87), and combined estrogen and progestogen (HR = 0.78; 95% CI = 0.70-0.87) HRT. Longer duration of HRT use (1-2 years [HR = 0.93; 95% CI = 0.87-0.99]; 3-4 years [HR = 0.77; 95% CI = 0.70-0.84]; and ≥5 years [HR = 0.71; 95% CI = 0.64-0.78]) was associated with a dose-response reduced risk of asthma onset.

CONCLUSION

We found that HRT was associated with a reduced risk of development of late onset asthma in menopausal women. Further cohort studies are needed to confirm these findings.

Predictors of 30-day unplanned hospital readmission among adult patients with diabetes mellitus: a systematic review with meta-analysis

Adult patients with diabetes mellitus (DM) represent one-fifth of all 30-day unplanned hospital readmissions but some may be preventable through continuity of care with better DM self-management. We aim to synthesize evidence concerning the association between 30-day unplanned hospital readmission and patient-related factors, insurance status, treatment and comorbidities in adult patients with DM. We searched full-text English language articles in three electronic databases (MEDLINE, Embase and CINAHL) without confining to a particular publication period or geographical area. Prospective and retrospective cohort and case-control studies which identified significant risk factors of 30-day unplanned hospital readmission were included, while interventional studies were excluded. The study participants were aged ≥18 years with either type 1 or 2 DM. The random effects model was used to quantify the overall effect of each factor. Twenty-three studies published between 1998 and 2018 met the selection criteria and 18 provided information for the meta-analysis. The data were collected within a period ranging from 1 to 15 years. Although patient-related factors such as age, gender and race were identified, comorbidities such as heart failure (OR=1.81, 95% CI 1.67 to 1.96) and renal disease (OR=1.69, 95% CI 1.34 to 2.12), as well as insulin therapy (OR=1.45, 95% CI 1.24 to 1.71) and insurance status (OR=1.41, 95% CI 1.22 to 1.63) were stronger predictors of 30-day unplanned hospital readmission. The findings may be used to target DM self-management education at vulnerable groups based on comorbidities, insurance type, and insulin therapy.

Do alternative weighting approaches for an Index of Multiple Deprivation change the association with mortality? A sensitivity analysis from Germany

OBJECTIVES

This study aimed to assess the impact of using different weighting procedures for the German Index of Multiple Deprivation (GIMD) investigating their link to mortality rates.

DESIGN AND SETTING

In addition to the original (normative) weighting of the GIMD domains, four alternative weighting approaches were applied: equal weighting, linear regression, maximization algorithm and factor analysis. Correlation analyses to quantify the association between the differently weighted GIMD versions and mortality based on district-level official data from Germany in 2010 were applied (n=412 districts).

OUTCOME MEASURES

Total mortality (all age groups) and premature mortality (<65 years).

RESULTS

All correlations of the GIMD versions with both total and premature mortality were highly significant (p<0.001). The comparison of these associations using Williams's t-test for paired correlations showed significant differences, which proved to be small in respect to absolute values of Spearman's rho (total mortality: between 0.535 and 0.615; premature mortality: between 0.699 and 0.832).

CONCLUSIONS

The association between area deprivation and mortality proved to be stable, regardless of different weighting of the GIMD domains. The theory-based weighting of the GIMD should be maintained, due to the stability of the GIMD scores and the relationship to mortality.

Assessing the potential utility of commercial 'big data' for health research: Enhancing small-area deprivation measures with Experian™ Mosaic groups

In contrast to area-based deprivation measures, commercial datasets remain infrequently used in health research and policy. Experian collates numerous commercial and administrative data sources to produce Mosaic groups which stratify households into 15 groups for marketing purposes. We assessed the potential utility of Mosaic groups for health research purposes by investigating their relationships with Indices of Multiple Deprivation (IMD) for the British population. Mosaic groups showed significant associations with IMD quintiles. Correspondence Analysis revealed variations in patterns of association, with Mosaic groups either showing increasing, decreasing, or some mixed trends with deprivation quintiles. These results suggest that Experian's Mosaics additionally measure other aspects of socioeconomic circumstances to those captured by deprivation measures. These commercial data may provide new insights into the social determinants of health at a small area level.

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Mosaic groups showed a significant association with IMD quintiles.

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Trend patterns varied between different Mosaic groups across IMD quintiles.

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Mosaic groups have potential to enhance routinely used socioeconomic measures in research.

[Indices of Multiple Deprivation for the analysis of regional health disparities in Germany : Experiences from epidemiology and healthcare research]

BACKGROUND

Deprivation indices allow material and social differences at the regional level to be described in a statistically efficient and concise manner and to use these in health analyses. Following the British example, Indices of Multiple Deprivation (IMDs) are now available for Germany, the German Index of Multiple Deprivation (GIMD) as well as its regional versions. In this study, empirical experiences based on the use of these indices in health studies will be presented.

METHOD

The German IMDs consist of seven deprivation domains, which represent single aspects of deprivation (income, employment, and educational deprivation, municipal revenue deprivation, social capital deprivation, environment and security deprivation). Specific indicators were generated from data of official statistics and assigned to the deprivation domains. The weighted single domains were finally combined to an overall index. The German IMDs are available at a municipal level and at a district level.

RESULTS

Analyses using the IMDs showed significant associations between regional deprivation and mortality, morbidity and aspects of health services research. Multilevel analyses showed significant associations with regional deprivation, independent of individual factors.

CONCLUSIONS

The German IMDs are valid and efficient tools for the use in epidemiology and health services research, but also for health policy. When constructing deprivation indices, several methodological challenges have to be considered.

Charity financial support to motor neuron disease (MND) patients in Greater London: the impact of patients' socioeconomic status-a cross-sectional study

OBJECTIVE

There is an immense socioeconomic burden for both the patients with motor neuron disease (MND) and their families. The aim of this study is to evaluate the extent to which the provision offered by the Motor Neurone Disease Association is distributed among patients with MND living in the ethnically and socially diverse area of Greater London, according to the patients' socioeconomic situation and needs.

SETTING

Greater London, where age and sex-adjusted prevalence rates of MND in 2016 were calculated.

PARTICIPANTS

Prevalent MND cases in Greater London, using anonymised data extracted from the Association's database.

EXPOSURE

Demographic and socioeconomic characteristics PRIMARY AND SECONDARY OUTCOME MEASURES: Receiving a Motor Neurone Disease Association grant, and the amount of money received.

RESULTS

396 individuals with amyotrophic lateral sclerosis were detected, the age-specific and sex-specific prevalence of MND was 4.02 per 100 000 inhabitants, higher among men (5.13 per 100 000) than women (3.01 per 100 000). Men were statistically significantly 40% less likely to receive a grant compared with women; among grant recipients, the younger the age of the participant, the higher the size of the grant received. The Index of Multiple Deprivation was not associated with either receiving a grant nor the amount of money received, among recipients.

CONCLUSION

Financial support by the Motor Neurone Disease Association is provided across individuals and across boroughs regardless of their socioeconomic circumstances. Differences that benefits women and younger patients were detected.

[A deprivation index to reform the financing model of primary care in Catalonia (Spain)]

OBJECTIVE

To build a deprivation index for the assignation of the budgets of the primary healthcare teams in Catalonia (Spain) valid for both urban and rural environments and updatable with greater frequency than indices built from census variables.

METHOD

Starting from a review of the most common deprivation indices, variables were selected from sources that allow frequent updating and are representative at the territorial level of primary care. The correlations were calculated between the chosen variables and variables of need for healthcare and morbidity. principal components analysis was applied. Finally, the correlations of the index built with the MEDEA index and with variables of use of healthcare resources and morbidity was calculated stratifying by geographical dispersion.

RESULTS

The variables of income, occupation and education are the ones with the highest correlation with the need for healthcare and morbidity. The composed socioeconomic index (CSI) ranges from -.01 to 5.68, with an average value of 2.60 and a standard deviation of .91. The correlation between the CSI and the MEDEA index is .89. The CSI correlates with use for healthcare in both urban and rural environments, although in rural environments the association is lower.

CONCLUSIONS

The CSI was built with data that allow frequent updating and was integrated in the model for allocating resources to primary healthcare starting in 2017.

A framework for the identification and classification of homogeneous socioeconomic areas in the analysis of health care variation

BACKGROUND

Detecting the variation of health indicators across similar areas or peer geographies is often useful if the spatial units are socially and economically meaningful, so that there is a degree of homogeneity in each unit. Indices are frequently constructed to generate summaries of socioeconomic status or other measures in geographic small areas. Larger areas may be built to be homogenous using regionalization algorithms. However, there are no explicit guidelines in the literature for the grouping of peer geographies based on measures such as area level socioeconomic indices. Moreover, the use of an index score becomes less meaningful as the size of an area increases. This paper introduces an easy to use statistical framework for the identification and classification of homogeneous areas. We propose the Homogeneity and Location indices to measure the concentration and central value respectively of an areas' socioeconomic distribution. We also provide a transparent set of criteria that a researcher can follow to establish whether a set of proposed geographies are acceptably homogeneous or need further refining.

RESULTS

We applied our framework to assess the socioeconomic homogeneity of the commonly used SA3 Australian census geography. These results showed that almost 60% of the SA3 census units are likely to be socioeconomically heterogeneous and hence inappropriate for presenting area level socioeconomic disadvantage. We also showed that the Location Index is a more robust descriptive measure of the distribution compared to other measures of central tendency. Finally, the methodology proposed was used to analyse the age-standardized variation of GP attenders in a metropolitan area. The results suggest that very high GP attenders (20+ visits) live in SA3s with the most socioeconomic disadvantage. The findings revealed that households with low income and families with children and jobless parents are the major drivers for discerning disadvantaged communities.

CONCLUSION

Reporting indicators rates for geographies grouped according to similarity may be useful for the analysis of geographic variation. The use of a framework for the identification of meaningful peer geographies would be beneficial to health planners and policy makers by providing realistic and valid peer group geographies.

The development of an index of rural deprivation: A case study of Norfolk, England

Geographical deprivation indices such as the English Index of Multiple Deprivation (IMD) have been widely used in healthcare research and planning since the mid-1980s. However, such indices normally provide a measure of disadvantage for the whole population and can be inflexible to adaptation for specific geographies or purposes. This can be an issue, as the measurement of deprivation is subjective and situationally relative, and the type of deprivation experienced within rural areas may differ from that experienced by urban residents. The objective of this study was to develop a Rural Deprivation Index (RDI) using the English county of Norfolk as a case study, but with a view to adopting a flexible approach that could be used elsewhere. It is argued that the model developed in this research gives clarity to the process of populating an index and weighting it for a specific purpose such as rural deprivation. This is achieved by 'bundling' highly correlated indicators that are applicable to both urban and rural deprivation into one domain, and creating a separate domain for indicators relevant to the setting of interest, in this case rural areas. A further domain is proposed to account for population differences in rural areas. Finally, a method was developed to measure variability in deprivation within small areas. The RDI results in more rural areas in Norfolk falling in the most deprived quintile, particularly those classified as 'Rural town and fringe in sparse settings'; these areas also have high levels of heterogeneity of deprivation when using the variability measure created. This model proposed has the potential to provide a starting point for those who wish to create a summary deprivation measure taking into account rurality, or other local geographic factors, and as part of a range of approaches that can be used to allocate, or apply for, resources.

Association between smoking and health outcomes in an economically deprived population: the Liverpool Lung Project

BACKGROUND

The association between smoking and several health outcomes among those from the most deprived communities in the UK has not previously been detailed. The aim of this study is to examine the impact of smoking on health outcomes specifically among a particularly deprived population in a developed country (Liverpool; one of the most deprived local authorities in England).

METHODS

The Liverpool Lung Project recruited a prospective cohort of 8753 participants from across Liverpool, aged 45-79 years between 1998 and 2008. Participants were followed annually through the Hospital Episode Statistics until 31 January 2013. Logistic regression models were used to identify health outcomes of smoking.

RESULTS

From our study population, 5195 were smokers and 3558 were non-smokers. Smoking was associated with male gender (OR 1.62, 95% CI 1.48 to 1.77), pneumonia (1.28, 95% CI 1.10 to 1.49), chronic obstructive pulmonary disease (1.30, 95% CI 1.14 to 1.48), emphysema (5.46, 95% CI 3.48 to 8.55), bronchitis (1.85, 95% CI 1.65 to 2.07), other cancers (1.69, 95% CI 1.44 to 1.99), lung cancer (6.0, 95% CI 3.72 to 9.69), diabetes (1.21, 95% CI 1.02 to 1.43) and cardiovascular disease (1.45, 95% CI 1.25 to 1.67).

CONCLUSIONS

Smokers from deprived backgrounds in Liverpool showed increased risk of developing pneumonia, emphysema, chronic obstructive pulmonary disease, bronchitis, lung cancer, other types of cancer, cardiovascular disease and diabetes. These findings are in line with the literature and may help to inform public health policies and ultimately work towards addressing smoking-related health inequalities.

Utilizing Lung Cancer Risk Prediction Models to Promote Smoking Cessation: Two Randomized Controlled Trials

Purpose:

The current project sought to examine whether delivery of lung cancer risk projections (calculated using the Liverpool Lung Project [LLP] risk model) predicted follow-up smoking status.

Design:

Two single-blinded randomized controlled trials.

Setting:

Stop Smoking Services in Liverpool (United Kingdom).

Participants:

Baseline current smokers (N = 297) and baseline recent former smokers (N = 216) were recruited.

Intervention:

Participants allocated to intervention groups were provided with personalized lung cancer risk projections, calculated using the LLP risk model.

Measures:

Baseline and follow-up questionnaires explored sociodemographics, smoking behavior, and lung cancer risk perceptions.

Analysis:

Bivariate analyses identified significant differences between randomization groups, and logistic regression models were developed to investigate the intervention effect on the outcome variables.

Results:

Lung cancer risk projections were not found to predict follow-up smoking status in the trial of baseline current smokers; however, they did predict follow-up smoking status in the trial of baseline recent former smokers (odds ratio: 1.91; 95% confidence interval: 1.03-3.55).

Conclusion:

The current study suggests that lung cancer risk projections may help maintain abstinence among individuals who have quit smoking, but the results did not provide evidence to suggest that lung cancer risk projections motivate current smokers to quit.

Incorporating Environmental Justice into Second Generation Indices of Multiple Deprivation: Lessons from the UK and Progress Internationally

Second generation area-based indices of multiple deprivation have been extensively used in the UK over the last 15 years. They resulted from significant developments in political, technical, and conceptual spheres for deprivation data. We review the parallel development of environmental justice research and how and when environmental data was incorporated into these indices. We explain the transfer of these methods from the UK to Germany and assess the progress internationally in developing such indices. Finally, we illustrate how billions of pounds in the UK was allocated by using these tools to tackle neighbourhood deprivation and environmental justice to address the determinants of health.

What's in a Name? Exploring the Nomenclature of Science Communication in the UK

This study, via a consideration of the literature, and a limited survey of active science communicators, presents concise and workable definitions for science outreach, public engagement, widening participation, and knowledge exchange, in a UK context. 

Sixty-six per cent of participants agreed that their definitions of outreach, public engagement, and widening participation aligned with those of their colleagues, whilst 64% felt that their personal definitions matched those of their institute. However, closer inspection of the open-ended questions found the respondents often differed in the use of the nomenclature. In particular, the respondents found it difficult to define knowledge exchange in this context. It is hoped that this initial study will form the foundation of future work in this area, and that it will help to further develop the debate regarding the need for a consistent nomenclature across science communication.

Evaluating the social determinants of teenage pregnancy: a temporal analysis using a UK obstetric database from 1950 to 2010

BACKGROUND

Teenage pregnancy is a known social problem which has been previously described using a number of deprivation measures. This study aimed to explore the temporal patterns of teenage pregnancy in Aberdeen, Scotland and to assess the discriminating ability of three measures of socioeconomic status.

METHODS

This was a population-based study from 1950 to 2010, using data from the Aberdeen Maternity Neonatal Databank (AMND). The main outcome variable was conceptions occurring in women aged less than 20 years. This study used two area-based measures, the Scottish Index of Multiple Deprivation (SIMD) and the Carstairs index, and one individual-based measure the Social Class based on Occupation (SCO). These measures were compared for their association with teenage conceptions using logistic regression models. The models were used to determine receiver operating characteristic (ROC) curves showing the discriminating ability of the measures.

RESULTS

There was an overall decline in teenage conceptions over the 60-year period, but an increase in the rate ratio for deprived areas. All the measures of socioeconomic status were highly associated with teenage pregnancy. The adjusted OR of SIMD and teenage conception was 5.72 (95% CI 4.62 to 7.09), which compared the most deprived decile with the least deprived decile. The use of ROC curves showed that socioeconomic measures performed better than chance at determining teenage conceptions (χ(2)=21.67, p≤0.0001). They further showed that the SIMD had the largest area under the curve (AUC) with a value of 0.81 (95% CI 0.80 to 0.82), followed by the Carstairs index with an AUC of 0.80 (95% CI 0.78 to 0.80), then by SCO with an AUC of 0.79 (95% CI 0.78 to 0.80).

CONCLUSIONS

Despite a slight decline in teenage pregnancies over the past decades, there is still an evident association between deprivation and teenage pregnancy. This study shows that all the measures of socioeconomic status were highly associated with teenage pregnancy, with the SIMD having the greatest discriminatory effect.

Maternal residential proximity to major roads in north west England and adverse pregnancy outcomes

OBJECTIVE

To investigate the effects of maternal residential proximity to major roads on adverse pregnancy outcomes.

METHODS

Major road networks in North West England were linked to the maternal residence of 190,909 births (2004 to 2008). Distance between the residence and the nearest major road was calculated and dichotomized at 200 m. Logistic regression analyses were performed to investigate the association between distance to the major road with small for gestational age, low birth weight, and preterm birth. Analyses were adjusted for maternal age, ethnicity, socioeconomic status, parity, birth season, smoking, and body mass index.

RESULTS

No significant associations were observed between preterm birth (odds ratio [OR] = 1.04; 95% confidence interval [CI] = 0.98 to 1.11), low birth weight (OR = 0.99; 95% CI = 0.93 to 1.05) and small for gestational age (OR = 1.00; 95% CI = 0.95 to 1.06) and living less than 200 m from a major road.

CONCLUSIONS

These results, from a study with high statistical power, suggest that living less than 200 m from a major road per se does not pose any great risk of an adverse perinatal outcome. Nevertheless, it may be limited to this geographic location. Further work is needed to quantify individual pollutant effects in pregnancy.

Tourette syndrome and chronic tic disorder are associated with lower socio-economic status: findings from the Avon Longitudinal Study of Parents and Children cohort

AIM

Only a few studies have examined the relationship between Tourette syndrome or chronic tic disorder and socio-economic status (SES). Existing studies are primarily cross-sectional, arise from specialty clinics, and use single measures of SES. In this study we examine this relationship in a longitudinal, population-based sample.

METHOD

Data are from 7152 children born during 1991 and 1992 in the county of Avon, UK, from the Avon Longitudinal Study of Parents and Children, who were followed up to age 13. After exclusions for intellectual disability* and autism, 6768 participants (3351 males [49.5%]) and 3417 females [50.5%]) remained. Parental SES was assessed using multiple measures during pregnancy and at 33 months of age. Presence of Tourette syndrome or chronic tics was determined from repeated maternal questionnaires up to when the child was 13 years of age.

RESULTS

Multiple SES measures were associated with an approximately twofold increased risk of Tourette syndrome and chronic tics. A postnatal composite factor score (lowest vs highest tertile odds ratio 2.09, 95% confidence interval 1.38-3.47) provided the best fit to the data.

INTERPRETATIONS

As is seen in several childhood conditions, such as cerebral palsy and autism, lower SES is a risk factor for Tourette syndrome/chronic tics. Potential explanations include differential exposure to environmental risk factors or parental psychopathology as a measure of an increased genetic risk leading to decreased parental SES.