Integrating national surveys to estimate small area variations in poor health and limiting long-term illness in Great Britain

Small area deprivation and stigmatising attitudes towards mental illness: a multilevel analysis of Health Survey for England (2014) data

PURPOSE

The aim of this study was to explore how small area deprivation is associated with attitudes towards mental illness in a large sample of individuals living in private households in England.

METHOD

Cross-sectional data from Health Survey for England (2014) were analysed using multilevel models. The exposure of interest was the deprivation level of the small area in which an individual resides as measured by Index of Multiple Deprivation (IMD) score. The primary outcome was an individual's overall attitude towards mental illness, measured using a 12 item version of the Community Attitudes toward the Mentally Ill (CAMI) scale. Further outcomes were the two subscales of the CAMI, reflecting attitudes of (1) prejudice and exclusion and (2) tolerance and support. Individuals were nested within household and small geographical area.

RESULTS

5820 participants were included. Results from unadjusted models found strong evidence that individuals residing in the most deprived areas of England have worse attitudes towards mental illness compared to individuals living in the least deprived areas (estimated difference = - 3.5 points; 95% CI - 4.8 to - 2.2; P < 0.001). After adjusting for age, sex, education level, ethnicity and weekly income there was no longer evidence for this association (adjusted difference = - 0.1 points, 95% CI - 1.3 to 1.2; P = 0.931). Similar patterns of results were found for the CAMI subscales.

CONCLUSIONS

The relationship between small area-level deprivation and attitudes towards mental illness is no longer observed when controlling for certain individual-level characteristics.

The utility of geodemographic indicators in small area estimates of limiting long-term illness

Small area health data are not always available on a consistent and robust routine basis across nations, necessitating the employment of small area estimation methods to generate local-scale data or the use of proxy measures. Geodemographic indicators are widely marketed as a potential proxy for many health indicators. This paper tests the extent to which the inclusion of geodemographic indicators in small area estimation methodology can enhance small area estimates of limiting long-term illness (LLTI). The paper contributes to international debates on small area estimation methodologies in health research and the relevance of geodemographic indicators to the identification of health care needs. We employ a multilevel methodology to estimate small area LLTI prevalence in England, Scotland and Wales. The estimates were created with a standard geographically-based model and with a cross-classified model of individuals nested separately in both spatial groupings and non-spatial geodemographic clusters. LLTI prevalence was estimated as a function of age, sex and deprivation. Estimates from the cross-classified model additionally incorporated residuals relating to the geodemographic classification. Both sets of estimates were compared against direct estimates from the 2011 Census. Geodemographic clusters remain relevant to understanding LLTI even after controlling for age, sex and deprivation. Incorporating a geodemographic indicator significantly improves concordance between the small area estimates and the Census. Small area estimates are however consistently below the equivalent Census measures, with the LLTI prevalence in urban areas characterised as 'blue collar' and 'struggling families' being markedly lower. We conclude that the inclusion of a geodemographic indicator in small area estimation can improve estimate quality and enhance understanding of health inequalities. We recommend the inclusion of geodemographic indicators in public releases of survey data to facilitate better small area estimation but caution against assumptions that geodemographic indicators can, on their own, provide a proxy measure of health status.