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APPENDIX A
Health Inequalities
in Dartford
Draft version 1.4
Conall Watson, Terry Hall and Mark Chambers Public Health, NHS West Kent
September 2008
West Kent
2
CONTENTS Page
Contents
2
Executive Summary 3
Introduction 8
Key to Electoral Wards 9
1. Deprivation and Health 10
1.1 Recommendations to address deprivation as a cause of poor health 12
2. Life Expectancy 13
2.1 Disease causes of the life expectancy gap 15
2.1.1 Under 75 circulatory disease mortality 16
2.1.2 Coronary heart disease 17
2.1.3 COPD 18
2.1.4 Under 75 cancer mortality 19
2.2 Lifestyle causes of the life expectancy gap 20
2.2.1 Smoking 20
2.2.2 Obesity, exercise and diet 21
2.3 Recommendations to address life expectancy inequalities 22
3. Sexual Health 23
3.1 Teenage pregnancy 23
3.1.1 Teenage conceptions by electoral ward 24
3.2 Chlamydia screening 25
3.3 Recommendations to improve sexual health in Dartford 26
4. Other Conditions contributing to health inequalities 27
4.1 Diabetes 27
4.2 Depression and mental health 28
4.3 Road traffic and other accidents 28
5. Infant Health 29
5.1 Infant Mortality 29
5.2 Low Birthweight babies 30
5.3 Breastfeeding continuation 31
Glossary 32
Appendix 1: 2007 Indices of deprivation maps 34
Information Sources 40
We thank the team at the Kent Public Health Observatory for the data underpinning this report.
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EXECUTIVE SUMMARY
This report aims to identify health inequality gaps in Dartford local authority area, and to provide recommendations and target areas for PCT commissioners and local authority leaders in addressing and reducing health inequalities. 1. Deprivation and Health Deprivation is the strongest determinant of ill health. Deprivation is measured nationally for small areas of around 1500 households using a range of criteria e.g. owning a car. These small areas are called Lower Layer Super Output Areas (LLSOAs) and have been ranked from the most deprived to the lowest deprived Kent. Almost half the population of Dartford live in areas considered in the most deprived 40% of Kent’s LLSOAs. When grouped into blocks of 20% (quintiles) from least to highest deprivation, there are strong trends for the worst deprived quintiles to have the worst health outcomes, particularly for male life expectancy. Ensuring that the people in those socio economic groups and geographical areas have better engagement in and access to health and leisure services, better lifestyle opportunities and aspirations can reduce the gap in health outcome between those worst off and those best off. 1.1 Recommendations to address deprivation as a cause of poor health
• Health impact assessment should be considered for all major public and private sector projects in Dartford e.g. ‘town centre re-development’ re impact on access to health services, air quality, noise pollution and green/open spaces.
• Tackling unemployment by improving access to skills e.g. Jobcentre Plus in Swanscombe and Joyce Green coupled with increased welfare rights and budgeting advice/credit unions.
• A range of deprivation reducing measures should be targeted towards the most deprived areas of Dartford such as Darenth, Swanscombe, Littlebrook and Joyce Green to address specific community needs, e.g. quality of housing, back to work schemes, access to health and social service signposting.
• Tackling specific community concerns at a local level e.g. litter, anti social behaviour and feelings of isolation are important. Pact schemes and other neighbourhood fora may be ways of engaging with local people and highlighting their concerns.
2. Life Expectancy
While life expectancy has improved in line with national trends, the average life expectancy for all persons in Dartford is 78.8 years which is a full year less than the Kent County average.
Life expectancy in thirteen of the seventeen wards in Dartford is below the Kent average.
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The life expectancy gap between the people living in economically the best and worst wards in Dartford is 14 years and this is the largest gap of any local authority in Kent County. 2.1 Disease causes of the life expectancy gap The main contributors to differences in life expectancy gap between the most deprived quintile and the other areas are (largest first):
• Coronary heart disease (CHD)
• Chronic obstructive pulmonary/airway disease (COPD)
• Lung Cancer
• Stroke Other causes include suicide, other cancers in men, road traffic accidents in men, other accidents in women, heart failure in women and other circulatory causes in both sexes. CHD alone reduces male life expectancy by over a year between the most deprived quintile and the other areas. 2.2 Lifestyle causes of the life expectancy gap Smoking – The prevalence of smoking in Dartford is higher than the England average. Smoking rates are highest in the most deprived wards and this is the single greatest contributing agent to the top four killers in Dartford. Obesity, exercise and diet – Obesity rates in Dartford are higher than the England average. Dartford has significantly lower rates of adult physical activity and healthy eating than the England average. Obesity, lack of exercise and poor diets are associated with CHD, cancer and stroke, and contribute to other forms of ill-health such as diabetes, arthritis and depression. 2.3 Recommendations to address life expectancy inequalities
• Establish active lifestyle schemes based in leisure centres or through creative outreach to hard-to-reach groups and through referrals from GPs. These schemes should include exercise and weight management and help to get Dartford residents at risk of heart attacks and heart disease engaged with the excellent leisure facilities in the borough.
• Healthy living centres should be supported to provide non-NHS style, accessible services and provide a base for delivering health interventions to hard-to-reach groups e.g overweight white men in early 50s in a style relevant to that group of people (e.g. via social marketing).
• Workplace health schemes offering lunchtime exercise sessions and lifestyle support should be established at large local employers in the private and public sector.
• Tobacco control and smoking cessation – All smokers, particularly those already with a diagnosis of CHD, COPD or Cancer, should be offered referral to a smoking cessation service. Particular effort should be made to help those in
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the most deprived areas. Tobacco control should be rigorously enforced to prevent new uptake of smoking and prevent illicit sales.
• Identify, treat and make lifestyle referrals for people with high cardiac risk for people who have not yet had a major coronary event. GPs in the most deprived area should be supported to identify high cardiac risk patients, provide these patients with optimal medical preventative treatment, and to make referrals to a council-led exercise and lifestyle programme. Particular effort should be made to target hard-to-reach groups not normally attending GP services.
• Cardiac rehabilitation – Maintain and expand the cardiac rehabilitation service for patients following heart attack, coronary bypass surgery or percutanous coronary intervention. These are the highest risk cardiac patients. Consider extension to heart failure, abdominal aortic aneurysm, angina and those with implantable defibrillators.
• Better Management of depression and anxiety – This is also a risk factor for CHD. It is also an underlying reason for the rise in ‘risky’ health and lifestyle behaviours such as alcohol misuse and smoking, suicide and violence. By tackling this issue by raising awareness, reducing stigma, providing healthy ways of managing emotions e.g. through exercise and community participation, a range of health benefits can occur.
3. Sexual Health 3.1 Teenage pregnancy Compared with pregnancy in women in their 20s and 30s, teenage pregnancy is more likely to result in poor child and maternal health, and for mother and child to live in poverty. While the Dartford conception rate (41.3 per 1000 girls age 15-17) is similar to the national rate, the national rate is highest in Western Europe and should be halved. There is considerable variation within Dartford. Stone ward has one of the highest rates in the country, exceeding 100 per 1000 girls age 15-17. Joyce Green and Greenhithe wards have rates between 50 and 75 per 1000. Littlebrook, Town, Newtown, Swanscombe, Princes, Bean & Darenth and Longfield, New Barn & Southfleet also have rates above 25 per 1000. 3.2 Chlamydia screening Chlamydia is the most common sexually transmitted infection in the UK. Untreated, it can cause infertility and other health problems and screening for infection is a necessary first step for detection and treatment. Screening in Dartford has covered less than 1% of people aged 15-24, well below the national target of 15%. 3.3 Recommendations to improve sexual health in Dartford
• Expansion of the C-card (condom card) scheme for accessing condom and emergency contraceptive services. Currently only targeted at women, this could be expanded to cover men. Services should be targeted to the areas with the highest rates of teenage pregnancy.
6
• Comprehensive relationship and sex education schemes in schools. Experience from continental Europe has show the importance of relationships education as a necessary basis for sex education, rather than the biological models of sex education traditionally provided (if provided at all) in British schools.
• Support for teenage mothers to ensure they are not left behind in educational, social and economic opportunities.
• Community sexual health services e.g. within healthy living centres should be developed to deliver sexual health advice and services in deprived areas and should include information and signposting on chlamydia testing and the full range of contraceptive methods including reversible, emergency and long acting reversible contraceptives.
4 Other Conditions Contributing to Health Inequalities 4.1 Diabetes Diabetes is a major risk factor for cardiac disease, stroke, kidney disease and blindness. Hospital admission statistics suggest that more could be done to help diabetes patients in more deprived areas manage their condition better. Interventions on diet, exercise and weight management will reduce the onset of type two diabetes in the local population. 4.2 Depression and mental health Suicide in the most deprived quintile is also a contributor to the life expectancy gap in Dartford, and is suggestive of depression and poor mental health in the wider population. While the incidence of suicide is likely to be low, the relatively young age at which these events often occurs contributes to proportionally more lost years of life. A Kent-wide mental health needs assessment is underway and should be used to inform action in Dartford. 4.3 Road traffic and other accidents In the most deprived quintile, road traffic accidents in men and other accidents in women contribute to the life expectancy gap. While the number involved are relatively low, the relatively young age at which these events often occurs contributes to proportionally more lost years of life. Further investigation is necessary to determine if action is required, and what form any action should take. 5. Infant Health 5.1 Infant Mortality Infant mortality is lower in Kent County and the South East compared with the England average, and Dartford follows that trend. There is a slightly higher mortality rate in the most deprived quintile compared to the England average, though the data
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are prone to distortion at this level and should be monitored, rather than necessitating action at this time. 5.2 Low birthweight babies Dartford, Kent and the South East have lower rates of low birthweight deliveries than the England average. There is a deprivation link with low birthweight, though the rate of low birthweight in the most deprived quintile areas of Dartford is equivalent to the England average and does not present particular concern. 5.5 Breastfeeding Continuation The proportion of infants in Dartford being exclusively breastfed at 6-8 weeks is low in absolute terms and in comparison to Kent County Council area or the NHS West Kent area. The most deprived quintile in Dartford has a lower rate of breastfeeding than the other quintiles. Recent guidance from NICE (PH011) should be reviewed and appropriate action implemented.
8
INTRODUCTION
This report aims to identify health inequality gaps in Dartford local authority area, and to provide recommendations and target areas for PCT commissioners, local authority leaders and other partners in addressing and reducing health inequalities. Action to address health inequalities requires the work of multiple agencies and sectors, and this is reflected in the range of suggested interventions, which extend to a number of partners outside the NHS. The report incorporates data on current health status and information on factors known to influence health in relation to deprivation. Figures for the Kent, South East Region and England have been included where available to enable local, regional and national comparisons. It also provides a compendium of health indicators which can be distributed to staff in all organisations with an interest in health inequalities in Kent. For further information on some of the terms used, please see the glossary at the end of this report.
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KKKKEY TO EY TO EY TO EY TO EEEELECTORAL LECTORAL LECTORAL LECTORAL WWWWARD IN ARD IN ARD IN ARD IN DDDDARTFORD ARTFORD ARTFORD ARTFORD
LALALALA
© Crown Copyright 2007. All rights reserved. Ordnance Survey Licence number 100045473.
No. Ward Name
1 Sutton-at-Hone and Hawley
2 Longfield, New Barn and Southfleet
3 Joyce Green
4 Stone
5 Heath
6 Brent
7 Littlebrook
8 Greenhithe
9 West Hill
10 Bean and Darenth
11 Newtown
12 Castle
13 Wilmington
14 Swanscombe
15 Town
16 Joydens Wood
17 Princes
10
1. Deprivation and Health The Chief Medical Officer for England has identified coastal health inequalities as a health priority for the South East of England1. Dartford is one of those areas identified as having a health inequality gap.
Deprivation remains the greatest determinant of health and ill health at both a local and international level. The WHO Commission on Social Determinants of Health notes that where systematic differences in health are avoidable by reasonable action, they should be addressed2.
Nationally, deprivation is measured for small areas of around 1500 households using a range of criteria e.g. owning a car. These small areas are called Lower Layer Super Output Areas (LLSOAs) and have been ranked from the most deprived to the least deprived Kent.
Almost half the population of Dartford live in areas considered in the most deprived 40% of Kent’s LLSOAs. When grouped into blocks of 20% (quintiles) from least to highest deprivation, there are strong trends for the most deprived quintiles to have the worst health outcomes, particularly for male life expectancy. Ensuring that the people in those socio-economic groups and geographical areas have better engagement in and access to health and leisure services, better lifestyle opportunities and aspirations can reduce the gap in health outcome between those worst off and those best off.
A more complete description of the deprivation criteria is given in the glossary, under “Indices of Deprivation”. Appendix 1 maps the different forms of deprivation in Dartford.
1 Donaldson L 2006. Annual Report of the Chief Medical Officer. Department of Health: London.
p72 2 Marmot M et al 2008. Closing the gap in a generation: Health equity through action on the social
determinants of health. Geneva: Commission on Social Determinants of Health, WHO.
11
The following tables compare mortality (death) rates in the different deprivation quintile bands over two time periods. They show that while mortality rates in Dartford have improved in line with the rest of England between 1995-7 and 2004-6, a gap still exists between the most and least deprived quintiles. Although the gap between highest and lowest quintiles has narrowed, this is in part due to a rise in the mortality rate in the least deprived quintile, rather than more deprived quintiles fully “catching up” with the least deprived.
Directly age-standardised mortality per 100,000 residents, 2004 - 2006Source: ONS Annual deaths extract and census population enumerations
0
100
200
300
400
500
600
700
800
900
1000
1 2 3 4 5
Kent deprivation ( 1 = most deprived )
Ag
e-s
tan
dard
ised
mo
rtality
rate
Dartford
England
South East
KCC
Directly age-standardised mortality per 100,000 residents, 1995 - 1997
Source: ONS Annual deaths extract and census population enumerations
0
100
200
300
400
500
600
700
800
900
1000
1 2 3 4 5
Kent deprivation ( 1 = most deprived )
Ag
e-s
tan
dard
ised
mo
rtality
rate
Dartford
England
South East
KCC
12
1.1 Recommendations to address deprivation as a cause of poor health
• Health impact assessment should be considered for all major public and private sector projects in Dartford e.g. ‘town centre re-development’ re impact on access to health services, air quality, noise pollution and green/open spaces.
• Tackling unemployment by improving access to skills e.g. Jobcentre Plus in Swanscombe and Joyce Green coupled with increased welfare rights and budgeting advice/credit unions.
• A range of deprivation reducing measures should be targeted towards the most deprived areas of Dartford such as Darenth, Swanscombe, Littlebrook and Joyce Green to address specific community needs, e.g. quality of housing, back to work schemes, access to health and social service signposting.
• Tackling specific community concerns at a local level e.g. litter, anti social behaviour and feelings of isolation are important. Pact schemes and other neighbourhood fora may be ways of engaging with local people and highlighting their concerns.
• .
13
2. LIFE EXPECTANCY
Life expectancy is best considered as a snapshot of the health of the population, reflecting mortality (death) rates in all age groups. While life expectancy in Dartford has improved in line with national trends, the average life expectancy for all persons in Dartford is 78.8 years, which is a full year less than the Kent County average. Life expectancy in thirteen of the seventeen wards in Dartford is below the Kent average. The life expectancy gap between people living in the longest living and shortest living wards in Dartford is 14 years. The gap between the most deprived quintile of LLSOAs and least deprived quintile is 8.3 years. These are the largest life expectancy gaps of any local authority in Kent County, indicating relative inequality in life expectancy in Dartford, even beyond that predicted for deprivation alone.
Gaps in Local Authority Life Expectancy - ONS Ward Level
Statistics 1999-2003
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
Ash
ford
Can
terb
ury
Dar
tfor
d
Dove
r
Gra
vesh
am
Maidst
one
Seven
oaks
Shepway
Swal
e
Thanet
Tonbr
idge
& M
allin
g
Tunbr
idge
wel
lsKen
t
Gap
in
Life E
xp
ecta
ncy
Best/ WorstWard Gap
Best/WorstQuintile Gap
Gaps in Local Authority Life Expectancy – ONS ward statistics and by deprivation
14
Life Expectancies for Dartford Wards
When life expectancy by deprivation quintile (Dartford quintiles) is recorded by sex, the overall gap can be seen to be largely due to differences in male life expectancy.
Inequalities in life expectancy (2002-2006) for men and women who live in areas with different levels of deprivation (areas are ranked for Dartford local authority area, not Kent county area).
Source: APHO Dartford Profile 2008. Most deprived 20% of local wards are Joyce Green, Little Brook and Princes.
Area Best WardWorst
Ward
LA
Average
Best/ Worst
Ward Gap
Average LE
bottom quintile
Average LE top
quintile
Best/Worst
Quintile Gap
Ashford 85.6 74.1 80.2 11.5 76.9 83.2 6.2
Canterbury 85.0 75.7 79.6 9.3 77.1 82.9 5.7
Dartford 89.0 75.0 78.8 14.0 75.9 84.2 8.3
Dover 82.2 73.5 77.8 8.7 74.1 80.9 6.8
Gravesham 83.0 74.6 79.3 8.4 76.4 82.1 5.7
Maidstone 85.0 76.1 79.7 8.9 76.7 82.7 5.9
Sevenoaks 85.1 77.6 80.9 7.5 78.6 83.5 4.9
Shepway 84.1 73.6 78.7 10.5 75.3 82.9 7.5
Swale 82.4 74.2 78.2 8.2 75.4 81.2 5.9
Thanet 81.0 72.4 77.9 8.6 74.8 80.8 6.0
Tonbridge & Malling 85.0 76.3 79.9 8.7 77.1 82.7 5.5
Tunbridge wells 83.5 76.7 79.9 6.8 77.5 82.1 4.6
Kent 87.5 72.3 79.8 15.2 76.0 82.4 6.4
15
2.1 Disease causes of the life expectancy gap The London public health observatory gap analysis tool identifies diseases which could be targeted to reduce inequalities in life expectancy. The top three contributors to life expectancy gap between the most deprived quintiles and the other four quintiles are (in descending order) coronary heart disease (CHD), chronic obstructive pulmonary/airways disease (COPD) and lung cancer. Premature death from CHD alone reduces male life expectancy by over a year. Stroke is also a significant contributor to death, particularly in women. Other causes include suicide, other cancers in men, road traffic accidents in men, other accidents in women, heart failure in women and other circulatory causes in both sexes. Life expectancy gap between the most deprived quintile in Dartford and the average of the other four quintiles.
Source: LHO gap analysis tool, June 2008.
16
2.1.1 Under 75 Circulatory Disease Mortality These tables compare trends in the combined death rates for coronary heart disease, stroke and other circulatory disease causes of death in the under 75s. These diseases share common risk factors and together represent the largest contribution to the life expectancy gap between deprivation groups. Premature circulatory death rates have fallen across the range of deprivation quintiles. Significant improvement has been seen in the mortality rate for the most deprived quintile, which has reduced by around 50%, though mortality rates are still significantly higher in the two most deprived quintiles when compare to the least deprived quintile and rates for the south east of England.
Directly age-standardised mortality per 100,000 residents, 1995 - 1997
Source: ONS Annual deaths extract and census population enumerations
0
50
100
150
200
250
300
1 2 3 4 5
Kent deprivation ( 1 = most deprived )
Ag
e-s
tan
dard
ised
mo
rtality
rate
Dartford
England
South East
KCC
Directly age-standardised mortality per 100,000 residents, 2004 - 2006
Source: ONS Annual deaths extract and census population enumerations
0
50
100
150
200
250
300
1 2 3 4 5
Kent deprivation ( 1 = most deprived )
Ag
e-s
tan
dard
ise
d m
ort
ality
rate
Dartford
England
South East
KCC
17
2.1.2 Coronary Heart Disease Coronary heart disease (CHD) is the “furring-up” of the arteries supplying the heart with blood. If there is insufficient blood supply, this can cause chest pain (angina), while a full blockage leads to death of heart muscle and is a “heart attack” (myocardial infarction). CHD is the single largest contributor to the life expectancy gap in Dartford. There is a clear deprivation-associated trend; the admission rate is significantly higher in the two most deprived quintiles compared to the two least deprived quintiles. CHD hospital admissions Hospital emergency admission reflect a number of factors, not only the local health of the population, but also how their illnesses are managed by the patients and in primary care, and the ability of the public to access appropriate services, both NHS and non-NHS, such as social services. CHD has a number of modifiable risk factors such as smoking, obesity, not taking exercise, having high cholesterol or high blood pressure. Intervention to reduce hospital admissions and CHD deaths is required at many levels. Alongside cardiac rehabilitation, exercise programmes, weight management, tobacco control and smoking cessation, there is work that can be done in GP practices or similar to ensure that people with risks for CHD are appropriately treated with statins for cholesterol and appropriate blood pressure lowering medication.
Directly age-standardised emergency admission rate for CHD by
deprivation quintile; Dartford LA residents aged 16+, 2004/05-2006/07
0
200
400
600
800
1000
1200
1400
1600
1800
1 2 3 4 5
Kent deprivation quintile (1=most deprived)
Avera
ge a
nnual e
merg
ency a
dm
issio
n r
ate
per
100,0
00 r
esid
ents
aged 1
6+
Dartford
KCC area
West Kent PCT
Sources: Admissions from NWCS & SUS;
Deprivation from DCLG IMD 2007; Populations
from ONS 2001 Census
18
2.1.3 COPD Chronic obstructive airway/pulmonary disease (COPD) represents a loss of lung and airway function, presenting as shortness of breath. It can progress to respiratory failure and death and is almost entirely associated with smoking. COPD hospital admissions Emergency admission rates for Dartford patients in deprivation quintiles 1 and 2 are above the average for Kent County Council area. The rate in the most deprived quintile is more than twice the local average, and more than five times higher than the rate in the least deprived quintile. This is a significant health inequality, reflecting smoking and industrial exposure in the most deprived quintile. Intervention to help smokers quit and to discourage new smokers will reduce the incidence of COPD, and stopping smoking will significantly improve the disease course for an established COPD patient, more than any medication-based treatment. There may also be a role for respiratory outreach teams optimising treatment of new and established COPD patients.
Directly age-standardised emergency admission rate for COPD by
deprivation quintile; Dartford LA residents aged 16+, 2004/05-2006/07
0
200
400
600
800
1000
1200
1400
1 2 3 4 5
Kent deprivation quintile (1=most deprived)
Avera
ge a
nnual e
merg
ency a
dm
issio
n r
ate
per
100,0
00 r
esid
ents
aged 1
6+
Dartford
KCC area
West Kent PCT
Sources: Admissions from NWCS & SUS;
Deprivation from DCLG IMD 2007; Populations
from ONS 2001 Census
19
2.1.4 Under 75 Cancer Mortality Under 75 cancer mortality rates have improved in line with England trends, though mortality rate gains have not been shared equally across deprivation quintiles. Though the statistical confidence intervals do not allow it to be stated with certainty, there is a strong suggestion from the data that premature cancer death rates are still higher the more deprived areas of Dartford. The breakdown of cancer life expectancy gaps presented in section 2.1 indicates that there are deprivation related gaps in life expectancy due to cancers of the lung, oesophagus (throat), stomach and colon-rectum. Preventative strategies for these cancers should address smoking, healthy diets and obesity.
Directly age-standardised mortality per 100,000 residents, 1995 - 1997
Source: ONS Annual deaths extract and census population enumerations
0
20
40
60
80
100
120
140
160
180
200
1 2 3 4 5
Kent deprivation ( 1 = most deprived )
Ag
e-s
tan
dard
ised
mo
rta
lity
ra
te
Dartford
England
South East
KCC
Directly age-standardised mortality per 100,000 residents, 2004 - 2006
Source: ONS Annual deaths extract and census population enumerations
0
20
40
60
80
100
120
140
160
180
200
1 2 3 4 5
Kent deprivation ( 1 = most deprived )
Ag
e-s
tan
dard
ised
mo
rtality
rate
Dartford
England
South East
KCC
20
2.2 Lifestyle causes of the life expectancy gap 2.2.1 Smoking The prevalence of smoking in Dartford is higher than the England average of 24% (Health Survey of England 2003-5). Although there are wide confidence intervals associated with the ward-level data, the trend strongly suggests smoking prevalence is higher in more deprived wards. Smoking is the single greatest preventable contributor to the top four killer diseases in Dartford.
0
10
20
30
40
50
60
Swan
scom
be
Joyc
e Gre
en
Littleb
rook
Sto
ne
Prin
ces
Cas
tle
New
town
Town
Gre
enhith
e
Bea
n an
d Dar
enth
Bre
nt
Sutto
n-at
-Hon
e an
d Haw
ley
Wes
t Hill
Hea
th
Joyd
ens W
ood
Wilm
ingt
on
Long
field, N
ew B
arn
and
South
fleet
Dar
tford
LA
Electoral ward
Estim
ate
d s
mo
kin
g p
reva
len
ce
(%
)
Synthetic Estimates of Smoking Prevalence for Dartford LA Electoral Wards Source: Community Health Profiles 2006, APHO and Department of Health - Crown Copyright 2006
21
2.2.2 Obesity, exercise and diet Adult obesity rates in Dartford (24.8%) are higher than the England average (23.6%). Dartford has significantly lower rates of adult physical activity (8.9% vs 11.6%) and healthy eating (21.8% vs 26.3%) than the England average. Regardless of the comparators to England these factors need addressed as obesity, lack of exercise and poor diets are associated with CHD, cancer and stroke, and contribute to other forms of ill-health such as diabetes, arthritis and depression. Obesity in childhood is also of concern, with rates higher than England average (11.6% vs 9.9%) and lower rates of physical activity (83.7% vs 85.7%).
Source: APHO Dartford Profile 2008.
22
2.3 Recommendations to address life expectancy inequalities The previous sections of this report have the main causes of life expectancy gaps in Dartford, both in terms of disease causes and lifestyle factors causing disease. This section puts forward a number of programmes to address these gaps, from specific NHS programmes, to areas requiring action by the local authority and other agencies in addressing causative factors beyond the reach of the NHS.
• Establish active lifestyle schemes based in leisure centres or through creative outreach to hard-to-reach groups and through referrals from GPs. These schemes should include exercise and weight management and help to get Dartford residents at risk of heart attacks and heart disease engaged with the excellent leisure facilities in the borough.
• Healthy living centres should be supported to provide non-NHS style, accessible services and provide a base for delivering health interventions to hard-to-reach groups e.g overweight white men in early 50s in a style relevant to that group of people (e.g. via social marketing).
• Workplace health schemes offering lunchtime exercise sessions and lifestyle support should be established at large local employers in the private and public sector.
• Tobacco control and smoking cessation – All smokers, particularly those already with a diagnosis of CHD, COPD or Cancer, should be offered referral to a smoking cessation service. Particular effort should be made to help those in the most deprived areas. Tobacco control should be rigorously enforced to prevent new uptake of smoking and prevent illicit sales.
• Identify, treat and make lifestyle referrals for people with high cardiac risk for people who have not yet had a major coronary event. GPs in the most deprived area should be supported to identify high cardiac risk patients, provide these patients with optimal medical preventative treatment, and to make referrals to a council-led exercise and lifestyle programme. Particular effort should be made to target hard-to-reach groups not normally attending GP services.
• Cardiac rehabilitation – Maintain and expand the cardiac rehabilitation service for patients following heart attack, coronary bypass surgery or percutanous coronary intervention. These are the highest risk cardiac patients. Consider extension to heart failure, abdominal aortic aneurysm, angina and those with implantable defibrillators.
Better management of depression and anxiety – This is also a risk factor for CHD. It is also an underlying reason for the rise in ‘risky’ health and lifestyle behaviours such as alcohol misuse and smoking, suicide and violence. By tackling this issue by raising awareness, reducing stigma, providing healthy ways of managing emotions e.g. through exercise and community participation, a range of health benefits can occur.
23
3. SEXUAL HEALTH
3.1 Teenage Pregnancy Compared with pregnancy in women in their 20s and 30s, teenage pregnancy is more likely to result in poor child and maternal health, and for mother and child to live in poverty. UK research suggests teenage pregnancies are not the result of attempts to gain council properties or income support, but are usually unintended and unexpected, even when contraception has not been used3. Research also points to the heterogeneity of teenage mothers. Fifty percent of teenage mothers in the UK are lone parents, 40% cohabit and 10% are married (ONS Census Data 2001). Inequalities in health and life outcomes between these groups can be addressed by targeting support to lone mothers, those without developed family and social networks and to those experiencing other forms of deprivation. While the Dartford conception rate for 2003-2005 (41.3 per year per 1000 girls age 15-17; Source: Teenage Pregnancy Unit) is similar to the UK rate, the UK rate is the highest rate in Western Europe. The national teenage pregnancy strategy aims to halve conception rates from those of 1998 by 2010, from 46.6 per 1000 to 23.3 per 1000. The Dartford rate has slightly increased from 1997-1999 rates of 40.4 per 1000. 3 Allen I and Bourke Dowling S 1998. Teenage Mothers: Decisions and Outcomes.
London: Policy Studies Institute
24
3.1.1 Teenage conceptions by electoral ward There is considerable variation within Dartford. Stone ward has one of the highest rates in the country, exceeding 100 per year per 1000 girls age 15-17 in the years 2002-2004. Joyce Green and Greenhithe wards have rates between 50 and 75 per 1000. Littlebrook, Town, Newtown, Swanscombe, Princes, Bean & Darenth and Longfield, New Barn & Southfleet also have rates above 25 per 1000. Note that actual numbers of conceptions in Dartford area for for girls aged c15-17 are relatively small e.g. around sixty per year.
25
3.2 Chlamydia screening Chlamydia is the most common sexually transmitted infection in the UK. Untreated, it can cause infertility and other health problems and screening for infection is a necessary first step for detection and treatment. During the time the screening programme has been running in Dartford, less than 1% of people aged 15-24 were tested, well below the national target of 15%, and behind the results achieved for the rest of West Kent PCT area and Kent County. As the numbers taking up screening are so low, there are no clear trends in Dartford regarding deprivation and rates of screening.
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
Deprivation quintile ranked in Kent (ID 2007)
Dartford 0.84% 1.09% 0.58% 0.71% 0.70%
WK PCT 1.83% 2.00% 1.96% 2.06% 1.87%
Kent 2.54% 2.37% 2.38% 1.93% 1.92%
1 2 3 4 5
Chlamydia Screening - Proportion of 15-24 year olds tested in each Deprivation quintile (01/01/07 to 30/09/07)
Sources: East and West Kent Chlamydia Screening Programmes, ONS Mid-2006 Population estimates
26
3.3 Recommendations to improve sexual health in Dartford
• Expansion of the C-card (condom card) scheme for accessing condom and emergency contraceptive services. Currently only targeted at women, this could be expanded to cover men. Services should be targeted to the areas with the highest rates of teenage pregnancy.
• Comprehensive relationship and sex education schemes in schools. Experience from continental Europe has show the importance of relationships education as a necessary basis for sex education, rather than the biological models of sex education traditionally provided (if provided at all) in British schools.
• Support for teenage mothers to ensure they are not left behind in educational, social and economic opportunities.
• Community sexual health services e.g. within healthy living centres should be developed to deliver sexual health advice and services in deprived areas and should include information and signposting on chlamydia testing and the full range of contraceptive methods including reversible, emergency and long acting reversible contraceptives. Chlamydia home testing kits can be made available through these services.
27
Directly age-standardised emergency admission rate for diabetes by
deprivation quintile; Dartford LA residents aged 16+, 2004/05-2006/07
0
50
100
150
200
250
300
350
400
450
1 2 3 4 5
Kent deprivation quintile (1=most deprived)
Avera
ge a
nnual e
merg
ency a
dm
issio
n r
ate
per
100,0
00 r
esid
ents
aged 1
6+
Dartford
KCC area
West Kent PCT
Sources: Admissions from NWCS & SUS;
Deprivation from DCLG IMD 2007;
Populations from ONS 2001 Census
4.4.4.4. OOOOTHER THER THER THER CCCCONDITIONS CONTRIBUTIONDITIONS CONTRIBUTIONDITIONS CONTRIBUTIONDITIONS CONTRIBUTING TO NG TO NG TO NG TO
HHHHEALTH EALTH EALTH EALTH IIIINEQUALITIESNEQUALITIESNEQUALITIESNEQUALITIES 4.1 Diabetes Diabetes is a disorder of sugar usage, where the blood sugar levels are too high. Uncontrolled or badly managed diabetes is a significant contributor to coronary heart disease, stroke, kidney failure and blindness, due to its damaging effects on large and small blood vessels. Type two diabetes makes up around 90% of cases of diabetes and is closely linked with being overweight or obese – 80% of patients newly diagnosed with type two diabetes are overweight or obese. Interventions on diet, exercise and weight management will reduce the onset of type two diabetes in the local population. Diabetes emergency admissions show a clear deprivation-associated trend; the admission rate is significantly higher in the two most deprived quintiles compared to the two least deprived quintiles. There is likely to be a higher prevalence in the deprived quintiles, though this does fully account for higher admission rates - diabetic emergencies are usually avoidable, and there is scope for avoiding diabetes-related admissions with better primary care management in these patient groups.
28
4.2 Depression and mental health Suicide in the most deprived quintile is also a contributor to the life expectancy gap in Dartford, and is suggestive of depression and poor mental health in the wider population. While the incidence of suicide is likely to be low, the relatively young age at which these events often occurs contributes to proportionally more lost years of life. Recommendations The completion of the Kent-wide mental health needs assessment should be used to inform action in Dartford. 4.3 Road traffic and other accidents In the most deprived quintile, road traffic accidents in men and other accidents in women contribute to the life expectancy gap. While the number involved are relatively low, the relatively young age at which these events often occurs contributes to proportionally more lost years of life. Recommendations Further investigation is necessary to determine if action is required, and what form any action should take.
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5. INFANT HEALTH
5.1 Infant Mortality Infant mortality is lower in Kent County and the South East compared with the England average, and Dartford follows that trend. There is a slightly higher mortality rate in the most deprived quintile compared to the England average. Infant mortality rates have a significant bearing on in life expectancy – the gap analysis in section 2.3 highlights there is a loss of around 0.1 life years due to male infant mortality in the most deprived quintile compared to the other four quintiles in Dartford. It should be noted that there are some areas of Dartford with much better than average rates which affects this comparator. The data are prone to distortion at this level and should be monitored, rather than necessitating action at this time.
Dartford Local Authority - Average Annual Infant Mortality Rate per 1000 Live Births
in the years 2002 to 2006 inclusive by Deprivation Quintile
Source: ONS - Vital Statistics/ DCLG 2007 IMD
0.0
1.0
2.0
3.0
4.0
5.0
6.0
1 2 3 4 5
Kent Deprivation Quintile ( 1 = most deprived)
Infa
nt
Mo
rtality
Ra
te p
er
100
0 L
ive B
irth
s
Dartford England
South East GOR Kent County
30
5.2 Low birthweight babies Low birthweight is one of a number of predictors of likely short and long term ill health, though should be taken as indicative only, as other factors may be stronger determinants of health and foetal development. Dartford, Kent and the South East have lower rates of low birthweight deliveries than the England average. There is a deprivation link with low birthweight, and so the more deprived quintile areas of Dartford show higher rates of low birthweight delivery than Kent or the South East. However, for the most deprived quintile, the rate of low birthweight delivery is at the England average and so there is no pressing concern around low infant birthweight in Dartford.
Dartford Local Authority - Average Annual Low Birthweight (<2500 gms) Rate
in the years 2002 to 2006 inclusive by Deprivation QuintileSource: ONS - Vital Statistics/DCLG 2007 IMD
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
1 2 3 4 5
Kent Deprivation Quintile (1 = most deprived)
Lo
w B
irth
weig
ht
(<2
500
gm
s)R
ate
per
100 L
ive
an
d S
till
Bir
ths (
sta
ted
bir
thw
eig
ht)
Dartford England
South East GOR Kent County
31
5.3 Breastfeeding continuation Breastfeeding is considered to give infants the best start to life, providing adequate nutrition and support for a healthy immune system. It is recommended that all babies are exclusively breastfed for the first six months of life. The proportion of infants being exclusively breastfed at 6-8 weeks is low for all deprivation quintiles in Dartford and is lower than for Kent County Council area or the NHS West Kent area. The most deprived quintile in Dartford has a lower rate of breastfeeding than the other quintiles. Recommendations Guidance from the National Institute for Health and Clinical Excellence on “Improving the nutrition of pregnant and breastfeeding mothers and children in low-income households” (PH011, March 2008) should be reviewed and appropriate action implemented.
0%
5%
10%
15%
20%
25%
30%
35%
40%
Deprivation quintile ranked in Kent (ID 2007)
Dartford 13.80% 20.19% 19.49% 21.36% 21.74%
WK PCT 14.84% 22.43% 27.77% 29.45% 33.38%
Kent CC 15.43% 22.92% 26.93% 30.34% 32.62%
1 2 3 4 5
Percentage of infants being exclusively breastfed at 6-8 weeks by deprivation quintile
Source: Kent & Medway Child Health Information System, Live Births from 01/04/05 to 31/03/07
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GLOSSARY
Kent deprivation quintile Every LLSOA in Kent has been allocated to a Kent deprivation quintile based on the DCLG Index of Multiple Deprivation (IMD) rank out of all LLSOAs in Kent (see below for explanation of IMD and LLSOAs). Therefore, the number of LLSOAs in each quintile for a local authority will not necessarily be equal as they will be dependent on deprivation levels in the district in relation to the rest of Kent. Directly age-standardised rate The number of occurrences (i.e. deaths or admissions) per 100,000 people. These rates have been age standardised to a “normal” population (i.e. the European Standard Population). Standardisation adjusts for differences in population age structure between areas and allows comparisons to be made. Teenage conception rate The number of live births per 10000 women aged 15-17 years. Chlamydia screening rate The percentage of 15-24 year olds tested for Chlamydia. Infant mortality rate The number of children dying in the first year of life per 1,000 live births.
Low birthweight babies rate Live and stillborn infants with birthweight under 2500g per 100 total live and stillbirths with stated birthweight. Breastfeeding continuation at 6-8 weeks The number of infants being exclusively breastfed at 6-8 weeks per 100 live births. Indices of Deprivation The English Indices of Deprivation 2007 have been produced by the Department for Communities and Local Government (DCLG) as an update to the ODPM 2004 Indices to measure deprivation at a local level. It comprises of information made available by the 2001 Census and other sources to give a more detailed overview of the extent and types of deprivation experienced in small areas termed “Lower Layer Super Output Areas” or LLSOAs. The Indices of Deprivation 2007 consist of seven domains of relative deprivation: � Income Deprivation � Employment Deprivation � Health Deprivation and Disability � Education, Skills and Training Deprivation � Barriers to Housing and Services � Living Environment Deprivation � Crime
These are then combined to give the overall Index of Multiple Deprivation (IMD).
33
There are also two supplementary indices produced as subsets of the Income Domain: � The Income Deprivation Affecting Children Index (IDACI) � The Income Deprivation Affecting Older People Index (IDAOPI)
IDACI
The percentage of children within a lower layer super output area (LL-SOA) living in families either:
In receipt of Income Support and Income-Based Job Seeker’s Allowance, or
In receipt of Working Families Tax Credit/Disabled Persons Tax Credit
whose equivalised income is below 60% of median before housing costs.
IDAOPI
The percentage of the population aged over 60 within a lower level super output area (LL-SOA) who themselves, or their partners are either:
In receipt of Income Support, or
In receipt of Income-Based Job Seeker’s Allowance
whose equivalised income is below 60% of median before housing costs.
The indicators for these indices are expressed as simple rates. Therefore, if an area has a score of 35.3, then 35.3% of the resident children or older people of that area may be said to be income deprived.
Data for both supplementary indices are provided by the Department for Work and Pensions, 2001.
Lower Layer Super Output Areas (LLSOAs) Output Areas (OAs) were introduced for the 2001 Census and are built from adjacent unit postcodes and contain an average of 125 households. They are designed to be as homogenous as possible. Lower Layer Super Output Areas (LL-SOAs) are formed by the aggregation of OAs and have an average population size of 1500 (minimum 1000). Again, these are as homogenous as possible in their tenure and dwelling type. LL-SOAs may be studied individually for detailed local level analyses, or aggregated to higher level boundaries such as electoral wards, Local Authorities and PCTs. There are 1047 LL-SOAs in Kent and Medway.
34
APPENDIX 1:
2007 INDICES OF DEPRIVATION MAPS 1. Index of Multiple Deprivation
35
2. Income Deprivation
3. Income Deprivation Affecting Children
36
4. Income Deprivation Affecting Older People
5. Employment Domain
37
6. Health Deprivation and Disability Domain
7. Education, Skills and Training Domain
38
8. Barriers to Housing & Services Domain
9. Crime Domain
39
10. Living Environment
40
INFORMATION SOURCES
Indicator Sources
All age, all cause mortality trends
Numerator: Deaths from all causes from ONS Annual District Deaths Extract 1995-97 and 2004-06 Denominator: Populations from ONS 2001 Census populations for Lower Layer Super Output Areas
Under 75 circulatory disease mortality trends
Numerator: Deaths from circulatory diseases (ICD-10 I00-I99) from ONS Annual District Deaths Extract 1995-97 and 2004-06 Denominator: Populations from ONS 2001 Census populations for Lower Layer Super Output Areas
Under 75 cancer mortality trends
Numerator: Deaths from cancer (ICD-10 C00-C97) from ONS Annual District Deaths Extract 1995-97 and 2004-06 Denominator: Populations from ONS 2001 Census populations for Lower Layer Super Output Areas
Smoking prevalence Community Health Profiles 2008, APHO & Department of Health (data from ONS Synthetic Estimates of Healthy Lifestyle Behaviours 2000-02).
5.1 Teenage conceptions by electoral ward
Numerator: Under 18 conceptions in 2002-04 from Teenage Pregnancy Unit Denominator: Population of females aged 15-17 from ONS mid-2002, mid-2003 & mid-2004 resident population estimates
5.2 Chlamydia screening rates by deprivation
Numerator: Number of 15-24 year olds screened from East and West Kent Chlamydia Screening Programmes, 1
st Jan – 30th Sept 2007
Denominator: Population of 15-24 year olds from ONS Mid-2006 Resident Population Estimates
6. Infant Health
6.1 Infant mortality Numerator: Infant deaths (age <1 year) from ONS Vital Statistics 2002-06 Denominator: Live births from ONS Vital Statistics 2002-06
6.2 Low birthweight babies
Numerator: Low birthweight babies (<2500g) from ONS Vital Statistics 2002-06 Denominator: Live and still births (with stated birthweight) from ONS Vital Statistics 2002-06
6.3 Breastfeeding continuation
Numerator: Infants exclusively breastfed at 6-8 weeks 2004/05 -2006/07 from Kent & Medway Child Health Information System Denominator: Live births from Kent & Medway Child Health Information System 2004/05 -2006/07
Hospital Emergency Admissions
CHD in adults
Numerator: Hospital admissions for CHD (Primary diagnosis ICD-10 I20-I25) from NWCS (2004/05-2005/06) and SUS (2006/07). Denominator: Populations from ONS 2001 Census populations for Lower Layer Super Output Areas
COPD in adults
Numerator: Hospital admissions for COPD (Primary diagnosis ICD-10 J40-44 & J47) from NWCS (2004/05-2005/06) and SUS (2006/07). Denominator: Populations from ONS 2001 Census populations for Lower Layer Super Output Areas
Diabetes in adults
Numerator: Hospital admissions for Diabetes (Primary diagnosis ICD-10 E10-E14) from NWCS (2004/05-2005/06) and SUS (2006/07). Denominator: Populations from ONS 2001 Census populations for Lower Layer Super Output Areas
2007 Indices of Deprivation maps
DCLG Indices of Deprivation, 2007
