Alan Marshall (University of Leeds)

1. Exploring the impact of local trends in self- reported morbidity (1991-2001) on spatial health inequalities BSPS conference 2011 York 9th September 2011 Alan Marshall (University of Leeds) a.d.marshall@leeds.ac.uk

2. Aim • Capture and project forwards district trends in age/sex specific rates of limiting long term illness between 1991 and 2001 up to 2021 • What factors might explain the persisting spatial inequalities in the projections?

3. Other research on LLTI (1991-2001) This research extends that above by: • Considering change in LLTI by age and sex and district (relational models) • Evaluating spatial patterns of LLTI using the ONS area classification (rather than deprivation quintiles) • Controlling for issues of LLTI question change (1991-2001) identified by Boyle (2004) (and other e.g. Bajekal (2004)) • Examining what continuation of trends in district LLTI might imply for future spatial patterns • Providing a methodology to apply to 2011 census LLTI data

4. Validity of LLTI • There are strong relationships between LLTI and other health outcomes including all cause and cause-specific mortality (Charlton, et al. 1994; Bentham, et al. 1995; Idler & Benyamini 1997) as well as sickness benefits claims from different health conditions. • Self-assessed – perceptions of illness • Assessment involves physical condition, expectation and comparison

5. Variability in the relationship between LLTI and mortality Scotland England Wales Source: Mitchell 2005

6. 1991 and 2001 LLTI census questions 1991 LLTI question Do you have any long-term illness, health problem or handicap which limits your daily activities or the work you can do? Include problems which are due to old age. 2001 LLTI question Do you have any long-term illness, health problem or disability which limits your daily activities or the work you can do? Include problems which are due to old age

7. Changes in LLTI 1991-2001 • Increase in census rates of LLTI between 1991 and 2001 • Not observed in other surveys with long running (consistently worded) LLTI questions • Stigma associated with ‘handicap’ in 1991 is though to have led to lower rates of LLTI (Bajekal et al 2004)

8. LLTI in 1991 and 2001 (census) Grey = 1991, Black=2001

9. LLTI in 1991 and 2001 (GHS)

10. LLTI rates in 1991 (original and adjusted) and 2001 Age specific rates of LLTI (Britain, Males) – 2001, 1991 and 1991 adjusted

11. Apply national adjustments to local LLTI rates LLTI rates in Glasgow (females) 1991 (adjusted), 2001 and projections for 2011 and 2021

12. Standardised illness ratios 2001 and 2021 SIRs 2001 SIRs 2021 District area classification IH MT PSE All SIRs are relative to the UK (2001) and calculated using the direct standardisation procedure

13. Spatial changes in LLTI – attributable to local LLTI trends Change in LLTI population (LLTI rates) District area classification Industrial hinterlands Manufacturing towns Prospering Southern England

14. Growth in LLTI population between 2001 and 2021 (as a proportion of 2001 LLTI population) due to increases in LLTI rates

15. Industrial hinterlands (increasing LLTI rates) Grey = 2001 Black = 2021

16. Prospering Southern England – (declining rates) Grey = 2001. Black = 2021

17. Recap Findings • Polarisation of spatial patterns of LLTI • Increases in Scotland • Increases in industrial and manufacturing areas • Exceptions – Rhonda • Particularly hard hit districts – Barrow • Declining LLTI rates – older ages in PSE Explanations • Migration • Health expectations • Hidden unemployment • Health of individuals

18. Migration - polarisation • Migration is an important determinant of population health in an area, Norman et al. (2005) demonstrate (1971-1991) that: • Healthy people tend to migrate away from the most deprived areas • Unhealthy people migrate to the most deprived areas • Reflects a polarisation of wealth and other socioeconomic characteristics (Dorling and Rees 2003) during the 1990s

19. Scotland - Health expectations • Mitchell (2005) notes that the tendency for Scots to under report LLTI relative to levels of mortality compared to those in England and Wales. • This finding held in 1991 and 2001 but was less strong in 2001 • The increase in LLTI rates in Scotland may reflect a convergence of health expectations towards that of England and Wales

20. Hidden unemployment • Increase in sickness benefits in some areas attributed to ‘hidden unemployment’(Beatty et al. 2000; Fieldhouse and Hollywood 1999). • The expansion of ‘hidden unemployment’ in such areas during the 1990s is likely to contribute to LLTI rises. • Particularly relevant to Barrow in Furness. See Beatty and Fothergill (2002)

21. What about the health of individuals? • Could people in a certain area be more/less likely to suffer from an LLTI than their equivalents in the recent past? • Expansion/compression of morbidity depending on area? • Can we separate the roles of migration, hidden unemployment and changing health expectation?

22. Conclusions • Polarisation of spatial patterns of LLTI (districts) • Exceptions – Scotland (Coastal and Countryside), Rhondda. Particularly hard hit areas • Explanations: • Migration • Converging expectations of health, • Hidden unemployment • Trends in individual’s health • 2011 census provides an opportunity to see if LLTI trends (1991-01) have continued

23. References Bajekal, M., Harries, T., Breman, R. and Woodfield, K. (2003). Review of disability estimates and definitions. London, HMSO. Beatty, C., Fothergill, S., Macmillan, R. (2000) A theory of employment, unemployment and sickness. Regional Studies. 34(7): p617-630 Beatty, C., Fothergill, S. (2002) Hidden unemployment amongst men: a casestudy. Regional Studies. 8(1); p811-823 Bentham. G., Eimermann, J., Haynes, R., Lovett, A. and Brainard, J. 1995. Limiting long-term illness and its associations with mortality and indicators of social deprivation. Journal of Epidemiology and Community Health 49: S57-S64. Boyle PJ (2004). The nation’s health: the picture from the 2001 census. Census 2001: the findings. Royal Geographical Society, June 8. Charlton, J., Wallace, M. and White, I. 1994 Long-term illness: results from the 1991 census. Population Trends 75: 18-25.

24. References Dorling, D. and Thomas, B. (2004). People and Places: a 2001 census atlas of the UK. Bristol, Policy Press. Dorling, D. and Rees, P. (2003). A nation still dividing: the British census and social polarisation (1971-2001). Environment and Planning A. 35. p1287-1313 Fieldhouse, E., Hollywood, E. (1999) Life after mining: Hidden unemployment and changing patterns of economic activity amongst miners in England and Wales 1981-1991. Work, Employment and Society. 13(3): 483-502. Idler, E. and Benyamini, Y. 1997. Self-rated health and mortality: a review of twenty-seven community studies. Journal of Health and Social Behavior 38: 21-37. Mitchell, R. (2005). "Commentary: the decline of death--how do we measure and interpret changes in self-reported health across cultures and time?" International journal of Epidemiology34(2): 306-8. Norman, P., Boyle, P., Rees, P. (2005) Selective migration, health and deprivation: a longitudinal analysis, Social Science & Medicine. 60(12)