Does where you live influence your health or the reporting of ill-health? Michael Rosato, Gemma Catney, Sheelah Connolly, Seeromanie Harding, Dermot O’Reilly

Std Mortality Rates

Self-reported Health Std Mortality Rates

Project 019: Variations in alcohol related deaths in Northern Ireland Background: Globally 4% of all deaths Impact on crime, productivity and families Costs ~£20billion/year in England Epidemiology not entirely clear Ecological studies show strong association to area deprivation and urban living

Source: Registrar Generals Office

Aims To examine differences in alcohol-related mortality between areas Urban/rural Affluent/deprived To determine if these differences were due to characteristics of the individuals living in these areas or to specific area effects.

Data (i) Northern Ireland Mortality Study (NIMS) 720,627 people aged 25-74 Non-institutionalised Age, sex, marital status, LLTI & GH SES, NS-SEC, Educ attainment, Housing tenure & cars (for area deprivation only) Area: Income domain of NIIMD Settlement band (Urban, intermediate, Rural)

Data (ii) ICD-10 codes for alcohol-related deaths: F10—mental and behavioural disorders due to use of alcohol; G31.2 - degeneration of nervous system due to alcohol; G62.1- alcoholic polyneuropathy; I42.6- alcoholic cardiomyopathy; K29.2- alcoholic gastritis; K70- alcoholic liver disease; K73- chronic hepatitis, not elsewhere classified; K74- fibrosis and cirrhosis of liver (excluding K74.3-K74.5—biliary cirrhosis); K86.0- alcohol-induced chronic pancreatitis; X45- accidental poisoning by and exposure to alcohol; X65- intentional self-poisoning by and exposure to alcohol; and Y15- poisoning by and exposure to alcohol, undetermined intent. Deaths: 5-years follow-up 578 alcohol related deaths

Results: Males (Deaths = 377) Females (Deaths = 201) Age 25-44 1.00 45-54 2.46 (1.89, 3.20) 2.29 (1.57, 3.34) 55-64 1.85 (1.36, 2.52) 1.64 (1.06, 2.53) 65-74 1.17 (0.78, 1.76) 1.01 (0.60, 1.71) Marital status Married Single 1.81 (1.34, 2.45) 0.61 (0.36, 1.02) Divorced/widowed/separated 3.00 (2.22, 4.06) 1.10 (0.75, 1.62) Household composition Multi person household Single person household 0.97 (0.74, 1.27) 1.32 (0.88, 2.00)

Males Females Housing tenure (ref owner) Private renter 0.96 (0.63, 1.47) 1.13 (0.62, 2.05) Social renter 1.65 (1.26, 2.16) 1.59 (1.11, 2.28) Car access (ref 2+) One 1.47 (1.06, 2.03) 2.13 (1.36, 3.32) None 4.48 (3.08, 6.52) 4.05 (2.37, 6.93) NS-SEC (ref prof) Intermediate 0.98 (0.60, 1.62) 0.63 (0.35, 1.12) Own account worker 1.02 (0.68, 1.53) 1.31 (0.60, 2.86) Lower supervisory 0.99 (0.67, 1.46) 0.35 (0.13, 0.90) Routine 0.95 (0.67, 1.33) 0.95 (0.60, 1.50) Not working 1.49 (1.00, 2.22) 1.21 (0.69, 2.13) Education (ref degree) A-level + 1.09 (0.61, 1.94) 1.76 (0.65, 4.77) GCSE + 0.92 (0.56, 1.50) 2.43 (1.12, 5.26) GCSE 1.26 (0.81, 1.96) 2.23 (1.02, 4.89) No qualifications 0.80 (0.53, 1.19) 1.71 (0.79, 3.71) General health (ref good) Fair 1.80 (1.33, 2.43) 1.94(1.29, 2.91) Not good 3.04 (2.12, 4.35) 3.49 (2.13, 5.74) LLTI (ref none) Yes 1.57 (1.16, 2.12) 1.38 (0.92, 2.08)

Association with area deprivation Unadj’ed Adjusted for demography + SES + SRH (Area) Quintile of deprivation Males Least deprived 1.00 2 1.04 (0.70, 1.56) 1.02 (0.65, 1.46) 0.79 (0.53, 1.19) 0.77 (0.51, 1.16) 3 1.62 (1.11, 2.35) 1.39 (0.96, 2.02) 0.95 (0.64, 1.03) 0.90 (0.61, 1.32) 4 2.48 (1.75, 3.51) 1.94 (1.37, 2.74) 1.08 (0.75, 1.57) 1.00 (0.69, 1.45) Most deprived 3.70 (2.65, 5.18) 2.54 (1.81, 3.58) 0.96 (0.66, 1.41) 0.85 (0.58, 1.25) Females 1.33 (0.82, 2.15) 1.31 (0.81, 2.13) 1.03 (0.64, 1.68) 1.00 (0.61, 1.62) 1.00 (0.59, 1.70) 0.97 (0.57, 1.63) 0.64 (0.37, 1.09) 0.60 (0.35, 1.03) 1.87 (1.19, 2.95) 1.74 (1.10, 2.75) 0.96 (0.59, 1.55) 0.88 (0.54, 1.43) 2.67 (1.72, 4.15) 2.36 (1.51, 3.70) 0.92 (0.56, 1.51) 0.79 (0.48, 1.30)

Adjusted for demography Association with urban/rural Settlement band Adjusted for demography + SES + SRH + other area factors Males Urban 1.00 Intermediate 0.93 (0.74, 1.17) 0.92 (0.73, 1.16) 0.96 (0.76, 1.21) 0.96 (0.76, 1.22) Rural 0.54 (0.41, 0.71) 0.54 (0.41, 0.72) 0.59 (0.44, 0.78) 0.62 (0.46, 0.83) Females 0.70 (0.51, 0.96) 0.68 (0.49, 0.93) 0.71 (0.52, 0.98) 0.70 (0.51, 0.97) 0.34 (0.22, 0.52) 0.32 (0.21, 0.50) 0.36 (0.24, 0.56) 0.37 (0.24, 0.57)

Conclusions: Higher mortality risk for disadvantaged individuals. No independent effect of area deprivation. Mortality lower in rural areas. Explanations for these findings?? Area of residence and alcohol-related mortality risk: A five–year follow-up study. Connolly S, O’ Reilly D, Rosato M, Cardwell C. (Addiction DOI: 10.1111/j.1360-0443.2010.03103.x)

Project 011: Area influences on health: does community or religious segregation matter?

Background/theory Aims: Good Bad Variations in mortality risk across different levels of denominational concentration Variations in cause-specific mortality

Distribution of population Most Protestant Catholic % Catholic <10% 10-29% 30-69% 70-89% 90+% %Protestant Protestants No. 226,206 128,910 84,726 14,871 3,707 % 49.3 28.1 18.5 3.2 0.8 Catholics 10,114 27,261 78,761 65,339 137,214 8.6 24.7 20.5 43.1

Catholics Protestants Concentration <10% 10-29% 30-69% 70-89% 90+% Social Class   Professional 39.9 37.6 35.2 27.4 21.0 27.5 33.4 31.1 27.3 26.5 Int’ OwnLower 30.4 29.9 29.7 32.1 33.2 33.3 35.0 32.0 Routine 25.7 27.6 28.8 33.7 40.4 35.8 30.8 31.3 33.5 Not Working 3.4 4.3 5.6 7.9 11.5 3.5 4.4 6.1 7.6 Unclassified 0.7 0.6 0.5 0.3 0.4 Car access 2+ 44.9 44.7 45.5 40.3 27.1 40.0 46.6 46.8 44.2 35.6 1+ 42.4 43.1 42.7 45.2 47.5 43.6 43.3 44.3 12.8 12.2 11.8 14.6 25.4 16.4 10.4 10.8 12.5 20.1 Economic activity Employed 68.7 66.2 64.1 57.5 47.2 60.0 63.8 62.6 57.1 52.0 Unemployed 2.7 3.1 3.2 6.0 3.0 2.4 2.6 2.8 4.8 Permanently sick 8.0 9.5 12.1 16.7 9.9 7.7 8.4 13.9 Other 21.1 22.7 23.1 26.1 30.2 27.2 29.2 29.3 Education level to:degree+ 25.1 24.6 24.3 17.7 12.4 14.0 18.7 18.4 15.5 16.3 to:aLevel 7.2 6.7 5.3 5.8 6.5 to:gcse 33.6 31.7 28.0 30.9 30.0 28.1 27.8 None 36.5 39.7 47.0 54.4 49.3 45.6 50.6 50.1

Mortality risk according to level of dissonance Adj’ed Age & sex + SES + Area Most concordant 1.22 (1.19 ,1.26) 1.05 (1.01 ,1.08) 1.02 (0.99 ,1.06) 2nd 1.03 (0.99 ,1.06) 1.01 (0.98 ,1.05) 3rd 1.00 4th 1.08 (1.03 ,1.14) 1.06 (1.00 ,1.12) 1.05 (1.00 ,1.11) Most discordant 1.28 (1.18 ,1.40) 1.19 (1.09 ,1.29) 1.17 (1.07 ,1.27)

Mortality risk by level of concordance Community background Catholic (12,312 deaths) Community background Protestant (21,128 deaths) Model 1 * Model 2 * Concordance level Concordant 1.36 (1.30, 1.42) 1.06 (1.01, 1.11) 1.14 (1.10, 1.19) 1.00 (0.96, 1.04) 2nd 1.10 (1.04, 1.16) 1.02 (0.96, 1.08) 1.01 (0.97, 1.05) 1.00 (0.96, 1.05) 3rd 1.00 4th 1.10 (1.02, 1.19) 1.11 (1.03, 1.20) 1.04 (0.96, 1.12) 0.99 (0.91, 1.07) Discordant 1.22 (1.09, 1.36) 1.31 (1.15, 1.50) 1.10 (0.96, 1.26) Model 1 is adjusted for age (in 5-year bands), sex and marital status; Model 2 is Model 1 further adjusted for educational activity, NS-SEC, housing tenure, car availability, economic activity, house value and settlement band

Variations in cause-specific mortality Catholics Protestants Concord’ 2nd 3rd 4th Discord’ Circ Dis 1.10 1.04 1.00 1.07 1.21 1.03 IHD 1.08 1.20 1.02 1.11 1.36 Stroke 1.12 0.89 1.15 0.87 0.56 All Cancer 0.98 1.06 Lung ca 0.91 1.01 1.09 Resp. 1.05 1.57 1.23 1.34 External 0.69 1.16 Alcohol 0.94 1.51 1.55 1.14 1.18 1.27 1.48

Conclusions The more polarized areas are the most deprived Mortality is higher in the more polarized areas The higher mortality in concordant areas is due to SES. The higher mortality of Catholics in Protestant areas (and to a lesser extent, of Protestants in the most Catholic areas) is unexplained. Clues in cause-specific mortality? Overall living in discordant areas may be bad for health??? Other explanations are possible

Does a weak labour market make people feel sick? Project 015: The socio-economic (& cultural influences) on the perception & reporting of self-reported health in NI Does a weak labour market make people feel sick? Dissonances in self-reported health and mortality across denominational groups in Northern Ireland O’ Reilly D, Rosato M. Soc Sci Med 2010; 71: 1011-1017

Self-reported Health Std Mortality Rates

Health-related benefits What happens when people become unemployed? U/E benefits Work No work Health-related benefits

Hypotheses Where labour market is poor people are more likely to report ill-health The relationship between SRH and mortality should vary according to strength of labour market Aims: Logistic regression to explore relationship between labour market and levels of ill-health Cox proportional hazards to investigate effect modification by areas on SRH-mortality relationship

Data & methods NIMS with ‘usual suspects’ Labour market %working age who are U/E or permanently sick <10%; 10%-14.9%; 15%-19.9%; 20%-24.9%; 25% and over Good correlation with %employment; and employment domain of NIIMD Mortality: 6.7 years of follow-up

Labour Market Strongest 2nd 3rd 4th Weakest 16-24 18.0 19.6 20.7 23.1 Population 16-59/64* 309,338 299,128 197,307 76,346 78,692 Age (%) 16-24 18.0 19.6 20.7 23.1 24.3 25-44 48.5 47.5 47.1 45.7 45-64 33.6 32.9 32.3 29.9 30.0 Sex (%) Female 49.0 48.4 49.3 50.6 51.1 Marital status (%) Currently 60.9 55.3 40.4 33.3 Single 32.0 36.1 39.0 44.5 48.0 Sep/W/Div 7.1 8.6 12.0 15.1 18.7

Strongest 2nd 3rd 4th Weakest Health (%) Degree 25.6 16.1 12.1 10.1 Education Attainment (%) Degree 25.6 16.1 12.1 10.1 7.1 Other 49.6 47.7 45.5 43.9 39.6 None 24.8 36.2 42.4 46.0 53.3 Car availability (%) Two 60.3 49.8 35.6 21.3 One 34.6 40.7 46.2 48.0 43.8 5.1 9.5 18.2 30.8 44.0 Housing tenure (%) Owner 88.6 82.9 72.1 58.7 Private Renter 8.3 6.6 6.9 8.1 6.5 Social renter 3.2 10.5 21.1 33.2 49.4 Economic activity (%) Employed 72.5 66.0 59.0 50.7 40.8 Unemployed 2.4 3.9 5.7 7.9 10.2 Student 9.8 8.9 8.8 8.7 Retired 2.3 1.7 1.5 1.2 1.1 At home 6.0 7.6 9.3 11.3 13.6 Perm Sick 4.8 11.1 13.7 17.9 5.3 6.4 7.8 Health (%) LLTI 11.6 15.9 19.9 23.3 28.3

Likelihood of reporting a limiting long term illness. Data represent odds ratios (95% confidence intervals) from logistic regression models. Adjusted for age/sex Fully adjusted ** Labour market Strongest 1.00 2nd 1.51 (1.48, 1.53) 1.21 (1.19, 1.22) 3rd 2.06 (2.02, 2.09) 1.35 (1.33, 1.37) 4th 2.69 (2.64, 2.76) 1.47 (1.43, 1.50) Weakest 3.61 (3.54, 3.69) 1.61 (1.57, 1.65) ** Adjusted for age, sex, marital status, educational attainment, housing tenure and car availability

Additional mortality risk associated with LLTI

Conclusions Some indication that weak labour market shifts perception of health Likelihood of reporting poor health is higher where labour market is weakest Relationship of LLTI to mortality is modified by labour market Does this have repercussions for the health services?

Thank you Questions?

Acknowledgements The help provided by the staff of the Northern Ireland Longitudinal Study (NILS) and NILS Research Support Unit (RSU) is acknowledged. NILS is funded by the HSC R&D function of the Public Health Agency. They also funded some of the projects which comprise this talk. The NILS-RSU is funded by the ESRC and the Northern Ireland government. The authors alone are responsible for the interpretation of the data.