Rural/urban mortality differences and the effect of deprivation adjustment in England and Wales Dissertation project for Masters in Public Health 2007 + HSQ article Andrea Gartner, Health information and intelligence analyst, Wales Centre for Health, Cardiff

The project ONS suggested the work (Myer Glickman and Prof. David Fone,Cardiff University) Previous work on WCfH publication “A profile of rural health in Wales” Supervisors: Prof. Frank Dunstan and Dr. Daniel Farewell, Cardiff University ONS provided mortality data access and HSQ article arrangements (HSQ 39 autumn 2008) WCfH study leave

Is there a difference in mortality between rural and urban areas of England and Wales? Investigate variation amongst rural/urban sub-classes (compare rates for all-cause mortality) Examine differences between rural and urban areas whilst adjusting for deprivation (Logistic regression analysis for all-causes and six specific causes) (3. Investigate rural/urban differences in relationship of mortality and deprivation)

Challenges with rural/urban analysis Definition of “rural” varies in literature Large variation in rural health outcomes – poor results hidden by averages (Haynes & Gale,2000;) Deprivation measures thought to be more urban-centred (Farmer et al.,2001; Christie & Fone,2003) Migration Few published studies on the topic IMD/WIMD different

Rural or urban? Six rural/urban classes of at LSOA level (2004 classification) 20% of population in England live in a rural area (35% in Wales)

All-cause mortality rates 2002-2004 by rural/urban class Rural “Village and dispersed” tend to have lowest rates Source: ONS

Rural/urban distribution of deprivation (WIMD 2005) -> Urban areas are classed as more deprived

Regression analysis: models Logistic regression model fitted with variables age and rurality Second model with variables age, rurality and five deprivation measures Townsend Index of Deprivation Index of Multiple deprivation 2004 (IMD), Welsh Index of Multiple deprivation (WIMD) (W)IMD excluding health domain (W)IMD Employment domain (W)IMD Income domain Run separately for male/female, England/Wales, causes and deprivation measures (168 runs)

Regression analysis: output Estimated odds ratio for rurality variable relative to urban (95% confidence interval, significance value) Interpreted as risk ratio of mortality England male Before adj After adj. IMD excl. All causes 0.85* (15%) 0.96* (4%) Lung cancer 0.73* (27%) 0.89* (11%) Suicide (15+) 0.90* (10%) 1.11* (11% higher) *Statistically significant (p-value< 0.05)

Rural/urban rates similar for… Male before Male after Female before Female after All causes 0.90* 0.95* 0.92* 0.96* Cancer 0.91* 0.95 0.94 0.98 Circulatory 0.93* 0.96 1.00 *Statistically significant (p-value< 0.05) ** Odds ratio rural relative to urban, Wales 2002-2004, before and after adjustment for WIMD Rural/urban differences narrowed Deprivation accounted for much of the difference

Rural rates lower for… Largest rural/urban differences before Male before Male after Female before Female after Lung cancer 0.85* 0.93 0.78* 0.87 Respiratory disease 0.87* 0.96 * Statistically significant (p-value< 0.05) ** Odds ratio rural relative to urban, Wales 2002-2004, before and after adjustment for WIMD Largest rural/urban differences before Deprivation accounted for some of the difference, but still substantial diff.

Rural rates higher for… Male before Male after Female before Female after Accidents 1.14 1.27* 1.06 1.11 Suicides (pattern unclear ) 0.96 1.04 1.16 1.27 * Statistically significant (p-value< 0.05) ** Odds ratio rural relative to urban, Wales 2002-2004, before and after adjustment for WIMD Rural/urban differences widened to substantial difference (accidents) Suicides unclear/not stat. significant

Conclusions Effect of adjustment similar for five deprivation measures (Wales effect smaller) Association between mortality and deprivation similar in rural and urban areas Large differences for some causes are of significant public health concern Deprivation adjustment removed many initital rural/urban mortality differences Rural populations were not inevitably “healthier” than urban populations

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