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

2. Std Mortality Rates

3. Self-reported Health
Std Mortality Rates

4. 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

5. Source: Registrar Generals Office

6. 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.

7. 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)

8. Data (ii) ICD-10 codes for alcohol-related deaths:
F10—mental and behavioural disorders due to use of alcohol;
G 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

9. 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)

10. 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)

11. 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)

12. 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)

13. 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:  /j x)

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

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

16. 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

17. 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

18. 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)

19. 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

20. 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

21. 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

22. 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:

23. Self-reported Health
Std Mortality Rates

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

27. 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

28. 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

29. 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

30. 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

31. 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

32. Additional mortality risk associated with LLTI

33. 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?

34. Thank you
Questions?

35. 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.