Rachael Wood

Measuring inequalities in health: the case for healthy life expectancy

Objective: To evaluate healthy life expectancy (HLE) as a measure of health inequalities by comparing geographical and area-based deprivation-related inequalities in healthy and total life expectancy (TLE). Design: Life table analysis based on ecological cross-sectional data. Setting and population: Council area quarters and postcode sector-based deprivation fifths in Scotland. Main outcome measures: Expectation of life in good self-assessed general health, or free from limiting long-term illness, and TLE, for females and males at birth. Results: Women in Scotland have a life expectation of 70.3 years in good health, 61.6 years free from limiting long-term illness, and a TLE of 78.9 years. Comparable figures for men are 66.3, 58.6 and 73.5 years. TLE and HLE decrease with increasing area deprivation. Differences are substantially wider for HLE. A 4.7-year difference is seen in TLE between women living in the most and least deprived fifth of areas. The difference in HLE is 10.7 years in good health and 11.6 years free from limiting long-term illness. The degree of deprivation-related inequality in HLE is 2.5 times wider for women and 1.8 times wider for men than in TLE. Conclusions: Differences in TLE underestimate health inequalities substantially. By including morbidity and mortality, HLE reflects the excess burden of ill health experienced by disadvantaged populations better. Inequalities in length of life and health status during life should be taken into account while monitoring inequalities in population health.

Predicting Language Change Between 3 and 5 Years and Its Implications for Early Identification

BACKGROUND AND OBJECTIVE: Early language delays across the preschool period have important implications for children, parents, and services raising the significance of early identification. Screening tests are an appealing solution but have proved problematic. A combined risk model would seem promising but has yet to be tested. The goal of this study was to examine the factors that predict language change in a nationally representative sample of children between 3 and 5 years when most children are identified as being in need of services. METHODS: By using data from children (n = 13 016) in the Millennium Cohort Study (a national UK birth cohort), linear regression was used to predict 5-year performance from 3-year test performance data coupled with sociodemographic and within-child factors and indicators of parental concern. Patterns of change were identified and logistic regression was used to predict the difference between children for whom profiles change and those for whom they do not. RESULTS: The final model (predicting 32% of the variance) included maternal education, pattern construction, behavior, language concerns, and 3-year vocabulary. Four change patterns were identified: one consistently low (n = 201), one consistently high (n = 12 066), a group that is resilient (n = 572), and one with a declining profile (n = 177). The models accurately predicted 71% of the declining group and 99% of the resilient group. Maternal education (odds ratio: 0.49) and behavior (odds ratio: 0.9) were significant predictors for the former and maternal education (odds ratio: 0.6) and pattern construction (odds ratio: 1.03) the latter. CONCLUSIONS: Early identification of delayed language remains problematic but, once identified, there are key indicators that predict which children are likely to be more or less at risk across time. The implications are discussed in terms of policy and practice.

STOPPIT Baby Follow-Up Study: The Effect of Prophylactic Progesterone in Twin Pregnancy on Childhood Outcome

Objectives To determine the long-term effects of in utero progesterone exposure in twin children. Methods This study evaluated the health and developmental outcomes of all surviving children born to mothers who participated in a double-blind, placebo-controlled trial of progesterone given for the prevention of preterm birth in twin pregnancies (STOPPIT, ISRCTN35782581). Follow-up was performed via record linkage and two parent-completed validated questionnaires, the Child Development Inventory and the Health Utilities Index. Results Record linkage was successfully performed on at least one record in 759/781 (97%) children eligible for follow-up. There were no differences between progesterone-exposed and placebo-exposed twins with respect to incidence of death, congenital anomalies and hospitalisation, nor on routine national child health assessments. Questionnaire responses were received for 324/738 (44%) children. The mean age at questionnaire follow-up was 55.5 months. Delay in at least one developmental domain on the Child Development Inventory was observed in 107/324 (33%) children, with no evidence of difference between progesterone-exposed and placebo-exposed twins. There was no evidence of difference between the progesterone and placebo groups in global health status assessed using the Health Utilities Index: 89% of children were rated as having ‘excellent’ health and a further 8% as having ‘very good’ health. Conclusions In this cohort of twin children there was no evidence of a detrimental or beneficial impact on health and developmental outcomes at three to six years of age due to in utero exposure to progesterone.

Early death in those previously hospitalised for mental healthcare in Scotland: a nationwide cohort study, 1986–2010

Objectives To compare the mortality in those previously hospitalised for mental disorder in Scotland to that experienced by the general population. Design Population-based historical cohort study using routinely available psychiatric hospital discharge and death records. Setting All Scotland. Participants Individuals with a first hospital admission for mental disorder between 1986 and 2009 who had died by 31 December 2010 (34 243 individuals). Outcomes The main outcome measure was death from any cause, 1986–2010. Excess mortality was presented as standardised mortality ratios (SMRs) and years of life lost (YLL). Excess mortality was assessed overall and by age, sex, main psychiatric diagnosis, whether the psychiatric diagnosis was ‘complicated’ (ie, additional mental or physical ill-health diagnoses present), cause of death and time period of first admission. Results 111 504 people were included in the study, and 34 243 had died by 31 December 2010. The average reduction in life expectancy for the whole cohort was 17 years, with eating disorders (39-year reduction) and ‘complicated’ personality disorders (27.5-year reduction) being worst affected. ‘Natural’ causes of death such as cardiovascular disease showed modestly elevated relative risk (SMR1.7), but accounted for 67% of all deaths and 54% of the total burden of YLL. Non-natural deaths such as suicide showed higher relative risk (SMR5.2) and tended to occur at a younger age, but were less common overall (11% of all deaths and 22% of all YLL). Having a ‘complicated’ diagnosis tended to elevate the risk of early death. No worsening of the overall excess mortality experienced by individuals with previous psychiatric admission over time was observed. Conclusions Early death for those hospitalised with mental disorder is common, and represents a significant inequality even in well-developed healthcare systems. Prevention of suicide and cardiovascular disease deserves particular attention in the mentally disordered.

Targeting Health Visitor care: lessons from Starting Well.

Background: UK child health promotion guidelines expect health visitors to assess family needs before new babies are aged 4 months and offer targeted care on that basis thereafter. Data from an intensive family support programme were used to assess how accurately family needs can be predicted at this stage. Design: A population based cohort of 1202 families with new babies receiving an intensive health visiting programme. Analysis of routinely recorded data. Setting: Starting Well project, Glasgow, UK. Predictors: Health visitor rating of family needs. Main outcome measures: Families receiving high visiting rates or referred to social work services. Results: Of 302 families rated high need, only 143 (47%) were identified by age 4 months. Visiting rates in the first year for those initially rated high need were nearly double those for the remainder, but around two thirds of those with high contact rates/referred to social work were not initially rated high need. Six family characteristics (no income, baby born preterm, multiple pregnancy, South Asian, prior social work/criminal justice involvement, either parent in care as a child) were identified as the commonest/strongest predictors of contact rates; 1003 (83%) families had one such characteristics and/or lived in a highly deprived area, including 228 (93%) of those with high contact rates and 157 (96%) of those referred to social work. Conclusions: Most families at risk will not be identified on an individual basis in the early weeks. Most families in deprived areas need continued input if the most vulnerable families are to be reliably identified.

Trends in the coverage of 'universal' child health reviews: observational study using routinely available data.

Objectives Universally offered child health reviews form the backbone of the UK child health programme. The reviews assess childrens health, development and well-being and facilitate access to additional support as required. The number of reviews offered per child has been reduced over recent years to allow more flexible provision of support to families in need: equitable coverage of the remaining reviews is therefore particularly important. This study assessed the coverage of universal child health reviews, with an emphasis on trends over time and inequalities in coverage by deprivation. Design Assessment of the coverage of child health reviews by area-based deprivation using routinely available data. Supplementary audit of the quality of the routine data source used. Setting Scotland. Participants Two cohorts of around 40 000 children each. The cohorts were born in 1998/1999 and 2007/2008 and eligible for the previous programme of five and the current programme of two preschool reviews, respectively. Outcome measures Coverage of the specified child health reviews for the whole cohorts and by deprivation. Results Coverage of the 10 day review is high (99%), but it progressively declines for reviews at older ages (86% for the 39–42 month review). Coverage is lower in children living in the most deprived areas for all reviews, and the discrepancy progressively increases for reviews at older ages (78% and 92% coverage for the 39–42 month review in most and least deprived groups). Coverage has been stable over time: it has not increased for the remaining reviews after reduction in the number of reviews provided. Conclusions The inverse care law continues to operate in relation to ‘universal’ child health reviews. Equitable uptake of reviews is important to ensure maximum likely impact on inequalities in childrens outcomes.

Novel cross-sectoral linkage of routine health and education data at an all-Scotland level: a feasibility study

Abstract Background Analysis of routine data provides an efficient way of exploring health risks and outcomes. We aimed to undertake the first Scotland-wide linkage of childrens health and education data to show the feasibility of such cross-sectoral linkage for research. Methods We undertook a data linkage study of children in Scottish schools between 2006–07 and 2011–12. The main datasets were the annual Scottish Government pupil census, which contains Scottish candidate numbers (SCNs; unique identifier used on education records) and personal identifiers for children in publicly funded schools; and the Community Health Index (CHI) database held by NHS National Services Scotland (NSS), which contains CHI numbers (unique identifier used on health records) and identifiers for patients registered with a GP. Restricted pupil identifiers available for linkage in the pupil census (date of birth, sex, home postcode) were matched against patient identifiers held on the CHI database by a bespoke version of NSSs in-house medical record linkage software (previously validated). A best match CHI and additional possible (rival) CHIs were identified for each pupil and assigned probabilistic scores suggesting the amount of agreement between identifiers. Links were then partitioned into categories depending on scores. Links within specified categories (best match CHI with exact agreement on all identifiers or with postcode differing by one character only, and nearest rival CHI with lower score) were regarded as secure, and best match CHIs were accepted. Two methods of linkage were explored: linking identifiers from each years pupil census separately (A) and combining all the available pupil identifier data from each census into one record per pupil and then linking the combined records (B). Two quality checks were undertaken to assess whether accepted CHIs were correct. Pupil names are available in pupil census records, but the government is unable to share these for linkage purposes. NSS therefore returned SCNs and full names from the best matching CHI records to the government. The government then used name-matching algorithms to compare these with the names in the pupil census. The Scottish Qualifications Agency provided SCNs and full pupil identifiers (including names) for the subset of children registered for Scottish examinations. NSS ran these data through their established probabilistic matching algorithms and the CHI numbers obtained were compared with those from the pupil census linkage. The SCN–CHI key resulting from the linkage was used to construct an anonymised analysis dataset including childrens delivery records and their educational attendance, needs, and attainment records. This dataset was used to explore educational outcomes for children with different birth presentations and delivery modes to assess its utility in answering research questions. The results are reported elsewhere. Findings Using linkage method A, an acceptable CHI number could be found for 607 115 (86·3%) of 703 500 children in the 2006–07 census, increasing to 623 396 (92·9%) of 671 264 in 2011–12. Comparable figures using method B were 655 429 of 703 500 (93·2%) in 2006–07 and 638 011 of 671 264 (95·0%) in 2011–12. Linkage method B was therefore regarded as preferable. Using linkage method B, both quality checks suggested that over 99% of the accepted CHIs were indeed correct for children in the 2006–07 and 2011–12 censuses. Interpretation Routine health and education data in Scotland can be linked to an acceptable quality for public health research purposes, despite the absence of names available for linkage within education datasets. This finding opens up the potential for a range of policy-relevant life-course research drawing on routine data from different sectors. Funding Scottish Collaboration for Public Health Research and Policy (https://www.scphrp.ac.uk/node/264).

Informing the ‘early years’ agenda in Scotland: understanding infant feeding patterns using linked datasets

Background Providing infants with the ‘best possible start in life’ is a priority for the Scottish Government. This is reflected in policy and health promotion strategies to increase breast feeding, which gives the best source of nutrients for healthy infant growth and development. However, the rate of breast feeding in Scotland remains one of the lowest in Europe. Information is needed to provide a better understanding of infant feeding and its impact on child health. This paper describes the development of a unique population-wide resource created to explore infant feeding and child health in Scotland. Methods Descriptive and multivariate analyses of linked routine/administrative maternal and infant health records for 731 595 infants born in Scotland between 1997 and 2009. Results A linked dataset was created containing a wide range of background, parental, maternal, birth and health service characteristics for a representative sample of infants born in Scotland over the study period. There was high coverage and completeness of infant feeding and other demographic, maternal and infant records. The results confirmed the importance of an enabling environment—cultural, family, health service and other maternal and infant health-related factors—in increasing the likelihood to breast feed. Conclusions Using the linked dataset, it was possible to investigate the determinants of breast feeding for a representative sample of Scottish infants born between 1997 and 2009. The linked dataset is an important resource that has potential uses in research, policy design and targeting intervention programmes.

General practitioner provision of preventive child health care: analysis of routine consultation data

BackgroundGPs contribute to preventive child health care in various ways, including provision of child health surveillance (CHS) reviews, opportunistic preventive care, and more intensive support to vulnerable children. The number of CHS reviews offered in Scotland was reduced from 2005. This study aimed to quantify GPs’ provision of different types of preventive care to pre-school children before and after the changes to the CHS system.MethodsGP consultation rates with children aged 0–4 years were examined for the 2½ years before and after the changes to the CHS system using routinely available data from 30 practices in Scotland. Consultations for CHS reviews; other aspects of preventive care; and all reasons were considered.ResultsPrior to the changes to the CHS system, GPs often contributed to CHS reviews at 6–8 weeks and 8–9 and 39–42 months. Following the changes, GP provision of the 6–8 week review continued but other reviews essentially ceased. Few additional consultations with pre-school children are recorded as involving other aspects of preventive care, and the changes to CHS have had no impact on this. In the 2½ years before and after the changes, consultations recorded as involving any form of preventive care accounted for 11% and 7.5% respectively of all consultations with children aged 0–4 years, with the decline due to reductions in CHS reviews.ConclusionsEffective preventive care through the early years can help children secure good health and developmental outcomes. GPs are well placed to contribute to the provision of such care. Consultations focused on preventive care form a small minority of GPs’ contacts with pre-school children, however, particularly since the reduction in the number of CHS reviews.

The impact of cancer on subsequent chance of pregnancy: a population-based analysis

Abstract STUDY QUESTION What is the impact of cancer in females aged ≤39 years on subsequent chance of pregnancy? SUMMARY ANSWER Cancer survivors achieved fewer pregnancies across all cancer types, and the chance of achieving a first pregnancy was also lower. WHAT IS KNOWN ALREADY The diagnosis and treatment of cancer in young females may be associated with reduced fertility but the true pregnancy deficit in a population is unknown. STUDY DESIGN, SIZE, DURATION We performed a retrospective cohort study relating first incident cancer diagnosed between 1981 and 2012 to subsequent pregnancy in all female patients in Scotland aged 39 years or less at cancer diagnosis (n = 23 201). Pregnancies were included up to end of 2014. Females from the exposed group not pregnant before cancer diagnosis (n = 10 271) were compared with general population controls matched for age, deprivation quintile and year of diagnosis. PARTICIPANTS/MATERIALS, SETTING, METHODS Scottish Cancer Registry records were linked to hospital discharge records to calculate standardized incidence ratios (SIR) for pregnancy, standardized for age and year of diagnosis. Linkage to death records was also performed. We also selected women from the exposed group who had not been pregnant prior to their cancer diagnosis who were compared with a matched control group from the general population. Additional analyses were performed for breast cancer, Hodgkin lymphoma, leukaemia, cervical cancer and brain/CNS cancers. MAIN RESULTS AND THE ROLE OF CHANCE Cancer survivors achieved fewer pregnancies: SIR 0.62 (95% CI: 0.60, 0.63). Reduced SIR was observed for all cancer types. The chance of achieving a first pregnancy was also lower, adjusted hazard ratio = 0.57 (95% CI: 0.53, 0.61) for women >5 years after diagnosis, with marked reductions in women with breast, cervical and brain/CNS tumours, and leukaemia. The effect was reduced with more recent treatment period overall and in cervical cancer, breast cancer and Hodgkin lymphoma, but was unchanged for leukaemia or brain/CNS cancers. The proportion of pregnancies that ended in termination was lower after a cancer diagnosis, and the proportion ending in live birth was higher (78.7 vs 75.6%, CI of difference: 1.1, 5.0). LIMITATIONS, REASONS FOR CAUTION Details of treatments received were not available, so the impact of specific treatment regimens on fertility could not be assessed. Limited duration of follow-up was available for women diagnosed in the most recent time period. WIDER IMPLICATIONS OF THE FINDINGS This analysis provides population-based quantification by cancer type of the effect of cancer and its treatment on subsequent pregnancy across the reproductive age range, and how this has changed in recent decades. The demonstration of a reduced chance of pregnancy across all cancer types and the changing impact in some but not other common cancers highlights the need for appropriate fertility counselling of all females of reproductive age at diagnosis. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by NHS Lothian Cancer and Leukaemia Endowments Fund. Part of this work was undertaken in the MRC Centre for Reproductive Health which is funded by the MRC Centre grant MR/N022556/1. RAA has participated in Advisory Boards and/or received speaker’s fees from Beckman Coulter, IBSA, Merck and Roche Diagnostics. He has received research support from Roche Diagnostics, Ansh labs and Ferring. The other authors have no conflicts to declare.