Health and Health Behaviour The COSPH Project Dr. Ann Palmer Centre for Health Services Studies University of Kent 11th January EUREGHA Conference – Inequalities in Health

En partenariat avec: In partnership with: Avec le soutien de: With the support of: PROJET CONFINANCE PAR L’UNION EUROPEENNE (FEDER) FINANCED IN PART BY THE EUROPEAN UNION

Two regions, both have distinct rural and urban areas, affluent and poor areas, both have ex-mining areas, both have ex-dockyard Les deux régions – les agglomérations urbaines, le pays rural, les zones riches et de pauvreté, les bassins ex-mineurs, les ports dockyards English French Administrative Area Number of People Region (Kent, Medway, East Sussex and Brighton and Hove) 2,600,624 Région (Nord Pas de Calais) 3,995,871 County or Unitary Authority (4) 492,324 (East Sussex); 250,000 (Medway) 1,370,000 (Kent) 248,000 (Brighton and Hove) Département (2) 2,555,020 Nord and 1,441,568 Pas-de-Calais Local Authority 5 East Sussex; 12 Kent; Medway, Brighton and Hove 85,000 (Hastings) to 250,000 (Medway) Arrondissements (13) 99,249 (Montreuil) to 1,181,724 (Lille) Electoral Wards 249 (North Downs, Ashford) to 5666 (Beaver Ashford) Pseudo-Cantons 4919 (Le Quesnoy) to 93.531 Tourcoing 96,959 Roubaix and 184,647 Lille

The key question? La question la plus importante? Is the south east of England more or less healthy than northern France? expectation of life at birth is greater in France in both countries there is better health in the south of the country than in the north there is a complexity of pre-determinants including socio-economic factors, lifestyle and health behaviour Est-ce que les gens du sud-est d’Angleterre est plus ou moins en bon santé que le nord de la France? L’espérance de la vie est plus en la France qu’en Angleterre Les deux compagnies ont plus bon santé au sud que le nord Il y a une complexité des déterminants qui inclus les facteurs sociologiques, économiques et en plus les comportements de la santé Expectation of life / l’espérance de la vie France 82.8 for women and 75.3 for men England 79.9 for women and 75 for men

What indicators can we use to compare health across the channel What indicators can we use to compare health across the channel? Lesquels indicateurs nous pouvons utiliser a faire une comparaison de la santé les deux cotes de la Manche? Aim to develop / find key measures which will enable comparisons to be made at local level between the 2 sides of the channel. Variations in mortality and morbidity across geographical areas Variations across socio-economic strata Access to health and social care provision depending on availability, accessibility, acceptability and quality of care What data are available? Demography Social Indicators Mortality indicators Health indicators from the local health surveys Health service data How comparable are data across the channel? Collection and interpretation Use of standard measures Date of data Geographical and administrative boundaries Le but est à chercher les mesures qui faciliteront les comparaisons au niveau locale les deux cotés de la manche Les variations de la mortalité et la morbidité spatiales Les variations socio-économiques L’accès au soins de la santé et sociaux Notre concentration pour la commencement du projet était les mesures suivantes Les démographiques Les indicateurs sociologiques Les indicateurs de la mortalité Les indicateurs qui suivre des enquêtes de santé publiques dans les localités Est-ce que les indicateurs sont comparable les deux côtes de la Manche? Collection et interprétation Utilisation des mesures standardisés Dates des donnés Les sources les plus importantes nous avons utilisés sont le Census, les personnes décédés and les enquêtes

Using Townsend Scores to compare deprivation across SE England and N France La comparaison entre le nord de la France et la sud de l’Angleterre des inégalités utilisant l’Indice de Townsend More concentrated deprivation in northern France Coastal deprivation Central belt of deprivation through the mining regions of France La défavorisation est plus concentré au nord de la France et aux régions de la côté On trouve les zones de défavorisation centrale dans les régions anciennes des mineurs

Mortality indicators - are they comparable Mortality indicators - are they comparable? La mortalité – est-ce que c’est bien comparable? More recent mortality data is available in England, older data only available from 1986 French mortality data is available at Canton level from 1979 - 2001. Agreed that French mortality at Canton level would cover the years 1997-2001 whilst English mortality data would cover 1999-2003. Time trend data would be a three year rolling average from 1979 (France) and 1986 (England) at regional and departmental level. In France ICD 9 was used for coding deaths between 1979 and 1999 and ICD 10 from 2000; in England ICD 9 was used to the end of year 2000 and ICD 10 from the beginning of 2001 Les données de la mortalité en Angleterre sont des années 1986 – 2003 Pour la France les données sont possible des années 1979 mais seulement au 2001 La comparaison des Electoral Wards avec les Cantons (plus grands, plus de peuple) Pour les tendances 3 ans d’agrégations L’utilisation de ICD 9 et ICD 10 c’est changé en la France 2000 et en Angleterre l’an 2001

Hommes, 1996-2002 - Carte des SMR prématurés (0-64 ans) toutes causes Men : premature mortality (0-64 years) 1996-2002 –All causes Lissés par la méthode locale de Marshall using Local Linear Empirical Bayes Smoother SMR : Nord-Pas-de-Calais + south-east english regions = 100 The mortality in Nord – Pas-de-Calais is higher than in Southeast of England. In France, some areas show very high rates of mortality (areas with old mining industry, areas around Dunkerque,…)

Women, mortality 1996-2002 - SMR all cause and all ages Femmes, mortalité 1996-2002 - SMR toutes causes et tous âges Lissés par la méthode locale de Marshall Local Linear Empirical Bayes Smoother SMR : Nord-Pas-de-Calais + south-east english regions = 100

Mortality from cancer - Men : All ages, 1996-2002 La mortalité des cancers – hommes toutes ages 1996-2002 SMR of Kent, Medway, East-Sussex, Brighton & Hove, Nord – Pas-de-Calais = 100 Local Linear Empirical Bayes Smoother

Mortality from circulatory diseases - Women : All ages, 1996-2002 La mortalité des maladies circulatoires – femmes toutes ages, 1996-2002 SMRs for Kent, Medway, East-Sussex, Brighton & Hove, Nord – Pas-de-Calais = 100 Local Linear Empirical Bayes Smoother

Mortality from respiratory diseases: Men, all ages 1996-2002 La mortalité des maladies respiratoires: hommes toutes ages

Mortality from respiratory diseases: Women, all ages La mortalité des maladies respiratoires: Femmes toutes ages 1996-2002

Survey data Les données des enquêtes de la santé Three health surveys Enquête Santé 2002-2003 – Extension régionale Nord/Pas-de-Calais Survey of people in East Sussex, Brighton & Hove 2003 Kent and Medway Health and Lifestyles surveys Nord – Pas-de-Calais Kent and Medway East Sussex, Brighton & Hove Population 4.0 million 1.6 million 740,000 Sample 4,033 8,071 5,936 Timing – Date October 2002 - September 2003 5 waves June 2001 May 2003 Age 0+ 16+ registered with GP 18+ registered with GP Weighting Official INSEE Age and gender

Results: Prevalence of Health Behaviours Résultats: Les comportements de la Santé

Comparison of Survey Data – Smoking (women) Comparaison des données des enquêtes – Tabagisme (femmes) ESBH and K&M Nord –Pas-de-Calais

The focus group findings In the COSPH focus groups, participants were asked: Question What do you think are the most important things that can be done to improve the health of the nation or the population or the community that you live in? What do you think can be done to reduce health inequalities? What can the general public do to stop becoming sick? How do you think the general public could help government to create policies to reverse such inequalities?

Deprivation at the coast? Docks and Ports? I was surprised … that the low life expectancy are mainly on coastal areas - that was my first thoughts … I would have thought that in the coastal environment where food is supposed to be that much better, sea breezes and all this should constitute a better lifestyle and from a health point of view, but it doesn’t seem to … (Focus Group 2) Yeah it makes sense. You can see, they are all… first of all most of them are industrial areas which are run down - nearly all of them actually - and you have got the dock area around Dover, parts of that is… and then if you come to Folkestone, another run-down area. (Focus Group 9) There’s high unemployment around the Dover area which of course has made them areas of deprivation … we know around the Sheppey area there is high unemployment again from the sense of there’s less there’s dock work… (Focus Group 9)

And ex-mining areas in East Kent… Well one of the social factors here, specific to this ward, is it's an ex-mining community and there’s obviously a lot of respiratory disease here. But that is specific to this area. (Focus Group 13) Also particularly around Dover which, you know, we know well, is because of the unemployment because the closure of the pits … all of those were mining areas, the pits closed, the ferry closed http://home.freeuk.com/eastkent/mining/index.htm http://www.dover.gov.uk/kentcoal/intro.asp

Summary… Sommaire…….. Mortality from circulatory diseases is more important in England and the regions of south east England Health behaviour, especially consumption of fat, smoking in England There is less circulatory disease in France and in the north of France but premature mortality is a bigger issue Female cancer is more important in England Smoking has reduced quicker in England Premature mortality is more important in Nord – Pas-de-Calais than in south east England for both sexes in Nord – Pas-de-Calais there has been a great deal of industrialisation in the past (mining, port health) favouring industrial and environmental diseases including asbestosis A poorer socio-economic situation leading to Stress related disease including smoking, alcoholism Less likely to use health services Less likely to take part in screening campaigns La mortalité des maladies circulatoires est plus importante en Angleterre et les régions du sud-est Angleterre Les comportements de la santé, espécialement de la graisse, et le tabagisme en Angleterre Au nord de la France la mortalité prématurée est plus importante Chez les femmes le cancer est plus importantes en Angleterre La réduction du tabagisme en Angleterre a été plus rapide La mortalité prématurée est plus importante en Nord – Pas-de-Calais qu’en Sud Est Angleterre pour les deux sexes En Nord – Pas-de-Calais il y avait plus d’industrialisation (le bassin de mineurs, la santé du port) qui inclus le cancer de la plèvre La situation socio-économique est suivie par Les problèmes du stress Moins d’accès aux soins Moins de participation aux services de dépistage

Health and Health Behaviour The COSPH Project Dr. Ann Palmer Centre for Health Services Studies University of Kent 11th January EUREGHA Conference – Inequalities in Health A.P.Palmer@kent.ac.uk