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Social Science & Medicine 73 (2011) 1575e1584

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Social Science & Medicine

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Rising premature mortality in the UK’s persistently deprived areas:Only a Scottish phenomenon?

Paul Norman a,*, Paul Boyle b, Daniel Exeter c, Zhiqiang Feng b, Frank Pophamb

aCentre for Spatial Analysis & Policy, School of Geography, University of Leeds, Leeds LS2 9JT, UKb Longitudinal Studies Centre e Scotland (LSCS), School of Geography & Geosciences, University of St Andrews, St Andrews KY16 9AL, UKc School of Population Health, University of Auckland, PO Box 92019, Auckland 1142, New Zealand

a r t i c l e i n f o

Article history:Available online 13 October 2011

Keywords:Persistent deprivationDeprivation (im)mobilityPopulation residualisationPremature mortalityUKGlasgowScotland

* Corresponding author. Tel.: þ44 0 113 34 38199;E-mail address: p.d.norman@leeds.ac.uk (P. Norma

0277-9536/$ e see front matter � 2011 Elsevier Ltd.doi:10.1016/j.socscimed.2011.09.034

a b s t r a c t

In the international literature, many studies find strong relationships between area-based measures ofdeprivation and mortality. In the UK, mortality rates have generally fallen in recent decades but the lifeexpectancy gap between the most and least deprived areas has widened, with a number of Scottishstudies highlighting increased mortality rates in deprived areas especially in Glasgow. However, thesestudies relate health outcomes at different time points against period-specific measures of deprivationwhich may not be comparable over time. Using longitudinal deprivation measures where levels of areadeprivation are made comparable over time, a recent study demonstrated how levels of mortality changein relation to changing or persistent levels of (non-) deprivation over time. The results showed that areaswhich were persistently deprived in Scotland experienced a rise in premature mortality rates by 9.5%between 1981 and 2001.

Here, focussing on persistently deprived areas we extended the coverage to the whole of the UK toassess whether, between 1991 and 2001, rising premature mortality rates in persistently deprived areasare a Scottish only phenomenon or whether similar patterns are evident elsewhere and for men andwomen separately. We found that male premature mortality rates rose by over 14% in Scotland over the10-year period between the early 1990s and 2000s in persistently deprived areas. We found no signif-icant rise in mortality elsewhere in the UK and that the rise among men in Scotland was driven by resultsfor Glasgow where mortality rates rose by over 15% during the decade. Our analyses demonstrate theimportance of identifying areas experiencing persistent poverty. These results justify even more ofa public health focus on Glasgow and further work is needed to understand the demographic factors,such as health selective migration, immobility and population residualisation, which may contribute tothese findings.

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Introduction

Many studies find strong relationships between area-basedmeasures of deprivation and all-cause and cause-specific mortalityin the UK (Eames, Ben-Shlomo, &Marmot,1993; Law&Morris,1998;Romeri, Baker, &Griffiths, 2006) and acrossmanycountries in Europe(Huisman et al., 2004) including Spain (Benach, Yasui, Borrell, Sáez, &Pasarin, 2001), Belgium (Lorant, Thomas, Deliège, & Tonglet, 2001),and France (Rey, Eric Jougla, Fouillet, & Hémon, 2009). Strong rela-tionships between deprivation and mortality are also found in theUSA (Singh, 2003), Canada (Auger, Alix, Zang, & Daniel, 2010;Pampalon, Hamel, & Gamache, 2008), Australia (Butler, Petterson,

fax: þ44 0 113 34 33308.n).

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Bazemore, & Douglas, 2010) and New Zealand (Pearce & Dorling,2006). These relationships also exist for infant mortality (Norman,Gregory, Dorling, & Baker, 2008) and for morbidity (Boyle, Gatrell,& Duke-Williams, 1999; Norman & Bambra, 2007).

Of particular concern in the UK is that subnational inequalities inmortality have been increasing over the last few decades. Althoughmortality rates have generally fallen, the decline has been slower inmore deprived areas so that themortality gap between themost andleast deprived areas has widened (see, for example, Higgs, Senior, &Williams, 1998; O’Flaherty et al., 2009; Rees, Brown, Norman, &Dorling, 2003; Shaw, Dorling, Gordon, & Davey-Smith, 2004).Thomas, Dorling, and Davey Smith (2010) demonstrate that inBritain the ratio of standardised mortality ratios (SMRs) in the mostdeprived areas to SMRs in the least deprived areas increased from1.61 in 1990e1991 to 1.88 in 2006e2007, an increase of just over 1%per year. During the same period, inequalities for mortality for ages

P. Norman et al. / Social Science & Medicine 73 (2011) 1575e15841576

0e74 increased from a most to least deprived ratio of 2.17e2.79, anincrease of 1.8% per year. For countries in Europe, Huisman et al.(2004) find that whilst inequalities in relative socio-economicmortality generally decrease with age, absolute inequalitiesincrease. For Europe and selected countries in the rest of the world,Leon (2011) shows a general trend for longer life expectancies overtime, but that differences between countries are increasing in manycases with the differences in life expectancy for males and femalespersisting. Similarly, in New Zealand, whilst overall life expectancyhas increased during the last decades of the 20th Century, anincrease spatial polarisation of health occurred along with a sharprise in inequalities (Pearce & Dorling, 2006).

Compared with the UK and most of Europe, men and women inScotland have relatively low life expectancy (GROS, 2010). In 2007,males in Scotland had life expectancy at birth 1.0 year lower thanthe European Union (EU) average of 76.1 while the life expectancyfor females was 2.3 years lower than the EU average of 82.2. Formales, the life expectancy gap between Scotland and the whole ofthe UK has widened by 0.4 years since 1997 to 2.5 in 2010. Acrossthe EU, only Eastern European countries have shorter life expec-tancies than those experience in Scotland. For subnational geog-raphies, a small number of Scottish studies have actuallyhighlighted increasing mortality rates in deprived areas for: youngadults (Leyland, Dundas, McLoone, & Boddy, 2007; McLoone &Boddy, 1994); certain causes of disease (Boyle, Exeter, Feng, &Flowerdew, 2004; Leyland et al., 2007); and overall prematuremortality rates in men in the most deprived areas (Leyland et al.,2007). For example, Leyland et al. (2007) found a rise in prema-ture mortality rates for men in the most deprived areas of Scotlandin 2001 compared to 1991 driven by rising mortality in alcohol,drug and mental health related causes amongst young adultsparticularly in the Glasgow region of the country. Life expectancyhas also been shown to have declined slightly amongst men in themost deprived areas of Greater Glasgow from 65.3 years in 1981 to64.4 years in 2001 (Hanlon, Walsh, & Whyte, 2006). Subsequently,Walsh, Bendel, Jones, and Hanlon (2010) found that Glasgow hasa considerably worse level of health, compared with Liverpool andManchester, which could not be explained solely by socio-economic circumstances.

However, these studies have used period-specific measures ofdeprivation. This means that deprivation scores from one period tothe next are not directly comparable (Norman, 2010a), making itimpossible to study areas that have been amongst the consistentlymost deprived in absolute terms over time. Recently, Exeter, Boyle,and Norman (2011) introduced a novel method for calculatingCarstairs deprivation scores (Carstairs & Morris, 1989) that could becompared over time using areas in Scotland whose boundariesremained stable over the entire period 1981 to 2001. This analysisdemonstrates that the persistently most deprived areas in Scotland(1981e2001) had seen premature mortality rates rise by 9.5%during the two decades.

Given that at a national level in Scotland, and across the UK, lifeexpectancy has consistently risen year on year over this period, it isof concern that the average length of life for persons living in thepersistently most deprived areas may be shortening. In this paper,we extend Exeter et al.’s recent Scotland analysis to the whole ofthe UK to assess whether, between 1991 and 2001, rising prematuremortality rates in persistently deprived areas are a Scottish onlyphenomenon or whether similar patterns are evident in the othercountries and regions of the UK. If this has only occurred in Scot-land our results may provide some insight into the phenomenaknown as the Scottish and Glasgow ‘effects’, which refer to theinability of current levels of deprivation to fully explain Scotland’shigh mortality rates compared to the rest of the UK (Hanlon et al.,2005; Walsh, Bendel, et al., 2010; Walsh, Taulbut, & Hanlon, 2010).

Data and methods

Some fundamental difficulties restrict analyses of the relationshipbetween mortality and deprivation for small areas across the wholeof the UK; both cross-sectional and time-series. For this analysis werequire mortality and population denominator data for small areasthat are consistent through time between 1991 and 2001. TheConsistent Areas Through Time (CATTs) which have been created inScotland (Exeter, Boyle, Feng, Flowerdew, & Schierloh, 2005) andwere used by Exeter et al. (2011) cannot be replicated elsewhere inthe UK because, unlike in Scotland where the census geographieswere built around existing postcodes in every census since 1981, veryfew small area census boundaries are common across time in the restof the UK (Norman, Gregory, Dorling, & Baker, 2008). To convert databetween geographies, various techniques have been developedincluding areal interpolation (Gregory, 2002) and dasymetricmapping (Mennis, 2003). Norman, Rees, and Boyle (2003) demon-strate that socio-demographic data can be apportioned betweendifferent geographical systems to estimate a data time-series for oneset of boundaries. This apportionment is computed using a proxy forpopulation distribution, the counts of postcodes (weighted by thenumber of addresses at each), that fall in the intersections of the 1991and 2001 geographies. This method is well established and reliableenough that a similar approach has been adopted by the Office forNational Statistics (ONS) to provide mid-year estimates for non-standard areas (Bates, 2008). We therefore adopt this approach toconvert data relating to the 1991 Census and Vital Statistics for thewhole of the UK to the 2001 Census wards in England, Wales andNorthern Ireland and pseudo postcode sectors in Scotland. Thoughrelatively small, these areas have somewhat larger populations thantheCATTsused in theanalysis byExeteret al. (2011), but theydoallowfor a consistent analysis across the UK.

In England, the government’s currently preferred indicator ofdeprivation is the Index of Multiple Deprivation (IMD) (Noble,Wright, Smith, & Dibben (2006)). While IMDs have been producedat different time points, the input variables are not available inequivalent formats over time and the IMD constructed for England isbased on a different set of variables to those created for Wales, forScotland or for Northern Ireland. Thus, constructing UK-wide IMDscomparable over space and time is not feasible (Morelli & Seaman,2007; Whynes, 2009). Since the input variables are consistentlyavailable, deprivation has been calculated here using the Townsendindex (Townsend,1987), ameasure of deprivation commonly used inhealth studies (Adams, Ryan, & White, 2004; Higgs et al., 1998).Aiming to capture dimensions of deprivation relating to materialpoverty, the Townsend index is a composite score comprising fourcensus ward-level input variables: percentages of unemployment,no access to a car, non-home ownership and household over-crowding. For wards (England and Wales) and postal sectors (Scot-land) with populations greater than 200 persons, deprivation acrossthe UK has been calculated to ensure that the 1991 Townsend scoresare directly comparable with those for 2001 by placing each arearelative to the 1991e2001 UK average for each input variable(Norman, 2010a). This approach is equivalent to that adopted byExeter et al. (2011) for Scotland but applied to the whole of the UK.For the postal sector geography used here in Scotland, there arecorrelations of 0.93 in 1991 and 0.97 in 2001 between the Townsenddeprivation scores and the Carstairs scores used by Exeter et al.(2011). As a further consistency check we find a correlation of 0.88between Townsend scores for 2001 for the Lower Super Output Area(LSOA) geography with the IMD in England for 2004. Equivalentcorrelations are 0.85 inWales, 0.91 in Scotland and 0.92 in NorthernIreland. So, both here and in other work (Mackenzie, Nelder,Maconachie, & Radford, 1998) there is a strong correlation betweenschemes. However, we must acknowledge that the outcomes of

P. Norman et al. / Social Science & Medicine 73 (2011) 1575e1584 1577

a study using area deprivation might be sensitive to the measureused (Davey Smith, Whitley, Dorling, & Gunnell, 2001).

Exeter et al. (2011) presented premature mortality rates for theearly 1980s and 2000s for Scotland across seven categories of area.Of most interest were their results for the persistently mostdeprived areas (identified as those areas falling in the mostdeprived quintile in both 1981 and 2001) in which mortality ratesactually increased significantly over the twenty-year period.

Having defined population-weighted quintiles of deprivation forareas within Scotland, here we concentrate on the persistently mostdeprived areas, those categorised into quintile 5, the most deprivedquintile, in both 1991 and 2001. First, we seewhether our results areconsistent with Exeter et al. (2011) for Scotland even though we usea shorter time period (1991e2001, instead of 1981e2001), a slightlylarger set of geographical areas, and a different, but similar, measureof deprivation. Initially, we consider premature mortality forpersons aged 0e64 (as used by Exeter et al.), but in addition wecalculate male and female premature rates separately to testwhether similar patterns exist for men and women. We also definepopulation-weighted quintiles within each of Northern Ireland,Wales and the Government Office Regions in England so that we canbroaden the geographical coverage to determine changes inmortality in persistently deprived areas within these areas. It couldbe argued that Scotland should more sensibly be compared toNorthern regions of England than to England as a whole.

Mid-year age and sex counts were used for populationdenominators and these were estimated by Norman, Simpson, andSabater (2008) based on information supplied by ONS for Englandand Wales, the Northern Ireland Statistics and Research Agency(NISRA), and the General Register Office for Scotland (GROS). UsingVital Statistics data on deaths from the same data suppliers, wecalculate three year premature mortality rates (per 100,000) cen-tred on the decennial census year, age standardised to the EuropeanStandard Population, and 95% confidence intervals, for deaths fromall causes for those aged 0e64 years in 1990e1992 and 2000e2002.

Table 1Distribution of small areas, population aged 0e64 years (2001) and premature (0e64 ye

Countries/regions All small areas Persistently

Areas:CATTs

Populationaged 0e64,2001

Deathsaged 0e64,1999e2001

Areas:CATTs

Scotland(Exeter et al., 2011)

10,058 4,257,111 35,306 638

All areas Persistently

Areas:wards &postal sectors

Populationaged 0e64,mid-year 2001

Deathsaged 0e64,2000e2002

Areas:wards &postal secto

Scotland 935 4,236,893 35,495 56Glasgow 93 475,775 5650 46Outside Glasgow 842 3,761,119 29,845 10

Northern Ireland 582 1,465,353 8343 30Wales 881 2,404,191 16,421 46

England 7958 41,614,220 250,764 825North West 1006 5,691,286 40,562 96North East 484 2,120,874 14,965 61Yorkshire & The Humber 496 4,176,167 26,517 44West Midlands 761 4,438,603 28,514 38East Midlands 881 3,516,374 21,525 50London 625 6,425,285 34,752 268South East 1499 6,712,646 36,161 126South West 1088 4,021,429 23,127 61East of England 1118 4,511,556 24,641 81

UK 10,356 49,720,658 311,023 957

Source: Authors’ calculations based on census and vital statistics data.

The count of deaths to infants aged 0 includes neonatal and post-neonatal mortality but excludes stillbirths.

Results

The 56 areas classified here into the most persistently deprivedquintile in Scotland in both 1991 and 2001 represent 6% of the 935Scottish small areas used in this work (Table 1). In 2001, these areascontained 265,982 persons aged 0e64 representing 6% of Scot-land’s population of this age-group. Of the 35,495 prematuredeaths during 2000e2002 in Scotland as a whole, 4087 (12%)occurred in these persistently deprived areas resulting in a threeyear crude death rate of 5.12 per 1000 persons. In Exeter et al.’sstudy, the CATTs classified as being persistently deprived in both1981 and 2001 represent 6% of the total number of areas and in2001, of those aged 0e64, these contain 4% of Scotland’s populationand 8% of the deaths during 1999e2001; a crude death rate of 5.25per 1000 persons.

As noted above, Exeter et al.’s telling result was that in thepersistently deprived areas in Scotland, premature mortality ratesincreased significantly by 9.5% from 546 per 100,000 persons in1980e1982 to 599 per 100,000 in 1999e2001. Emulating this studywe find here that rates rose significantly by 7% from 507 per100,000 in 1990e1992 (95% CI 492e522) to 542 per 100,000persons in 2000e2002 (CI 525e559). Though not reported here, inboth studies therewere no significant rises inmortality in any othercombinations of quintiles. While there are differences between thetwo studies (their time points, small area geographies and depri-vation schemes), the consistency of the results lends weight to thefindings and gives us confidence to extend the work.

The premature age-standardised rates reported above are for allpersons so next we calculate rates separately for males and femalesfor Scotland’s most persistently deprived areas in both 1991 and2001. In these locations, premature mortality rates for malesincreased significantly by over 14% from 649 per 100,000

ars) deaths (c. 2001).

deprived areas

Populationaged 0e64,2001

Deathsaged 0e64,1999e2001

% Areas % Population % Deaths Crude deathrate/1000

188,143 2965 6 4 8 5.25

deprived areas

rs

Populationaged 0e64,mid-year 2001

Deathsaged 0e64,2000e2002

% Areas % Population % Deaths Crude deathrate/1000

265,982 4087 6 6 12 5.12220,705 3476 49 46 62 5.2545,277 611 1 1 2 4.50

113,551 1000 5 8 12 2.94175,719 1566 5 7 10 2.97

7,322,135 51,944 10 18 21 2.36778,794 7337 10 14 18 3.14352,500 3115 13 17 21 2.95554,531 4357 9 13 16 2.62562,393 4132 5 13 14 2.45437,920 3340 6 12 16 2.54

2,866,998 17,050 43 45 49 1.98814,221 5667 8 12 16 2.32406,128 3186 6 10 14 2.61548,650 3760 7 12 15 2.28

7,877,386 58,597 9 16 19 2.48

P. Norman et al. / Social Science & Medicine 73 (2011) 1575e15841578

(CI 625e674) in 1990e1992 to 743 (CI 715e771). However, forfemales, rates fell slightly, but insignificantly, from 376 for1990e1992 (CI 358e394) to 355 per 100,000 in 2000e2002(CI 336e374). Within Glasgow, 49% of the postal sectors used forthe dissemination of the 2001 Census are classified as persistentlydeprived (Table 1). In 2001, these areas contained 46% of Glasgow’spopulation aged 0e64 and 62% of the deaths to this age-group.Within Glasgow’s persistently deprived areas, male prematuremortality rose significantly by over 15% from 662 per 100,000 in1990e1992 (CI 615e708) to 765 in 2000e2002 (CI 733e796).Female mortality in persistently deprived areas in Glasgow fellfrom 383 in 1990e2002 to 354 in 2000e2002 but the change wasnot significant (CIs 363e403 and 333e375 respectively). Althoughmortality rates did rise slightly in persistently deprived areas in the

Fig. 1. UK distribution of areas persis

rest of Scotland outside Glasgow for both males and females, smallnumbers preclude any conclusions being drawn.

We also explored whether persistently deprived areas withinNorthern Ireland, Wales and the Government Office Regions inEngland have also experienced increasing premature mortalityrates. The distribution of persistently deprived areas across the UKis illustrated in Fig. 1. Of the 957 persistently deprived places in theUK, 77% of these locations are within urban areas with theremainder in more rural and coastal areas. As noted above, 49% ofareas within Glasgow are persistently deprived. In London, 43% ofthe wards are classified as deprived in both 1991 and 2001 with themajority concentrated in inner London. For more detail on thechanging geography of deprivation across the UK’s small areasduring 1991e2001 see Norman (2010a).

tently deprived, 1991 and 2001.

P. Norman et al. / Social Science & Medicine 73 (2011) 1575e1584 1579

Fig. 2a and b illustrates age-standardised premature mortalityrates for males and females in both 1990e1992 and 2000e2002. Tothe left of the graphs are the countries of Scotland (plus bars forareas in Glasgow and elsewhere in Scotland), Northern Ireland andWales, ranked left to right by their male mortality rates in 1991. Tothe right are the Government Office Regions (GORs) in England,also ranked by 1991 male mortality. These graphs clearly show thatmortality in Scotland is significantly higher than the other sub-UKregions; most particularly for males. In addition, there is evidencethat the worsening of premature mortality in persistently deprivedareas between 1991 and 2001 has only occurred for males inScotland. Elsewhere for males, there are reductions in mortality,though these improvements are not significant in Northern Ireland,Wales and in the SouthWest GOR in England. The largest reductionin male mortality is in London. Improvements in female mortalityrates are less marked than those for males and are only significantin the North East GOR and in London (although overall this resultsin a significant improvement for women in England as a whole).

Various studies have sought to determine whether health(however measured) within the UK is better or worse than would

Age-standardise

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Fig. 2. All-cause premature mortality (0e64 years) within the UK 1990e2002 and 2000eAge-standardised female mortality rates. Note: Error bars represent 95% confidence interva

be expected, given the prevailing socio-economic conditions (see,for example, Hanlon et al., 2005; Whynes, 2009). Here we are ableto compare the changing levels of deprivation and mortality in thepersistently deprived areas across the UK. Fig. 3a illustrates themean deprivation levels of these locations in Scotland, NorthernIreland and Wales and in Fig. 3b in the English GORs. The areas arepresented in the same order as the mortality rates in Fig. 2. TheTownsend scores here are comparable between 1991 and 2001 andacross the UK whereby higher scores represent more deprivedareas. Fig. 3a and b shows that in both 1991 and 2001, Scotland hasthe highest deprivation scores and the South East, South West andEast of England have the lowest levels of deprivation. Even in thesemost deprived areas though, deprivation has reduced during the1990s largely due to increasing levels of car and home ownershipand lower unemployment in 2001 compared with 1991 (Norman,2010a).

Fig. 3a and b also shows premature malemortality rates for 1991and 2001.While the general trend is that areas with higher levels ofdeprivation have higher mortality rates, apart from the significantincrease in male mortality in Scotland, there are several prominent

d male mortality ratesN

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2002 for persistently deprived areas. a.) Age-standardised male mortality rates. b.)ls.

Persistently deprived areas in Scotland, Northern Ireland and Wales

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Fig. 3. Mean deprivation levels and male all-cause premature mortality (0e64 years) in persistently deprived areas within the UK, 1991 and 2001. a.) Persistently deprived areas inScotland, Northern Ireland and Wales. b.) Persistently deprived areas in England. Notes: Error bars for deprivation represent standard deviations. Error bars for mortality represent95% confidence intervals.

P. Norman et al. / Social Science & Medicine 73 (2011) 1575e15841580

aspects of interest. Despite the reductions in deprivation in bothNorthern Ireland and Wales, improvements in mortality between1991 and 2001 are small. In 1991 the GORs of northern England hada strong gradient of deprivation with the North East having thehighest deprivation followed by the North East and then Yorkshire& Humberside. By 2001 the levels of deprivation across these GORshad reduced to be of a very similar level to each other. In 1991 themortality gradient for these areas in northern England aligned withthe deprivation gradient. Despite the easing of the deprivation andreductions in mortality levels, the mortality gradient between theareas persisted with the North East having significantly highermortality than elsewhere in northern England. This would point tothe possibility of lag effects between improvements in deprivationand any subsequent reduction inmortality. Across all of the regions,considering the levels of deprivation in both 1991 and 2001, Londonstands out as having a relatively good mortality experience.

Discussion

Here we have found that male premature mortality rates rose inScotland over the 10-year period between the early 1990s and2000s in persistently deprived areas. This is consistent with theevidence fromprevious studies using period-specific (Leyland et al.,2007) and longitudinal measures of deprivation (Exeter et al.,2011). Crucially we found that there is no significant rise inmortality in any of the other countries or regions of the UK and thatthe rise amongmen in Scotland is driven by the results for Glasgow.Since for Glasgow we find a 7% rise in premature mortality overa 10-year period compared with the 9.5% rise over the twenty yearssince 1981 found by Exeter et al., this suggests that most of theincrease occurred during the 1990s. Whilst reductions were small,throughout the UK premature mortality rates for women improvedduring the period in these persistently deprived areas.

P. Norman et al. / Social Science & Medicine 73 (2011) 1575e1584 1581

So, what demographic and deprivation changes have occurredthat might help explain why Glasgow and the rest of Scotland hasa different male mortality experience to other areas? Across the UK,in terms of population change during the 1990s, the general trend isthat the most deprived areas tend to have an excess of births overdeaths (natural change gain) but because this is more than offset bynet migration loss these areas have experienced population decline(Norman, 2010b). Over time then, population residualisation mightbe a factor whereby less healthy people remain in an area whilehealthier, more advantaged people leave. Table 2 details the pop-ulation change during 1991e2001 in the persistently deprivedareas across the UK. In terms of percentage population change,there is a distinct gradient with higher percentage net losses ofpopulation in the more deprived and higher mortality areas. Theareas located in the generally less deprived regions of southernEngland experienced population gain during the decade and theseareas have lower mortality rates. As we have noted, London haslower mortality than the deprivation levels would suggest andLondon experienced the highest levels of population gain. It islikely that this gain in population is through immigration and thelowmortality experience is due to healthy immigrant effects (Boyle& Norman, 2010). The persistently deprived areas in Glasgow arethe only locations in the present study that experienced populationloss through both natural change and net migration. All other areasexperience population growth through natural increase.

These ecological patterns are quite compelling. However, whileshrinking populations have been associated with worsening healthfor areas (Davey Smith, Shaw, & Dorling, 1998) subsequent Scottishstudies suggest that once the deprivation circumstances of areasare controlled, population decline has no significant relationshipwith deprivation (Boyle, Exeter, & Flowerdew, 2005; Exeter, Feng,Flowerdew & Boyle, 2005). Also, we found that persistentlydeprived areas elsewhere in the UK outside southern England alsoexperienced population declines (although not to the same extentas Glasgow), but no rise in mortality. Our calculations of populationchange are for all persons, but the mortality focuses on those aged0e64 so different demographic behaviour by age will affect theresults and any interpretations.

Some studies have demonstrated that health selective (im)mobility can also contribute to widening health gradients (Boyle,Norman, & Popham, 2009; Norman, Boyle, & Rees, 2005).However, recent evidence from an individual level longitudinalstudy following people from 1991 to 2001 who moved within andbetween different deprivation quintiles in the Greater Glasgow

Table 2Demographic change in the UK’s persistently deprived areas, 1991e2001.

Country/region Total persons 1991 Total persons 2001 Pop

Scotland 371,208 314,247 �5Glasgow 296,158 249,627 �4Not Glasgow 75,050 64,620 �1

Northern Ireland 137,578 127,895 �Wales 217,765 205,425 �1

England 8,192,380 8,334,836 14North West 974,999 895,651 �7North East 450,870 414,395 �3Yorkshire & The Humber 668,752 638,810 �2West Midlands 659,764 639,970 �1East Midlands 520,665 500,976 �1London 2,896,355 3,183,397 28South East 903,650 938,836 3South West 482,172 480,659 �East of England 635,153 642,142

UK 8,918,931 8,982,403 6

Source: Authors’ calculations based on census and vital statistics data.

region suggests that the residualisation effects of internal Scottishmigration are relatively small, and certainly would not account forthe extent of the rises identified here. The widening deprivationgradient occurred evenwhen thesemigrants were returned to theiroriginal locations (Popham, Boyle, O’Reilly, & Leyland, 2011).Nevertheless, at a population level, mobility between areas ofdifferent levels of deprivation in Scotland does seem to relate tomortality with rates highest in areas which reduced in populationsize (Brown & Leyland, 2010). Since the majority of migration isover short distances, perhaps the very small area geography(Census Output Areas) used by Brown and Leyland (2010) hasenabled these effects to emerge. Interestingly, these authors finda clear pattern usingmigration transitions over a short time period;the year before the census. Usually, longer time periods, such as the10-year intervals between censuses, allow time for patterns toemerge which otherwise can appear unclear; an issue highlightedby Curtis, Setia, and Quesnel-Vallee (2009) and deserving attentionin future research.

The average Townsend deprivation scores in the persistentlydeprived areas within Glasgow reduced from 12.67 in 1991 to 8.21in 2001. Although this improvement occurred, the level of persis-tent deprivation in Glasgow is stark compared to the rest of the UKand, given the strong link between deprivation and mortality, thismay be the most obvious explanation for the results seen here.While studies in Glasgow and Scotland using period-specificdeprivation have suggested that not all the mortality excess inthese areas compared to the rest of the UK can be explained bycurrent deprivation levels (Hanlon et al., 2005;Walsh, Bendel, et al.,2010), the level of deprivation in Glasgow is clearly higher thanelsewhere in the persistently deprived areas within the UK eventhough it improved considerably over the period. Controlling fordeprivation, and particularly long term persistent deprivation,more effectively may therefore be one key to understanding theScottish and Glasgow ‘effects’.

This may also be the case for studying the relationship betweendeprivation and health in London. Consistent with Whynes’ (2009:151) finding of a “London effect”, with “London’s health out-performing its socio-economic circumstances”, we find thatmortality rates in London are lower than the level of deprivation inthe persistently deprived areas might lead us to expect. It could bethat the Townsend index exaggerates deprivation in London (forexample, lack of car ownership may not be a reliable measure ofpoverty in London). However, for LSOAs within London, there isa correlation of 0.88 with the IMD even though the input variables

ulation change Percentage change Natural change Net migration

6,961 �15.34 �4077 �52,8846,531 �15.71 �5780 �40,7510,430 �13.90 1703 �12,1339683 �7.04 9597 �19,2802,340 �5.67 12,719 �25,059

2,456 1.74 646,791 �504,3359,348 �8.14 59,224 �138,5726,475 �8.09 15,564 �52,0399,942 �4.48 44,633 �74,5759,794 �3.00 72,855 �92,6499,688 �3.78 36,547 �56,2357,041 9.91 304,401 �17,3605,186 3.89 54,699 �19,5131513 �0.31 17,504 �19,0176989 1.10 41,364 �34,375

3,472 0.71 665,030 �601,558

P. Norman et al. / Social Science & Medicine 73 (2011) 1575e15841582

and method of calculation are different. In a cross-sectional anal-ysis, it is likely then that a very similar relationship with mortalitywould result.

Studying persistent deprivation for small areas is analogous toadopting a lifecourse approach for individuals. Evidence frommanystudies following individuals over time suggests that the socio-economic situation across the lifecourse, and not just at one pointin time, plays an important role in understanding a person’smortality risk (Galobardes, Lynch, & Smith, 2008; Pollitt, Rose, &Kaufman, 2005). Recently, similar longitudinal effects on mortalityhave been shown for where people live (Naess, Claussen, DaveySmith, & Leyland, 2008). Although Naess et al. (2008) did notinclude area deprivation, the authors conclude that future studies ofarea effects on mortality should adopt a lifecourse approach. Inter-estingly, recent work in England and Wales has shown that arealevel deprivation 100 years previously is related to currentmortalityrate independent of current deprivation level (Gregory, 2009).Further work is needed to understand the impact of persistentdeprivation on areas themselves, the people that live there, and howthis relates to mortality risk. Frameworks have been developed toshow how conditions throughout the lifecourse, contextual condi-tions in places of residence and individual characteristics can allinfluence health variations (Curtis, Southall, Congdon, & Dodgeon,2004). What may be needed would be parallel area and individuallevel studies which would show the effect of cumulative risk of thepersistent or changing deprivation of areas on the health of thepopulation as well as for individuals, adjusting for the length of stayin a (non-) deprived area. This is likely to bepossible for a populationlevel study for small areas but data restrictions might preclude ananalysis using microdata.

We should acknowledge thatmortality is rather a bluntmeasureof health and that investigating morbidity might also be revealing.However, there are few readily available data sources throughwhich to carry out a UK coverage small area study. The 1991 and2001 UKCensuses both collected data on ‘limiting long term illness’but the questions are not comparable; the word ‘handicap’ wasused in 1991 but substituted by ‘disability’ in 2001. Moreover,Mitchell (2005: 308) asks “whether we can compare self-reportedmeasures of illness between countries and cultures” and how theself-assessment of illness can be tracked “over time when cultures,expectations, and awareness of health are all in a state of flux”.Since it is formally diagnosed, a promising administrative indicatorof population level health available since the late 1990s would beIncapacity Benefit (IB). This benefit is paid to persons incapable ofwork because of illness or disability (Brown et al., 2008). IB hasbeen found to have utility as an updatable indicator of populationhealth (Norman & Bambra, 2007) though some consider that levelsof sickness benefit receipt may also reflect labour market condi-tions and may therefore be unreliable as a measure of health(Beatty & Fothergill, 2005). To inform on changes in health overspace and time, checks would have to be made that the benefit isassessed consistently across the UK and geographical harmo-nisation of datasets would be required so that all demographic andhealth indicators were available for the same small area definitions.In relation to the work we are reporting here it is telling that Brownet al. (2008: 54) find that the city in the UK “with the largest IBproblem” is Glasgow.

Our results indicate that the high premature mortality ratesamong men in Scotland, particularly in Glasgow, require furtherstudy. Elsewhere the importance of socio-economic variations havebeen linked to rising rates of mortality; for example, the dramaticrises in mortality rates in Russia as a whole has been shown to bedriven by those with low education, while the mortality rates forthe higher educated have fallen (Murphy, Bobak, Nicholson,Marmot, & Rose, 2006). However, Scotland has not experienced

the dramatic socio-economic transition that Russia witnessed overthis period and health care provision is essentially free at the pointof delivery through the National Health Service.

Exeter et al. (2011) demonstrate that in 1999e2001 for Scot-land’s persistently deprived areas, death rates from lung cancer,suicide, chronic liver disease and mental disorders due to alcoholwere 6.1, 5.6, 11.2 and 12.9 times greater than rates observed in thepersistently least deprived areas. Further extension of the presentstudy to cover the UK would help isolate whether an excess ofdeaths by these causes was a phenomenon common only to Scot-land. Using cause-specific mortality would enable separating outthose causes that relate most to area level deprivation and considertime lags since different causes of death may respond at differentrates to changes in deprivation.

Following the work by Walsh, Bendel, et al. (2010) and Walsh,Taulbut, et al. (2010) on the so-called ‘Glasgow effect’, Wilkinson(2010) suggests “that there remains a great deal to be under-stood about the relationship between deprivation and ill health.”This relationship is well established in the international literatureon a cross-sectional basis but various authors have begun toquestion whether a change in the level of deprivation can lead toa change in health (Boyle, Norman, & Rees, 2004; Curtis, Cave, &Coutts, 2002; Norman, Gregory, et al., 2008). Following recentfindings in relation to this by Exeter et al. (2011) we focused hereon one aspect e areas which do not change their deprivation butremain the most persistently deprived over time. For these loca-tions there has been no significant rise in mortality between 1991and 2001 in any of the other countries or regions of the UK buta rise in male mortality in Glasgow. Certainly, these results wouldseem to justify even more of a public health focus on Glasgow. Wealso need a deeper understanding of demographic change inrelation to variation and/or persistence in levels of deprivation,especially the way that the health and deprivation indicatorcharacteristics of populations change over time. Further work isneeded on health selective migration, immobility and populationresidualisation.

Acknowledgements

This research used Census data obtained via the MIMAS CAS-WEB facility and postcode directories and GIS boundary data ob-tained via the EDINA UKBORDERS facility, both services supportedby ESRC and JISC. The Census, official Mid-Year Estimates and VitalStatistics data for England and Wales, Scotland and Northern Ire-land have been provided by ONS, GROS and NISRA and the digitalboundary data by OSGB and OSNI. These data are Crown copyrightand are reproduced with permission of OPSI. Paul Norman’sresearchwas supported by ESRC Research Award RES-163-25-0012.The authors are grateful to the editor and anonymous refereeswhose comments were very useful.

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