J7ournal of Epidemiology and Community Health 1995;49(Suppl 2):S3-S8

Deprivation indices: their interpretation and usein relation to health

Vera Carstairs

AbstractStudy objective - To examine the use ofdeprivation indices in relation to health.Design - This paper reviews selected pub-lications which illustrate the diversity ofuse of deprivation indices in the past dec-ade. Most of this work is based in themajor routine databases which exist in thiscountry: the census, population, mortality,cancer register, and health service recordsall now incorporate a postcode identifierwhich permits the derivation of data atsmall area level, and thus the examinationof health events in relation to the char-acteristics of that area - usually ward orpostcode sector. The small area approachprovides a valuable tool both in dep-rivation and in other epidemiologicalstudies which examine the influenceof the environment on health.Setting - The setting is various journalsand official publications.Main results - The link between dep-rivation and health has been clearly dem-onstrated in a number of studies, withpopulations living in deprived areas ex-hibiting levels of mortality, particularlybelow the age of 65, which vastly exceed

Small area analysis

Postcodedirectory

I1 Census data

Table 1 Derivation of data at small area level.

those in affluent areas. In the decade 1981-91, these differentials increased in Scot-land and the Northern Health Region andinequalities in health are shown to havewidened. Analysis shows that particularcauses of death and sites of cancer aremore likely to reflect the influence ofsocio-economic factors. The work so far mostlyshows the associations between thesefactors and health measures and moreinvestigation is required into thedeterminants of health, which are likelyto reside as much in past as in currentcircumstances. A measure of deprivationhas proved of value in excluding the likelyvariation in the incidence of disease instudies directed towards determining theinfluence of the physical environment onpopulations living in the vicinity of pos-sible harmful industrial processes. A dep-rivation measure has been adopted by theDepartment of Health as a basis for mak-ing enhanced payments to general prac-titioners for patients living in these areas,but the resource allocation formula forallocating funds to regional authorities hasfailed to incorporate such a measure inthe formula.Conclusions - An area measure of dep-rivation has proved a valuable tool in ex-amining differentials in health and deathand is likely to prove of continuing valueto health authorities in planning the de-livery of health care. Future work shouldstrive to examine the determinants ofhealth as well as the associations, althoughthis is unlikely to be possible through theroutine databases which have provided themain basis for analysis so far.

(J Epidemiol Comm Health 1995;49(Suppl 2):S3-S8)

Methods of small area statistics are so fun-damental to the development of deprivationindices that some reference to these providesan introduction to the main substance of thispaper. Although there was some early work onthe relation between socioeconomic measuresand health, using an area base and data fromthe 1971 census, most of the important workfollows from the improved geographical baseprovided by the 1981 census' (fig 1) and themore consistent use of postcodes as a basis fordetermining the area of residence in routinestatistical records systems. As a result the pastdecade has seen an increasing use of small areabased approaches in health care, many ofwhichfocus on issues of health and deprivation.

Department of PublicHealth Sciences,University ofEdinburghV Carstairs

Correspondence to:Dr V Carstairs

Local government areas

Health board areas

Enumeration districts

Wards

Parish/locality island etc.

Grid reference

PopulationsArea characteristics

Grid reference

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Carstairs

Table 1 General practitioners weightings offactorsaffecting demand for primary care services

Percent Weight

1 Elderly living alone 6-622 Age under 5 years 4-643 Unskilled workers 3-744 Unemployed 3-345 One parent families 3 016 Overcrowded 2-887 Migrants 2-688 Ethnic minorities 2.50

Source: ref2

Table 2 Correlation of mortality with deprivation

1979-83

Townsend Carstairs

0-64y 0-64y 65+ y

Deprivation* 0-62 0 75 0 53Unemployed 0-61 0 70 0-51Overcrowded 0 55 0-64 0.49Lacking car 0-61 0 74 0 50Head in low social class 0 57 0-62 0 39Not in owner-occupierhousing 0*39 - -

* Definitions differ; see56

The small area approach may be categorisedin terms ofincreasing sophistication in analysis.At the simplest, descriptive level, small areastatistics can illustrate aspects of a populationrelevant to health planning - demography, so-cial circumstances, mortality, and morbidity.The smaller area level (postcode sector or ward)displays greater variation in many char-acteristics and provides a more sensitive basisfor the identification of need and delivery ofcare than the health district.An advance in methodology combines se-

lected variables into an overall index for an area,using various techniques. Still at the descriptivelevel, an important example is the combinationof demographic and social factors into the Jar-man underprivileged area (UPA) score.2 Theindividual factors are given weightings based

140 --- All ages0-Age 0-64 y-- Age 65+ y

120

100

80

60 [

Affluent Deprivation value Depr

Figure 2 Standardised mortality ratios (all causes) plotted against deprivation value,Scotland 1980-82.

on the opinions of general practitioners (table1) about the influence of the various factors ontheir workload (with some subsequent val-idation). The UPA8 score (containing eightvariables), developed to identify "needs forprimary care", has been adopted by the De-partments of Health for the purpose of makingadditional payments to GPs for populationsliving in areas with high scores on that index.In Scotland the score is now calculated atenumeration district (ED) level, since the post-code sector was considered to obscure someimportant differences within populations. Thescore has been the focus of a number ofcriticisms34 but it has the merit of being ac-ceptable to general practitioners.

Enquiries examining the association betweensocioeconomic area characteristics and healthevents have, in the main, made use of thepostcode sector (in Scotland) or ward (in Eng-land) as the area base. Much of the work hasfocussed on using a measure of "deprivation"- that is, a score composed of a number ofsocial variables from the census. A deprivationscore of this kind, producing a continuousvariable (albeit artificial), has the benefit ofoffering opportunities for statistical analysisthat are not available from the use of categoriessuch as ACORN, which derives descriptivecategories intended to discriminate betweenpopulations but which do not have rankingqualities.Work by Townsend et al in the Northern

Health Region5 and Carstairs and Morris inScotland6 exemplify this approach and providestrong evidence of the link between area dep-rivation and mortality, in particular at youngerages. (table 2, fig 2). A more recent paper hasalso shown similar gradients in mortality in fivehealth regions of England, for all causes andfor specific causes (fig 3). Given sufficient num-bers of events, the approach can also provideinformation on the association between specificcauses of death, or illness, and social factors(table 3).Not the least of the benefits of the small area

approach is that it permits the extension of ourunderstanding of inequalities in health beyondthe measure of mortality, using the traditionalapproach of social class. Only the death recordcontains information on occupation, and otherhealth records have not been susceptible to thisapproach. Using the postcode unit to allocatea record to an area level (or a grid reference)brings other health information into the areaof interrogation, with the cancer registers pro-viding a particularly rich source of informationon morbidity (fig 4).

Birth weight, perinatal and infant deaths,and temporary and permanent sickness (fromthe census) have all yielded information il-lustrating the diversity of health experiencebetween affluent and deprived areas.56

Since the completion of the 1991 census,some monitoring of trends in relation to in-equalities has become possible. Data both for

d Scotland8 and for the north of England9 showa widening of the gap in mortality betweenthose living in affluent compared with deprivedareas (figs 5 and 6). Of course death rates fell

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S5Deprivation indices - use and interpretation

180

160

* East Anglia- 0 South Western

* Midlands

a Mersevside

1981-85

140 _ A North Western

120

80

60 - All causes, men a

-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8

Increasing deprivation -*

Coronary heart disease, men180

160

140-

120

100 ----= ---_ _-

80 -

60 - c

.^ IIIII-5 -4 -3 -2 -1 0 1 2 3 4 5 6

Increasing deprivation -

7 8

180Smoking related diseases, women

160-

140-

120 -

100-_ _---------_-_ --_-__-_

80

60- b

404 3 - 1 0 2 3 4 5 6 7 8-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8

Increasing deprivation -*

Coronary heart disease, women180 r

160

140

120

100

80

60 d

4U-5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8

Increasing deprivation - *

Townsend index

Figure 3 Relation between premature mortality from different causes in men and women by the degree of deprivationdivided into fifths for five representative health regions. Source: ref 7.

Table 3 Mortality in relation to cause and socioeconomic factors in Scotland 1980-85 (correlation coefficients)*

Cause Age (y) Men unemployed Low social class No car Overcrowding DEF score

All causes 0-64 *72 *61 *74 *62 *76Chronic respiratory 0-64 *67 *52 *69 *61 *69Carcinoma, lung 0-64 *61 *60 *66 *57 *65Heart disease 0-64 *56 50 *54 *55 59Hypertension/stroke 0-64 *41 *34 *41 *37 *42Acute respiratory 0-74 *42 *31 39 *38 *41Carcinoma, stomach All *36 30 *38 *37 39Carcinoma, cervix All *23 *22 *22 *22 *25Non-traffic accidents All *22 *23 *23 *19 *24Road traffic accidents All *02 *12 -04 04 *04Carcinoma breast 0-74 -*06 -*06 -05 -04 -*06

Correlation over 56 LGDs* Source: ref5

Ratios: all - 100~00

75

-25

50 Oeso[DphagLJS Stomi- achl LLnI1g 0-64 Celrvix

AfflUent 2 3

DE PCAT

4 1 5 6

Figure 4 Cancer registrations for 1979-82 in Scotland in relation to deprcategory (DEPCAT). Source: refj.

overall, but affluent areas made greater gainsin the decade than those living in deprivedareas in Scotland (as illustrated by two specificcauses: table 4), while in the Northern HealthRegion ratios increased in the most deprivedwards in all age groups, and with one exceptionfell in the most affluent (table 5).

* (Under-reporting in the 1991 census has- presented some problems in the computation of

rates for specific age groups, but these analysesaddress this problem and show that the gra-dients in mortality are not unduly influenced

BI add(ler by the shortfall.)Many examples exist ofthe use ofdeprivation

measures at local level within health authorities- Deprived but there is not space here to review these.10D All of these analyses tell us about the as-

ivation sociation between health events and dep-rivation measures, but so far there is little

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200 r

04-

0Ea)cn

CeV

CU

1991-92

175 F

150 e1980-82

125 F-

100 H

Table 4 Percentage change in mortality ratios forischaemic heart disease (IHD) and cancer of the lungbetween 1980-82 and 1990-92 in people aged 40-64years in Scotland*

1981 Depcat group IHD Ca lung

1-2 Affluent -40 -283-5 - 31 - 176-7 Deprived -20 - 11

* Source: ref8

75

50

25

II II-9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 11Affluent Carstairs score

Figure 5 LOWESS curves showing the relationship betweetn age and sex standmizortality ratios (ages 0-64 years) and Carstairs deprivation score. Source: refj.

80

60

40

0

20co

0

-40- dep 10thAffluent

Figure 6 Mortality ratios for those aged <65 years in the Northern Health Regbetween 1981-83 and 1989-91. Source: ref'.

Figure 7 Factors that explain differences in health.

Table 5 Change in mortality ratios in northern Englandbetween 1981 and 1991*

Age (\) Most deprived Least depnrved(fifth) (fifth)1981 1991 1981 1991

0-14 116 130 80 7715-44 117 128 86 7745-54 130 162 79 8355-64 145 151 92 8765-74 123 133 94 88

* Source: ref

189 91 evidence about the processes involved (fig 7).89-9 1 In Scotland some relevant evidence comes fromthe Scottish heart health study, carried out atlocal government district level" which reportslevels of smoking, dietary, and even biological

81-83 factors which are more favourable in affluentthan in deprived areas (table 6).

It is also the case that all of these analyses usedata relating to current circumstances whereascurrent health (and death) is likely to be aproduct of life long circumstances, perhapseven conditions before birth; a number of en-quiries in recent years have begun to explorethese links."2One important example of small area analysis

concerned with equity rather than epi-demiology is that carried out for the De-partment of Health to provide an empirical

+ dep 10th basis for the development of the resource al-Deprived location formula.'3 '1 At least one major finding

was subsequently incorporated into the for-oil mula'5 - that of a reduction in the weighting

in respect of the standardised mortality rate(SMR) for a region which acts to increase ordiminish the allocation of resources for specificcomponents of the formula, originally by 1%for each point of the SMR above or below 100.The analysis found that a weighting below unitywas a better predictor ofvariation in the hospitaldischarge rates at ward level (other factors takeninto account) that was accepted as a measureof need for health care. A notable omission,however, was failure to take on board the find-ings in respect of levels of deprivation whichwere shown to make a contribution over andabove that of mortality in explaining the vari-ation in the need measure. Despite recentchanges in the organisation of the health ser-vice, methods of resource allocation provide acontinuing topic for debate.'6 A more com-prehensive and up to date analysis has sub-sequently been commissioned, and has beenreported to the Department of Health: fulldetails are not yet publicly available, althoughsome information on method has been pub-lished. '7

Explaining differences in health

Inborn characteristics Early experience

- genetic - illness

- acquired - nutrition

Environment - physical Environment - social

- air pollution - living conditions

- work hazards - life events

- lead in water - stress

- radiation - lifestyles

- etc. - health behaviour

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Table 6 Health characteristics of local government districts for men aged 40-59 years*

DEP score % smokers % not eating SMR smoking BP diastolic

Fruit Greens

Most affluentEastwood -5-65 29 8 15 68 84Inverness -2-08 38 13 20 88 83Perth & Kinross -2-05 32 9 18 84 83Stirling -1 79 35 8 16 93 81E Lothian -1-58 38 8 19 89 83Roxburgh -1 55 33 7 15 86 84Most deprivedHamilton 0-52 39 16 24 104 87Renfrew 0-62 43 7 26 113 88Cunninghame 0-85 42 10 20 106 85Dundee 0-89 41 12 21 100 84Monklands 2-95 51 15 22 113 86Glasgow 4 06 52 20 30 124 87

* Source: refP

Table 7 Incidence of cancer (Ca) of the larynx and lungaround waste disposal incinerators

Ratios: OIE

Without WithCarstairs Carstairs

Ca larynxLag 5 y

0-3 km 1-08 1-043-10 km 1 07 1-04

Lag 10 y0-3 km 1-05 1-083-10 km 0-87 094

Ca lungLag 5 y

0-3 km 1 01 0 973-10 km 1-03 100

Lag 10 y0-3 km 0-92 0943-10 km 0-92 0-98

The lower limit of confidence intervals is <1 in all except oneinstance. There is no evidence of a difference from unity.Source: refP

The small area approach has also been usedin a number of studies designed to assess theimpact of the physical environment on health.(That is, those seeking to establish a causaleffect.) An early example is that which ex-amined health statistics in the vicinity of awaste disposal plant in Scotland'8 (no longerin operation). The area was assembled by theaggregation of enumeration districts to createa circle with a radius of 5 km from the plant,a strategy which has provided the basis formuch subsequent enquiry.'9 The results wereinconclusive, and underlined the lack of a database concerned with less serious aspects ofmorbidity than appear in the present statisticalsystems.More well known examples are those en-

quiring into the possibility of a raised incidenceof leukaemia in young people in the neigh-bourhood of nuclear processing plants at Sel-lafield20 and Dounreay.21 Studies attempting toestablish the differences between cases andcontrols have followed, as have studies of otherclusters in the population, with much stimulusbeing given to the development of statisticalmethods in the analysis and interpretation ofthe small cluster phenomenon.22 These earlyenquiries presage the work programme nowundertaken by the Small Area Health StatisticsUnit; this has taken a step forward in method-ology by the incorporation of a deprivationmeasure to allow for the effects of social factorsin examining the incidence ofdisease in relationto environmental influences. An example (table

7) comes from an examination of cancer in-cidence around waste disposal incinerators: thedifferences between the ratios without and withthe Carstairs score indicate the extent of socialinfluence on the rates,23 which could serve toconfound the interpretation of the data if nottaken into account.The small area approach has many benefits

- but also many problems - which I do nothave space to examine. Deprivation measuresare also subject to criticism, in terms of theselection of variables and ways of combiningthese into a score, and proponents of this ap-proach are by no means in agreement. Never-theless, the explanatory power in relation tohealth events seems robust, and variations inmethod are not critical, although the Jarman(UPA) score, if identified as a measure of dep-rivation, shows weaker correlation with healthevents than with health service use,24 probablybecause of the inclusion of demographic vari-ables.The lack of population and social data, ex-

cept at 10 yearly intervals, presents a real prac-tical problem to researchers in this field. Canwe expect that the family practitioner registerswill eventually become reliable enough to pro-vide usable population information betweencensuses? This is not impossible, but the com-prehensive collection of morbidity data fromthis source is probably precluded by the size ofthe necessary database.

What of the future?Small area data on both social and health fac-tors are likely to remain of value to healthauthorities in their efforts to direct resourcesin relation to need, and will continue to prove ofvalue in determining the relationships betweenthese factors and in monitoring trends overtime. Studies based on routine statistics areunlikely, however, to yield more revelationsabout health inequalities since they can rarelydo more than describe the associations. In time,however, the recommendations of the Chorleycommittee25 may result in enhancements to thedatabase in respect ofsome physical features ofthe environment. Some measure of deprivationwill continue to provide a basis for excludingthe socioeconomic factors which confound ex-amination of the distribution of disease in re-lation to the physical environment. It seems

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likely that we can expect little further progress

in looking at the relationship between socialfactors and health events. What is needed ismore information on the determinants ofhealth, and so far such data are notable by theirabsence in studies using routine statistics. Theinclusion of the question on long standing ill-ness and disability in the 1991 census may

enhance possibilities of analysis, although levelsreported differ from those found in the generalhousehold survey26 and problems in relationto people's perceptions of ill-health will raisequestions about the validity of these measures.

The surveys being carried out by the De-partment of Health, in England27 and now inScotland, will provide more objective in-formation at an individual level, on the healthstate and its variation in the population. Thisis to be welcomed, although identification andmeasurement of many of the determinants islikely to continue to prove elusive.

Denham C. The geography of the census 1971 and 1981.Office of Population Census and Surveys, Population Trends1980;19:6-12.

2 Jarman B. Identification of underprivileged areas. BMJ1983;286:1705-9; Underprivileged areas: validation anddistribution of scores, BM3r 1984;289:1587-92.

3 Senior ML. Deprivation payments to GPs: not what thedoctor ordered. Environment and Planning C: GovernmentPolicy 1991;9:79-84.

4 Davey-Smith G. Second thoughts on the Jarman index.BMJ 1991;302:359-60.

5 Townsend P, Phillimore P, Beattie A. Health and deprivation:inequalities and the north. London: Croom Helm 1988.

6 Carstairs V, Morris R, Deprivation and health in Scotland.Aberdeen: Aberdeen University Press, 1991.

7 Eames M, Ben-Shlomo T, Marmot MG. Social deprivationand premature mortality: regional comparison across Eng-land, BMJ 307:1097-102.

8 McLoone P, Boddy A. Deprivation and mortality in Scot-land, 1981 and 1991. BMJ309:1465-70.

9 Phillimore P, Beattie A, Townsend P. Widening inequalityof health in northern England 1981-1991, BMJ 1994;308:1125-8.

10 Spencer N, James H. Uses and abuses of deprivation indices.Proceedings of a conference held at the University of Warwick,December 1992.

11 Tunstall-Pedoe H, Smith WCS, Crombie K, TavendaleR. Coronary risk factors and lifestyle variations acrossScotland: results from the Scottish heart health study, ScotMedJ7 1989;34:550-5, 556-60.

12 Ben-Shlomo Y, Davey-Smith G. Deprivation in infancy orin adult life: which is more important for mortality risk?Lancet 1991;337:530-5.

13 Coopers and Lybrand. Integrated analysis of RA WP London:Queen Margaret College and St Mary's Medical School,1988.

14 Department of Health and Social Security, Review of theResource Allocation Working Party: final report by the NHSManagement Board. London: DHSS, 1988.

15 Departments of Health. Working for patients: funding andcontracts for hospital services. Working paper no 2. London:HMSO, 1989.

16 GilmanE, MundayS, Somerville L, Strachan R. Resourceallocation and health needs: from research to policy. (Pro-ceedings of a conference held at Birmingham University. Lon-don: HMSO, 1994.

17 Carr-Hill R, Hardman G, MartinS, PeacockS, Sheldon T,Smith P. Small area utilisation and resource allocation.Resource allocation and health needs:from research to policy.(Proceedings of a conference held at Birmingham University).London: HMSO, 1994.

18 Lenihan (chair), Bonnybridge/Denny morbidity review. Ed-inburgh: Scottish Home and Health Department, 1985.

19 Carstairs V, Lowe M. Small area analysis: creating an areabase for environmental monitoring and epidemiologicalanalysis, Community Med 1986;8: 15-28.

20 Black D (chair). Investigation of the possible increased incidenceof cancer in West Cumbria. London: HMSO, 1984.

21 Committee on the Medical Aspects of Radiation and theEnvironment (COMARE). Second report: investigation ofpossible increased incidence of leukaemia in young people nearthe Dounreay nuclear establishment, Caithness, Scotland. Lon-don: HMSO, 1988.

22 WHO Regional Office for Europe. Data requirements andmethods for analysing spatial patterns of disease in smallareas: summaries from a WHO consultation, Rome 1990.Copenhagen: WHO EUR/ICP/CEH/087/A 9748s.

23 Elliott P, Hills M, Beresford J, Kleinschmidt I, et al. In-cidence of cancers of the larynx and lung near incineratorsof waste solvents and oils in Great Britain, Lancet 1992;340:854-8.

24 Morris R, Carstairs V. Which deprivation? A comparison ofselected deprivation indexes, _7 Pub Health Med 1991;13(4):318-26.

25 Department of the Environment. Handling geographic in-formation. London: HMSO 1987.

26 Office of Population Censuses and Surveys and RegistrarGeneral (Scotland). 1991 Census. Limiting long-term illness,Great Britain, Topic Monitor London: OPCS, 1993.

27 Department of Health, Health survey for England 1991.London: HMSO, 1993.

Open discussionELLIOTT - You talked, Dr Carstairs, about the differ-ence between 1981 and 1991 and the widening ofthe gap in mortality between the affluent and de-prived. How much of that do you think is real andhow much a measurement problem - that is, thenotion that the deprivation index might be measuringsomething different in each census.

CARSTAIRS - Those who have done the analyses"2have considered the measurement problem closelyand, at least for Scotland, the analysis for 1991-92has used the 1981 deprivation score for the postcodesectors to examine differences over the decade, sothat there is no difference between the two. I mightadd that under-reporting in the 1991 census has ofcourse created great problems for computation ofrates because of the shortfall in populations in par-ticular age groups. But these analyses' have ex-amined that issue very carefully and have come tothe conclusion that the shortfall does not have anundue effect on the variations that are reported.

DRAPER - You showed a graph (fig 3) of standardisedmortality rates in relation to deprivation index andto health region. It seemed to me that there wereconsiderable differences, almost to the extent thatin some regions the rate at the lowest level of dep-rivation was almost equal to the rate at the highestlevel in another region. What is the explanation? Arethere geographical factors that matter? Are bothdeprivation and region in a sense measuring somesort of index but doing so incompletely? Or is therean altemative explanation - that there is some sortof interaction - that deprivation indices matterdifferently in different places?

CARSTAIRS - I think the importance of the deprivationindex may vary in different regions. It is also thecase, however, as we find in Scotland too, that thereis much greater variation in mortality in areas whichexhibit greater variability in socioeconomic con-ditions.

1 McLoone P, Boddy A. Deprivation and mortality in Scotland,1981 and 1991. BMJ 1994;309:1465-70.

2 Phillimore P, Beattie A, Townsend P. Widening inequality ofhealth in northern England 1981-1991. BMJ1994;308:1125-8.

Carstairs

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