exercise_across_birmingham_a_health_equity_audit_2004

Origin - South Birmingham PCT Public Health Team March 2004

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Exercise across Birmingham -A Health Equity Audit

1. Introduction

To quote the Chief Medical Officer

“Physical activity not only contributes to well-being, but is also essential forgood health. People who are physically active reduce their risk of developing major chronic diseases – such as coronary heart disease, stroke and type 2 diabetes – by up to 50%, and the risk of premature death by about 20-30%. The annual costs of physical inactivity in England are estimated at £8.2 billion –including the rising costs of treating chronic diseases such as coronary heart disease and diabetes. This does not include the contribution of inactivity to obesity – an estimated further £2.5 billion cost to the economy each year.” (Source: At least five a day, Department of Health, 2004)

1.1. Recommendations for active living throughout the lifecourse Children and young people should achieve a total of at least 60 minutes of at least

moderate intensity physical activity each day. At least twice a week this should include activities to improve bone health (activities that produce high physical stresses on the bones), muscle strength and flexibility.

For general health benefit, adults should achieve a total of at least 30 minutes a day of at least moderate intensity physical activity on 5 or more days of the week.

The recommended levels of activity can be achieved either by doing all the daily activity in one session, or through several shorter bouts of activity of 10 minutes or more. The activity can be lifestyle activity* or structured exercise or sport, or a combination of these.

More specific activity recommendations for adults are made for beneficial effects for individual diseases and conditions. All movement contributes to energy expenditure and is important for weight management. It is likely that for many people, 45-60 minutes of moderate intensity physical activity a day is necessary to prevent obesity. For bone health, activities that produce high physical stresses on the bones are necessary.

The recommendations for adults are also appropriate for older adults. Older people should take particular care to keep moving and retain their mobility through daily activity. Additionally, specific activities that promote improved strength, co-ordination and balance are particularly beneficial for older people.(Source: At least five a day, Department of Health, 2004)


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2. Health Equity Audit

This report fits into step 2 of the HEA cycle – Equity profile: identify the Gap (see Figure 1).

The guidance is to:

Use data to compare service provision with need, access, use & outcome Measures to include proxies for disadvantage, social class, wards in the bottom quintile,

Black and Minority Ethnic groups, gender or other population group Focus on the third of population with poorest health outcomes

This report does not look at the effectiveness of the intervention, only whether the service can be described as being equitable given the population and prevalence of adverse outcomes.

Figure 1: The Health Equity Cycle.

Source: http://www.dh.gov.uk/assetRoot/04/06/90/87/04069087.pdf


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3. Methodology

There are three phases to this report:

1. Identify needa. Identify conditions diseases and conditions that are ameliorated by activityb. Identify the number of deaths that result from these diseases and conditionsc. Investigate the relationship between mortality and demographyd. Investigate the relationship between mortality and deprivatione. Investigate the relationship between mortality and ethnicityf. Estimate activity rates in the population by demography, ethnicity and

deprivation

2. Identify Interventions/service provisiona. Provision of facilities (both public and private)b. Membership of BCC centresc. Exercise on prescription

3. Identify Gapa. Access rates, b. Do services meet need considering demographic, ethnicity and deprivation

factors


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4. Phase 1: Identifying the need

4.1. Mortality from diseases and conditions from diseases and conditions related to activity

The evidence on the conditions that can be ameliorated by activity have been recently and best summarised in the Department of Health’s report “At least five a week”. The table of evidence is included in Appendix A. A lack of physical exercise will not be the sole reason for all of these deaths.

It is estimated that over 3,421 people a year die from these diseases across Birmingham, see table.

Table 1: Number deaths occurring in Birmingham death rates from diseases and conditions that are ameliorated by activity, 2002.

Disease Men Women Total

Coronary heart disease 1084 817 1901Cerebrovascular Disease 385 586 971Essential (primary) hypertension 3 8 11

Depression 79 16 95

Falls 51 50 101Malignant neoplasm of colon 67 69 136

Non-insulin-dependent diabetes mellitus 17 9 26Total 1686 1555 3241

Source: ONS2002

There is very poor data on prevalence of chronic conditions in the population. In the future more could be made of the data from primary care as information systems improve with the introduction of the new GMS contract.

4.2. Variation in mortality by Sex

Figures 2 & 3 show the geographical variation in mortality from diseases and conditions ameliorated by activity at ward level. There is a twofold variation in the death rate across Birmingham for males, and a near four fold variation for females. The average male death rate is nearly twice that of females.


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Figure 2: Directly age standardised death rates from diseases that are diseases and conditions that are ameliorated by activity, for males aged over 30 years by ward, 2002 across Birmingham

Source: ONS 2002/3

Figure 3: Directly age standardised death rates from diseases that are diseases and conditions that are ameliorated by activity, for females aged over 30 years by ward, 2002 across Birmingham

Source: ONS 2002/3

Directly Standardised Mortality Rates from diseases and conditions that are ameliorated by activity by wardacross Birmingham, aged over 30, Males,

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Directly Standardised Mortality Rates from diseases and conditions that are ameliorated by activity by wardacross Birmingham, aged over 30, Females,

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4.3. Variation in mortality by deprivation

There is a strong relationship between local deprivation and deaths from are diseases and conditions that are ameliorated by activity. The more deprived the community the higher the death rates (see Figure 4).

Figure 4: SMR for deaths from diseases that are diseases and conditions that are ameliorated by activity plotted against the Index of Multiple Deprivation 2000 across Birmingham by the four PCTs

Source: ONS 2002/3Standardised to England

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4.4. Variation in mortality by deprivation

There is no data on the ethnic breakdown of those who die. The only detail available is their country of birth. This shows that deaths from diseases and conditions that are ameliorated by activity is highest amongst those of Caribbean, Irish or European birth (Table 2).

Table 2: Death rates per 10,000 from diseases and conditions that are ameliorated by activity by country of birth across Birmingham

Pop Deaths Rate LL ULAfrica 13611 25 18.4 11.2 25.6sig lowBangladesh 10784 20 18.5 10.4 26.7sig lowCaribbean 19534 109 55.8 45.4 66.2sig highChina 1411 1 7.1 0.0 21.0sig lowEurope 7558 52 68.8 50.2 87.4sig highIndia 23197 87 37.5 29.6 45.4Ireland 28911 252 87.2 76.4 97.9sig highMiddle east 5229 5 9.6 1.2 17.9sig lowNorth America 1553 7 45.1 11.8 78.4Pakistan 41724 113 27.1 22.1 32.1sig lowSouth America 545 2 36.7 0.0 87.5South Asia 5897 9 15.3 5.3 25.2sig lowUK 810208 2541 31.4 30.1 32.6sig lowBirmingham 970162 3223 33.2 32.1 34.4

Source: ONS 2002/3


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5. Estimates of activity prevalence rates

There are neither estimates nor measures of how much activity Birmingham’s population is undertaking at ward, PCT or City level. Therefore this report has had to estimate the levels of activity from the national Health Survey for England.

This is a high quality annual survey of the state of the national’s health based on a sizeable (20,000) sample of the population. This survey based on interviews and measurements undertaken by nurses provides the height and weight of each person interviewed. The strength of the survey design is that the sample has been drawn from the whole population and calculated to produce reliable prevalence data with reduced biases that can occur when undertaking opportunistic surveying.

The 1999 HSE was used here as it had a boosted sample to produce more reliable estimates for the ethnic populations. Vital when working with Birmingham’s population, which is the second most ethnically diverse population in England. So what we lose in terms of contemporary data we gain in the understanding of the prevalence levels by ethnicity.

Even with this enhanced survey measurements were not available for every ethnic group. Black Africans are poorly represented. However there was enough data for Indian, Pakistani, Bangladeshi, Black Caribbean and Chinese populations. The remaining ethnic groups were aggregated into an “other” group. The aggregated ethnic groups had very different activity patterns. The Bangladeshi population were the least activity, whilst the Black Caribbean and White populations were the most activity (Figure 5)

Figure 5: The number of times a person undertakes 30 minutes of activity in a week by ethnic group (HSE 1999).

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Unfortunately, it is not possible to build into the model a good measure of deprivation. The HSE records income and social class. The Census records Social Economic Status, which does not map on to social class. The only measure that is directly comparable between the HSE and the Census is economic activity. Economic activity does provide some marker of income deprivation as it provides numbers unemployed, permanently sick, those looking after families, and employed in part time jobs. This classification does however omit the wide pay differentials for those in employment and reduces the age categories to just two (16-24 and over 25).

The resulting estimates, given in table 3, therefore take into account differences in sex, ethnicity, economic activity and to a lesser degree age for the City and between PCTs.

Table 3: Prevalence (%) of people not achieving 5 sessions of 30 minutes per week, by economic activity, ethnic group, sex, and age.

sex age BangladeshiBlack

Caribbean Chinese Indian Other Pakistani white Overall

Male 16-25 70.0 40.0 75.0 71.0 56.3 64.9 50.4 56.1

over 25 72.4 60.4 77.3 65.4 74.6 63.2 65.2 65.8

Female 16-25 70.5 55.2 81.3 72.7 27.8 56.4 54.1 57.4

Employed fulltime

over 25 77.2 47.3 70.1 61.5 52.8 65.2 63.5 62.4

Male 16-25 78.6 85.7 80.0 87.5 83.3 83.3 63.4 74.2

over 25 78.3 68.4 81.3 80.4 60.0 68.2 76.6 75.6

Female 16-25 66.7 57.1 100.0 80.0 62.5 80.0 85.3 77.6

Employed part time

over 25 73.9 70.3 82.6 82.0 64.3 91.9 72.1 74.1

Male 16-25 93.9 50.0 0.0 100.0 100.0 90.3 82.8 89.6

over 25 89.3 82.5 95.6 88.9 77.8 87.3 80.7 85.0

Female 16-25 90.6 80.0 0.0 100.0 100.0 91.1 74.3 87.6

Looking after family

over 25 95.2 77.0 94.2 90.0 83.3 86.7 80.0 85.3

Male 16-25 75.0 0.0 0.0 100.0 0.0 75.0 66.7 75.0

over 25 66.7 50.0 100.0 85.7 66.7 100.0 60.0 71.1

Female 16-25 100.0 0.0 100.0 0.0 50.0 100.0 66.7 66.7

Other

over 25 40.0 50.0 100.0 75.0 100.0 60.0 73.9 68.1

Male 16-25 100.0 0.0 100.0 0.0 0.0 0.0 100.0 77.8

over 25 100.0 100.0 100.0 100.0 85.7 100.0 97.5 98.2

Female 16-25 100.0 50.0 0.0 100.0 0.0 100.0 100.0 84.6

Perm sick

over 25 100.0 96.9 100.0 100.0 100.0 100.0 93.5 95.7

Male over 25 95.0 96.6 88.0 92.5 100.0 95.2 89.5 90.5Retired

Female over 25 92.3 94.8 84.4 95.2 76.9 89.3 90.4 90.6

Male 16-25 100.0 0.0 0.0 0.0 0.0 62.5 44.4 52.2

over 25 53.8 31.0 75.6 63.2 42.9 85.2 56.4 60.8

Female 16-25 100.0 0.0 0.0 75.0 0.0 66.7 20.0 47.6

Self employed

over 25 40.0 38.5 83.3 70.8 36.4 69.2 54.8 59.3

Male 16-25 76.8 58.1 76.2 68.8 66.7 65.1 56.7 65.1

over 25 100.0 33.3 66.7 80.0 60.0 0.0 66.7 61.4

Female 16-25 71.8 65.5 67.9 75.0 59.4 73.3 72.2 71.2

Student

over 25 66.7 58.3 92.3 40.0 100.0 100.0 57.1 64.0

Male 16-25 100.0 100.0 0.0 0.0 100.0 100.0 71.4 85.7

over 25 100.0 66.7 100.0 100.0 100.0 100.0 73.3 82.1

Female 16-25 66.7 0.0 0.0 100.0 0.0 100.0 50.0 60.0

Unemployed

over 25 100.0 20.0 0.0 100.0 100.0 100.0 94.4 86.8

Grand Total 83.5 67.4 81.1 75.4 65.4 78.6 72.9 74.2

Source: HSE 1999


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Applying these prevalence rates to the census population it is possible to create an estimate of the total number of not undertaking exercise across Birmingham, the resident population of the PCTs and the wards or other areas by ethnic group and economic activity and sex. This analysis estimates the population of Birmingham aged over 16 who are not meeting the exercise target to be 491,177.

Table 4: The estimated number not meeting the exercise target for age sex ethnicity and economic activity in Birmingham from the 1999 HSE estimates and 2001 Census resident population.

sex age BangladeshiBlack

Caribbean Chinese Indian Other Pakistani White Overall

Male 16 to 24 726 681 506 1957 1741 3210 9794 18614

25 and over 77 106 193 170 674 0 1423 2643

Female 16 to 24 608 980 344 2211 1544 2680 13611 21979

student

25 and over 46 457 244 100 936 380 1667 3830

Male 16 to 24 217 195 45 656 498 1419 7570 10599

25 and over 540 3548 401 4760 2923 4351 68479 85002

Female 16 to 24 176 276 24 682 216 595 6757 8726

Employee - Full Time

25 and over 164 2967 251 3014 1704 932 40147 49179

Male 16 to 24 117 155 2 150 145 407 788 1764

25 and over 655 343 40 469 275 1035 4473 7291

Female 16 to 24 79 145 9 200 176 428 2392 3428

Employee - Part Time

25 and over 119 1847 96 1950 917 1017 31456 37402

Male 16 to 24 15 2 0 13 27 55 118 229

25 and over 180 162 11 203 204 804 2088 3651

Female 16 to 24 478 162 0 461 561 2509 2285 6457

Looking after home/family

25 and over 1958 881 209 2357 1782 8835 19202 35224Other Male 16 to 24 70 0 0 88 0 476 872 1505

25 and over 331 456 67 710 681 1869 3855 7969

Female 16 to 24 268 0 6 0 192 1307 1093 2866

25 and over 394 457 101 1021 982 2501 6320 11775

Male 16 to 24 17 0 0 0 0 0 613 630

25 and over 355 1190 27 1192 694 2219 17180 22857

Female 16 to 24 23 21 0 32 0 160 446 682

Permanently sick or disabled

25 and over 272 1098 31 1328 623 1730 14004 19086Retired Male 16 to 24 0 0 0 0 0 0 0 0

25 and over 391 2018 140 1010 583 1630 26301 32072

Female 16 to 24 0 0 0 0 0 0 0 0

25 and over 210 2427 170 1335 408 1209 37424 43183

Male 16 to 24 30 0 0 0 0 138 316 484

25 and over 246 224 129 1571 365 2892 11204 16632

Female 16 to 24 3 0 0 9 0 35 40 86

Self Employed

25 and over 11 102 92 594 118 224 3387 4526Unemployed Male 16 to 24 186 534 0 0 677 1516 2586 5499

25 and over 590 1147 52 1102 1346 2471 8865 15574

Female 16 to 24 95 0 0 224 0 768 965 2052

25 and over 135 177 0 687 713 715 5255 7682

Grand Total 9782 22757 3189 30255 21704 50514 352976 491177


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These estimates can be used to investigate differences by sex, age and ethnic group. The Bangladeshi and Pakistani populations are likely to have the highest proportion of people failing to meet the 5 a week target, whereas the Black Caribbean are most likely to have the lowest proportion failing to meet the target (Figure 6). When considering the two age groups available, the younger age group are more activity with fewer failing to reach the target (Figure 7).

Figure 6: The percentage of the population estimated not to be achieving the 5 a week target by Ethnic Group and sex across Birmingham based the HSE1999 estimates and 2001 Census resident population.

Figure 7: The percentage of the population estimated not to be achieving the 5 a week target by Ethnic Group and sex across Birmingham based the HSE1999 estimates and 2001 Census resident population

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6. Interventions

6.1. Local authority provision

Birmingham City Council (BCC) is the largest leisure provider in the city with X sites across the city (Figure 8). There are other private providers however there is no single source of these facilities, nor information on how many people use them.

Figure 8: A map of BCC leisure facilities and wards


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6.2. Exercise on prescription

In Birmingham there has been an Exercise on Prescription Scheme since 1994 and over 9,000 people have been referred by their GP.

The scheme is for people aged between 15 and 74 who have got some of the risk factors which can lead to coronary heart disease. This includes being overweight, smoking, high cholesterol, family history of heart disease, high blood pressure or a very stressful lifestyle.

Other people are referred to prevent osteoporosis, to improve mobility, to help control diabetes or to help treat depression to name but a few.

6.2.1. The service

If a GP or Practice Nurse feels that you are a patient is suitable person to be referred onto the Exercise on Prescription Scheme they will complete a Prescription Card and arrange an appointment with the most local Health and Fitness Advisor.

The initial consultation at the Leisure Centre with the Health and Fitness Advisor will last up to an hour and involves an explanation of the scheme, a talk about any relevant medical conditions, your current physical activity levels, the activities on offer locally, a tour of the Leisure Centre and devising an exercise plan.

At their next session referrals have the option of having a fitness appraisal; a set of measurements such as height, weight, body composition and fitness before starting an exercise programme. There are lots of activities to choose from - there's something for everyone.

Once a referral has started their exercise programme they will see their Health and Fitness Advisor for support and guidance during the next 12 weeks. At this point they will meet again to discuss progress, complete another fitness appraisal if appropriate and compare results and discuss future exercise participation. A report is then sent to the GP surgery.

The Exercise on Prescription Scheme operates at the following sites:

Cocks Moors Woods Leisure Centre Sparkhill Pool and Fitness Centre Kingstanding Leisure Centre Newtown Pool and Fitness Centre Shard End Community Centre and Sports Hall Saltley Community Leisure Centre Northfield Pool and Fitness Centre Fox Hollies Leisure Centre Wyndley Leisure Centre Stechford Cascades Handsworth Leisure Centre Erdington Pool & Turkish Suite Castle Vale Community Leisure Centre


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7. Access Rates

7.1. Birmingham City Council Leisure Card holders

The council’s Sport and Leisure department kindly provided data from their leisure card membership system on those people who have registered on this system. These data included people who held two types of cards available: (i) the standard card - free to all for collection of Points that accumulate to give discounts, and (ii) the Passport to Leisure card that costs £4 a year and is available to those over 60, full time students, those looking after child, carers or those in receipt of certain benefits. With this card a person pays reduced rates on activities at all centres.

The Leisure service made data available on all card holders and which leisure centre they had registered with. They could not provide data on Passport to Leisure separately, nor the activities undertaken.

7.1.1. Uptake by demography

There are two peaks in membership applications: the first in the 15-24 age group; and the second at retirement age, 60-64 for females and 65-69 for males. Overall females had higher membership rates (Figure 9).

Figure 9: Age sex specific rates of BCC Leisure card holders, rate per 1,000 population.

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7.1.2. Geographical uptake

There is a six fold difference in the uptake of BCC Leisure Cards across the City, ranging from a low of 6.7% in Ladywood to a high of 37.1% in Oscott; the average is 18.6% (Figure 10).

Figure 10: Percentage of the population who have Leisure Cards by ward

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7.1.3. Uptake by BME groups

Of those members whose ethnicity is recorded 74.1% of them classify themselves as white (compared to 70.4% of the population of Birmingham. For those from Black and Minority Ethnic groups the Bangladeshi, Indian and Pakistani populations were all less likely to have a Leisure card.

Figure 11: The comparison between the relative composition of the Leisure point members compared to the population of Birmingham, by Black and Minority Ethnic group.

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7.1.4. Uptake and Deprivation

There is a strong negative relationship between membership and deprivation. The most deprived communities have the lowest rates of membership.

Figure 12: Relationship between Leisure Card Membership and deprivation, with wards identified by PCT

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7.2. Exercise on Prescription

7.2.1. Data quality

The purpose of data collection for exercise services is not centred on population analysis. The main function is to provide the information required for the contract monitoring. This has serious implications for the completeness of recording of the data items that are used in population analysis namely age, sex, ethnicity, socio-economic data and residency. Nor is information routinely collected on reason for referral.

7.2.2. Variation by sex

The service is predominantly accessed by females, the ratio being 2:1 (Table 6).

Table 6: Exercise on Prescription: Usage by sex, by PCT 2003.

East HoB South North BirminghamMale 33.5 28.0 39.0 34.4 33.9Female 66.5 72.0 61.0 65.6 66.1

Overall 100.0 100.0 100.0 100.0 100.0

7.2.3. Variation by Age

The largest percentage of people on the scheme is in the 35-54 (43.4%), however this is also the widest age group spanning 20 years (Table 7). It is in fact the 55-64 age group that is enrolled more than any other age group.

Table 7: Exercise on Prescription: Usage by Age, by PCT 2003.

East HoB South North Birmingham0 – 16 1.4 1.0 0.3 0.7 0.817 – 24 2.2 5.3 3.9 1.6 3.625 – 34 9.4 14.6 8.6 6.6 10.135 – 54 44.0 47.8 41.6 40.0 43.455 – 64 24.5 17.0 26.6 26.6 23.465 – 74 18.4 14.3 19.0 24.5 18.7

Overall 100.0 100.0 100.0 100.0 100.0


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7.2.4. Variation by ethnic group

The ethnicity profiles of those referred to the scheme were compared to those of the PCTs resident population at the time of the 2001 Census. This found that East has poor access rates for its Black and Minority ethnic groups and South was not much better especially for the Black groups. Heart of Birmingham were referring many more Asians but not Blacks, whilst North again was referring fewer Blacks.

Table 8: Exercise on Prescription (EoP): Usage by sex, by PCT 2003 compared to ethnic population recorded in 2001 Census.

East HoB South North Birmingham

EoP Census EoP Census EoP Census EoP Census EoP CensusWhite – UK 71.9 18.8 72.9 82.8 58.7 Irish 4.7 2.6 3.0 4.2 3.4 Other 1.1 1.0 1.1 0.5 0.9White overall 77.7 90.7 22.4 29.1 77.0 84.4 87.5 90.7 63.1 71.6

Black – Caribbean 4.3 2.6 27.0 10.7 6.7 2.4 5.2 2.6 12.1 4.7 African 0.0 0.2 2.4 1.3 0.2 0.5 0.0 0.2 0.8 0.6 British 1.4 0.3 5.2 1.3 2.3 0.3 1.2 0.3 2.8 0.6

Asian - Indian 3.6 2.8 12.6 13.1 5.5 3.9 3.8 2.8 6.9 6.0 Pakistani 8.3 0.8 22.0 29.2 5.6 3.3 0.2 0.8 9.7 9.4 Bangladeshi 0.0 0.2 2.1 7.0 0.9 0.4 0.0 0.2 0.9 2.1 Kashmiri 0.7 0.7 0.3 0.0 0.4 British 2.2 2.2 0.2 0.9 1.2

Other 1.1 0.6 2.6 3.0 1.2 1.4 1.2 0.6 1.6 1.6Not disclosed 0.7 0.9 0.3 0.0 0.5

Overall 100.0 100.0 100.0 100.0 100.0


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7.2.5. Variation by Deprivation

The scheme does not report the postcode of the client and therefore it is not possible to report whether there are any socio-economic variations in the prescribing of scheme. It is highly likely that there are such inequities in the scheme. This assumption is based on the analysis of referrals to the scheme by South Birmingham PCT GPs compared to list deprivation. This analysis (see Figure 13) shows that despite a slight relationship between increased referrals and deprivation it is not consistent.

Figure 13: Exercise on prescription referral rate by Practice against estimated practice deprivation, 2003 SBPCT.

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0.2

0.4

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20 25 30 35 40 45 50

Affluent Deprivation Deprived

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8. Observations

Leisure Care uptake is inversely related to deprivation. If this reflects usage then it seems that the more deprived communities do not access City Council leisure facilities. Membership is low in the Indian, Pakistani and Bangladeshi populations

Exercise on prescription is used predominantly of females. There are very different referral patterns across the four PCTs and our Black populations are not being referred as much as the White and Asian population.

Exercise on prescription is not used by all GPs.

9. Recommendations

%%%%%%%%%%%%% Data collection needs to be overhauled to be useful for health equity audit evaluation

in particular the data needs to be stored electronically to enable cross tabulation of the data items and additional fields for practice and postcode of residence added.

The exercise estimates need to be validated either against the forthcoming lifestyle survey or from data recorded in primary care.


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AppendixAppendix A

Level and strength of evidence for a relationship between physical activity and contemporary chronic conditions (Source: At least five a week, Department of Health, 2004)

exercise_across_birmingham_a_health_equity_audit_2004

Documents

department of health

daily activity

health equity cycle

bone health activities

lifestyle activity

health equity audit1

health equity auditthis

general health benefit