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 for good 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)
Origin - South Birmingham PCT Public Health Team March 2004
1
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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Origin - South Birmingham PCT Public Health Team March 2004
3.
Methodology
There are three phases to this report: 1. Identify need a. Identify conditions diseases and conditions that are ameliorated by activity b. Identify the number of deaths that result from these diseases and conditions c. Investigate the relationship between mortality and demography d. Investigate the relationship between mortality and deprivation e. Investigate the relationship between mortality and ethnicity f. Estimate activity rates in the population by demography, ethnicity and deprivation 2. Identify Interventions/service provision a. Provision of facilities (both public and private) b. Membership of BCC centres c. Exercise on prescription 3. Identify Gap a. Access rates, b. Do services meet need considering demographic, ethnicity and deprivation factors
Origin - South Birmingham PCT Public Health Team March 2004
3
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
Coronary heart disease Cerebrovascular Disease Essential (primary) hypertension
Women
Total
1084 385 3
817 586 8
1901 971 11
Depression
79
16
95
Falls Malignant neoplasm of colon
51 67
50 69
101 136
17 1686
9 1555
26 3241
Non-insulin-dependent diabetes mellitus Total 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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Origin - South Birmingham PCT Public Health Team March 2004
as h
w oo d
H ea th Ki ng S ' s oh N o or N to H ec n an he ds lls w or t O h Sh sc ar ott S pa d E rk nd br o B i ok Fo lles l Ki x H ey ng o st llie an s Se din lly g O M ak o La sel e Sm dyw y a l oo lH d Ki ea ng th sb u Ya ry r S dle pa y rk S hil he l Er ldo di n ng to Ac oc W e n k' ole s G y r H od ee n Lo ge ng H i br ll id ge P e A st rr on Br y B an ar dw r H oo ar d Ed bor gb ne a S to Bo sto ck ur n Su lan nv tt d ille on G r N ee ew n H Q al ui l nt S S a o ut nd n to w e n V ll N es or e y t Su H hfi tt a on ll eld G Fo re en B ar ur tle Oa k y G s re en
W
Standardised Rate per 100,000 Population
Ki ng 's N Fo or x ton H ol lie Sp S s a r oh kb o r N ook S ec m h al ell lH s W ea L as a hw dy th oo wo d od H Er ea di th Sh ngt ar on d En d H Ast od o H ge n an ds Hil w l or Ya th Ed rd Ac g ley b St ock as oc 's ton kl G an re e d G n re Ki Mo en ng se st le an y d Sp in a g B rkh ou i rn ll v Ba W ille rt e l e ol e y G y r S a ee nd n w S e el ly ll O a O k Pe sc rr ott y B B arr ill es Sh ley e H ldo ar n S bo ut to Q rne n ui Fo nt u r on Br O an ak dw s S ut Kin oo to gs d n b N ur ew y N H or al Lo thf l n ie Su gb ld tt ri d on ge H Ves al l G ey re en
Standardised Rate per 100,000 Population
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 Directly Standardised Mortality Rates from diseases and conditions that are ameliorated by activity by ward across Birmingham, aged over 30, Males,
800
700
600
500
400
300
200
100
0
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 Directly Standardised Mortality Rates from diseases and conditions that are ameliorated by activity by ward across Birmingham, aged over 30, Females,
450
400
350
300
250
200
150
100
50
0
Primary Care Trust
Source: ONS 2002/3
Origin - South Birmingham PCT Public Health Team March 2004
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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 200 180 160
SMR
140 120 100 0
20
40
60
80
100
80 60 Affluent
IMD East
HoB
North
Deprived South
Linear fit
Source: ONS 2002/3 Standardised to England
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Origin - South Birmingham PCT Public Health Team March 2004
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
Africa Bangladesh Caribbean China Europe India Ireland Middle east North America Pakistan South America South Asia UK Birmingham Source: ONS 2002/3
Pop Deaths 13611 25 10784 20 19534 109 1411 1 7558 52 23197 87 28911 252 5229 5 1553 7 41724 113 545 2 5897 9 810208 2541 970162 3223
Rate 18.4 18.5 55.8 7.1 68.8 37.5 87.2 9.6 45.1 27.1 36.7 15.3 31.4 33.2
LL 11.2 10.4 45.4 0.0 50.2 29.6 76.4 1.2 11.8 22.1 0.0 5.3 30.1 32.1
UL 25.6sig low 26.7sig low 66.2sig high 21.0sig low 87.4sig high 45.4 97.9sig high 17.9sig low 78.4 32.1sig low 87.5 25.2sig low 32.6sig low 34.4
Origin - South Birmingham PCT Public Health Team March 2004
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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). 100% 90% 80% 70% 60% 50% 40% 30% 20% 10%
To ta l G ra nd
W hi te
ta ni Pa kis
O th er
In di an
ne se Ch i
be an ca r ib
ac k Bl
Ba ng l
ad es hi
0%
None
8
Less than 1
1 or 2 a week
3 or 4 a week
5 or more a week
Origin - South Birmingham PCT Public Health Team March 2004
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.
Employed fulltime
age
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 Employed part Male time
Male
Male
55.2
81.3
72.7
27.8
56.4
54.1
57.4
70.1
61.5
52.8
65.2
63.5
62.4
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
66.7
57.1
100.0
80.0
62.5
80.0
85.3
77.6
over 25
73.9
70.3
82.6
82.0
64.3
91.9
72.1
74.1
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
90.6
80.0
0.0
100.0
100.0
91.1
74.3
87.6
over 25
95.2
77.0
94.2
90.0
83.3
86.7
80.0
85.3
16-25
75.0
0.0
0.0
100.0
0.0
75.0
66.7
75.0 71.1
over 25
100.0
85.7
66.7
100.0
60.0
0.0
100.0
0.0
50.0
100.0
66.7
66.7
40.0
50.0
100.0
75.0
100.0
60.0
73.9
68.1
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
100.0
50.0
0.0
100.0
0.0
100.0
100.0
84.6
100.0
96.9
100.0
100.0
100.0
100.0
93.5
95.7
over 25
95.0
96.6
88.0
92.5
100.0
95.2
89.5
90.5
Female over 25
92.3
94.8
84.4
95.2
76.9
89.3
90.4
90.6
100.0
0.0
0.0
0.0
0.0
62.5
44.4
52.2 60.8
Male
16-25 over 25
Female 16-25 over 25 Male
16-25 over 25
Female 16-25 over 25 Unemployed
50.0
over 25
Self employed Male
Student
66.7 100.0
16-25
Female 16-25 Retired
Overall
47.3
over 25
Male
white
70.5
Female 16-25 Perm sick
Pakistani
77.2
Female 16-25 Other
Other
over 25
Female 16-25 Looking after family
Black Bangladeshi Caribbean Chinese Indian
sex
Male
31.0
75.6
63.2
42.9
85.2
56.4
0.0
0.0
75.0
0.0
66.7
20.0
47.6
40.0
38.5
83.3
70.8
36.4
69.2
54.8
59.3 65.1
76.8
58.1
76.2
68.8
66.7
65.1
56.7
100.0
33.3
66.7
80.0
60.0
0.0
66.7
61.4
71.8
65.5
67.9
75.0
59.4
73.3
72.2
71.2
66.7
58.3
92.3
40.0
100.0
100.0
57.1
64.0
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
66.7
0.0
0.0
100.0
0.0
100.0
50.0
60.0
100.0
20.0
0.0
100.0
100.0
100.0
94.4
86.8
83.5
67.4
81.1
75.4
65.4
78.6
72.9
74.2
Female 16-25 over 25 Grand Total
53.8 100.0
Source: HSE 1999
Origin - South Birmingham PCT Public Health Team March 2004
9
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 student
age
Looking after home/family
681
506
1957
1741
3210
9794
18614
Female
106 980
193 344
170 2211
674 1544
0 2680
1423 13611
2643 21979
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
16 to 24
176
276
24
682
216
595
6757
8726
25 and over
164
2967
251
3014
1704
932
40147
49179
Male
16 to 24
117
155
2
150
145
407
788
1764
Female
25 and over 16 to 24
655 79
343 145
40 9
469 200
275 176
1035 428
4473 2392
7291 3428
25 and over
119
1847
96
1950
917
1017
31456
37402
Male
16 to 24
15
2
0
13
27
55
118
229
180
162
11
203
204
804
2088
3651
25 and over 16 to 24
461
561
2509
2285
6457
209
2357
1782
8835
19202
35224
70
0
0
88
0
476
872
1505
25 and over 16 to 24
331 268
456 0
67 6
710 0
681 192
1869 1307
3855 1093
7969 2866
25 and over
394
457
101
1021
982
2501
6320
11775
17
0
0
0
0
0
613
630
355
1190
27
1192
694
2219
17180
22857
Male
16 to 24 25 and over 16 to 24
23
21
0
32
0
160
446
682
272
1098
31
1328
623
1730
14004
19086
Male
16 to 24
0
0
0
0
0
0
0
0
Female
25 and over 16 to 24
391 0
2018 0
140 0
1010 0
583 0
1630 0
26301 0
32072 0
25 and over
210
2427
170
1335
408
1209
37424
43183
30
0
0
0
0
138
316
484
246
224
129
1571
365
2892
11204
16632
Male
16 to 24 16 to 24 25 and over
10
0
881
Female
Female
Grand Total
162
16 to 24
25 and over
Unemployed
478 1958
Male
25 and over
Self Employed
Overall
77 608
Female Retired
White
726
25 and over
Permanently sick or disabled
Pakistani
16 to 24
Female Other
Other
25 and over 16 to 24
Female Employee - Part Time
Indian
Male
25 and over Employee - Full Time
Black Bangladeshi Caribbean Chinese
3
0
0
9
0
35
40
86
11
102
92
594
118
224
3387
4526
Male
16 to 24
186
534
0
0
677
1516
2586
5499
Female
25 and over 16 to 24
590 95
1147 0
52 0
1102 224
1346 0
2471 768
8865 965
15574 2052
25 and over
135
177
0
687
713
715
5255
7682
9782
22757
3189
30255
21704
50514
352976
491177
Origin - South Birmingham PCT Public Health Team March 2004
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).
al l ve r
te O
w hi
is ta ni Pa k
ot he r
n In di a
ne se C hi
ca rib
ac k bl
Ba n
be an
90 80 70 60 50 40 30 20 10 0 gl ad es hi
Prevalence (%)
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.
Male
Female
16-25
ve ra ll O
w hi te
an i Pa ki st
ot he r
In di an
C hi ne se
90 80 70 60 50 40 30 20 10 0
Ba ng la de bl sh ac i k ca rib be an
Prevalence (%)
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
over 25
Origin - South Birmingham PCT Public Health Team March 2004
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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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Origin - South Birmingham PCT Public Health Team March 2004
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
Origin - South Birmingham PCT Public Health Team March 2004
13
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.
600.0
Rate per 1,000 populaiton
500.0
400.0
300.0
200.0
100.0
0.0 0-4 5-9 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85+ 14 19 24 29 34 39 44 49 54 59 64 69 74 79 84 Males
14
Females
Origin - South Birmingham PCT Public Health Team March 2004
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
Birmingham Oscott Selly Oak Kingsbury Moseley Perry Barr Brandwood Sutton Vesey Sutton Four Shard End Kingstanding Fox Hollies Billesley Hall Green Acock's Green Stockland Green Sparkbrook Northfield Bournville Sheldon Aston Weoley Yardley Quinton Sutton New Hall Sandwell Harborne Erdington Soho Hodge Hill Small Heath King's Norton Edgbaston Longbridge Washwood Bartley Green Nechells Handsworth Sparkhill Ladywood 0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
% of population
Origin - South Birmingham PCT Public Health Team March 2004
15
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.
12.0 10.0
%
8.0 6.0 4.0 2.0
Members
16
M
Population
Origin - South Birmingham PCT Public Health Team March 2004
ta ni
O th er
Pa kis
ixe d
R
ac e
In di an
ne se Ch i
Ca rib be an Ba ng la de sh Bl i ac k Af ric an Bl ac k O th er
BA
As ia n
O th er
0.0
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
rate per 1,000 population
400
300
200
100
0 0
10
20
30
40
Affluent
50
60
70
Deprivation HoB
North
South
80
90
Deprived East
Linear fit
Origin - South Birmingham PCT Public Health Team March 2004
17
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 Male Female
33.5 66.5 100.0
Overall
7.2.3.
HoB
South 28.0 72.0 100.0
North
Birmingham 34.4 33.9 65.6 66.1 100.0 100.0
39.0 61.0 100.0
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 0 – 16 17 – 24 25 – 34 35 – 54 55 – 64 65 – 74 Overall
18
HoB 1.4 2.2 9.4 44.0 24.5 18.4 100.0
South 1.0 5.3 14.6 47.8 17.0 14.3 100.0
0.3 3.9 8.6 41.6 26.6 19.0 100.0
North 0.7 1.6 6.6 40.0 26.6 24.5 100.0
Birmingham 0.8 3.6 10.1 43.4 23.4 18.7 100.0
Origin - South Birmingham PCT Public Health Team March 2004
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 EoP White – UK
HoB
Census EoP
South
Census EoP
North
Census EoP
Birmingham
Census EoP
Census
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
White overall Black – Caribbean
77.7
90.7
22.4
29.1
77.0
84.4
87.5
0.9 90.7
63.1
71.6
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
Not disclosed
0.7
0.9
0.3
0.0
0.5
100.0
100.0
100.0
100.0
100.0
Overall
0.6
2.6
3.0
1.2
1.4
1.2
Origin - South Birmingham PCT Public Health Team March 2004
0.6
1.6
1.6
19
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.
1.6
Referral rate per 100 patients on list
1.4 1.2 1 0.8 0.6 0.4 0.2 0 20
25 Affluent
20
30
35
40
Deprivation
Origin - South Birmingham PCT Public Health Team March 2004
45 Deprived
50
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.
Origin - South Birmingham PCT Public Health Team March 2004
21
Appendix Appendix 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)
22
Origin - South Birmingham PCT Public Health Team March 2004