Community Medicine (1981) 3 , 4 - 1 3 Printed in Great Britain

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Multiple deprivation and health state
Vera Carstairs
Scottish Health Service Common Services Agency, information Services Division

INTRODUCTION
Public debate on the phenomenon of multiple deprivation followed publication of a paper
by Holtermann1 which analysed the distribution of a number of variables from the 1971
census which may be accepted prima facie as indicators of deprivation, this being identified
broadly as a low level of welfare. This and subsequent analyses are confined to variables
which may be derived from census data. The selection of relevant indicators (from the
number available) must be to some extent arbitrary, but from the analyses carried out and
the associations documented no one would doubt that the method allocates areas into
categories which reflect the observable realities.
Following from this, the development of policies in respect of areas which may be said to
be multiply deprived has been a major concern of social policy in recent years. In the main
these policies relate to urban regeneration in its physical context — economic planning and
improvements to housing stock and the physical environment provide the main foci of
action. In recognition of other aspects of deprivation, social work services and voluntary
services have also taken part in this process of regeneration.
Inevitably the question has been raised whether the health services have a contribution to
make to this process. The justification for positive discrimination in respect of the delivery
of health services undoubtedly rests in identifying greater need for health care in deprived
than in other areas. Both RAWP2 and SHARE3 endorse the principle that greater need
should attract more resources; if it can be shown that there is greater morbidity (or greater
need for health service care) in areas* of greater deprivation, then this has relevance to
resource allocation at various levels. This principle rests on considerations of equity: neither
report addresses the question of whether more resources would improve health state. The
association of mortality and social class is well known: perinatal and infant mortality rates
are higher in lower social classes,4 and death rates for men aged 15—64 show a continuous
gradient from social class 1 to social class 5. s Morbidity associations are more difficult to
document, as many measures reflect contact with a service. Data from the General Household
Survey, however, show reported sickness as greater in manual and particularly in unskilled
working groups than in professional and non-manual working groups, the association being
more apparent for chronic than for short term health problems.6 Despite being free of
factors relating to health service use, however, these measures may not reflect true morbidity.
People's assessments of their health state embody their perceptions, and, given the same
objective state, people will vary in whether they consider themselves to be sick. The class
differences have been reviewed in a number of publications lately. 7 ' 8 Given these known
associations and the links of social class and deprivation it would seem highly likely that

•Throughout this paper 'areas' is used in its common linguistic sense and not in connection with health
authorities.
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deprived areas will exhibit greater 'morbidity'. Little work has been done, however, on
measuring health in relation to deprived areas.
Scott-Samuel analysed data in respect of clusters of areas using a typology developed by
OPCS, and showed that infant mortality and hospital admissions for infectious diseases were
higher in those clusters with more of the population in social classes 4 and 5. The numbers
of cases were rather low but on the basis of this he stresses the importance of quantifying
the influences of socioeconomic variables other than social class.9
In an analysis of standard regions in England and Wales (of which there are ten), Forster
found associations — which are highest for mortality followed by chronic sickness, then
acute sickness (GHS data) — with the percentage of the population in unskilled occupations
and with the percentage unemployed.10 Unlike the data reported in this paper, however,
Forster shows no association with the percentage of households not having exclusive use of a
bath. It seems likely that in aggregating up to regions with large populations the effect of
these factors may have been obscured. Brennan and Lancashire have found housing density
and housing facilities to have a highly significant association with child mortality under 5
years:11 the association remained when social class and unemployment were eliminated,
pointing to an area effect. Skrimshire, in comparing sickness experience in two areas both
with working class populations, found acute illness higher in the area which was more
deprived.12
This paper examines some data available for Glasgow and Edinburgh in an attempt to
determine the associations between health state and multiple deprivation.

METHODS
In order to test any hypothesis that populations in deprived areas do have above-average
needs for health care it would be desirable to examine indicators of health state for areas
which are categorized by degrees of severity of deprivation. For a number of reasons it is
very difficult to assemble data on this basis. Prime among these is that the basic unit of
census analysis is that of the enumeration district (ED), and health data are not normally
available at this level.
As an approximation, data have been assembled and examined for the smallest unit for
which health data were available — the municipal wards, of which there were 37 in Glasgow
and 23 in Edinburgh under the old local authority structure. Wards are, of course, large in
comparison with EDs and with most of the areas which have been identified as severely
deprived; a ward is therefore likely to be less homogeneous in character than are EDs, and
the analysis might be challenged on this basis. It should be pointed out, however, that areas
of deprivation are also not homogeneous — it is the areas which are classified, and not all the
families in them will be deprived. The Scottish Development Department has analysed data
for both areas and households in Scotland, and shown that in local authority areas which can
be categorized as severely deprived, only 44 per cent of households in the area are deprived,
at a specified level, and only 34 per cent of the deprived households at this level are in the
severely deprived areas.13 Census data show (Table I) that Glasgow wards at the extreme of
the range had characteristics very similar to those of the most deprived areas in Scotland.
For instance, 27 per cent of households in the most deprived ward in Glasgow were over-
crowded compared with 25 per cent in the most deprived (worst 10 per cent) of local
authority areas. The ranges for some census (deprivation) variables for the Glasgow wards are
also shown (Table II); there is a considerable range for all the measures shown, except for
the last variable, the percentage of the population economically active. The fact that large
proportions of the population are children or elderly probably constrains the variation in
this measure.
Our method relates the selected census indicators to health data for 37 Glasgow wards
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Table I. Percentage of households in areas with deprivation characteristics

SDD study areas Glasgow wards

Severely Severely
deprived deprived Worst ward
LA areas' 1 rentedt

Households overcrowded 25.5 30.6 27.2

1-parent households with
children 2.6 3.8 8.1
Household heads unemployed
(EA men unemployed) 16.9 15.4 19.5
Household heads in SCs 4 and 5
(persons in SCs 4 and 5) 45.1 43.5 52.8
Households with 4 + children 16.7 6.6 10.5
Households lacking exclusive
use all amenities $ 89.6 85.4
Households with 1 —3 rooms 54.3 96.1 94.7
Households with no car 85.7 91.6 92.7

LA areas, areas where most housing is local authority; Rented, area where a high
proportion of property is rented.
* Worst 10 per cent of EDs.
t Worst 30 per cent of EDs.
% LA housing does not suffer from lack of amenities and this figure is not computed.

Table II. Percentage of households with deprivation characteristics: range

for Glasgow wards

Households overcrowded 3.1-27.2

Households lacking exclusive use of
all amenities 1.1-85.4
Persons classified in SEG 11 (SCV) 2.2-30.4
EA males seeking work or sick 4.5-26.5
Households no car 51.1-92.7
Households 1 —3 rooms 24.6-94.7
Total population economically active 42.5-49.5

and 23 Edinburgh wards separately. The health measures are restricted to data which were
available for the entire population, and are listed in Table III. Data come from the Scottish
hospital inpatient data banks held by the National Health Service, from the Registrar-
General's records and from records held by the former medical officers of health. Data for
3—4 years have been aggregated to give sufficient numbers. For most items data centres on
1971 to be close to the census, in view of the considerable movements of the population of
Glasgow since that time. For the perinatal and infant deaths this consideration is less relevant
as the denominators (the numbers of total and live births) do not come from the census. The
question being examined is whether populations in deprived areas have higher 'morbidity',
and where relevant data have been standardized to remove the effects of differing age/sex
compositions of the populations of the wards. This allows us to look at mortality and
morbidity without the confounding element of age.
In SHARE, in contra-distinction to RAWP, mortality was judged to be a more relevant
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Table III. Ward analysis data set

Glasgow Edinburgh'

1. Deprivation score, derived from 1971 census

2. Mortalityt 1 9 7 0 - 2 * 34180 11652
3. Perinatal deaths (1970—4) 1330 448
and infant deaths (1970—3) 1339 180
4. Dischargest general hospitals (1970-2) 319 556 112299
5. Bed-dayst general hospitals (1970—2) 5 741 824 2602450
6. Admissionst mental hospitals (1970-2) 13 975 4450
7. Low birthweight (1971) (<5.5lb) 1056 1922

•Years may vary for Edinburgh data.

tFor all and selected causes.

Table IV. Glasgow wards: range of values for health indicators

(annual standardized rates per 1000 population)

Discharges all causes 87-192

Bed-days all causes 1431-4648
Deaths all causes 8.6-16.1
Discharges 0—64 all causes 69-150
Bed-days 0—64 all causes 799-2702
Deaths 0 - 6 4 3.6-7.0
Discharges infectious diseases 1.9-11.9
Discharges respiratory disorders 6.8-32.6

Table V. Correlations of census variables with first principal

component (deprivation index)

Overcrowded 0.933
Lacking amenities 0.806
Percentage in SC5 0.941
Males economically active seeking work or sick 0.922
No car 0.936
Households 1 —3 rooms 0.833
Percentage of population economically active -0.803

Lacking/sharing hot water 0.828

No inside WC 0.788
Persons in SC4 and 5, percentage of all classified 0.886
Persons in SC4 and 5, percentage of total population 0.851
1-parent families 0.693

indicator of morbidity at 0—64 than at 65 and over, and the SMR for ages 0—64 is the factor
used in the SHARE calculation. The data (for Glasgow only) are also structured, therefore,
to show the age groups 0—64 and 65+ separately.
Ranges in some of the indicators are shown in Table IV for Glasgow. They are about
twofold for discharges and deaths all causes, and rather more for bed-days. For some specific
causes the range in values is much greater: discharges for infectious diseases and respiratory
disorders are shown.
A deprivation variable which characterized each ward was derived from a hst of indicators
used by the Scottish Development Department in identifying areas for priority treatment in
respect of planning; although based on Holtermann this list was modified in the light of
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particular Scottish circumstances. The correlations between the individual variables and the
health indicators were determined, and variables with a correlation significant at the 0.1 per
cent level were selected (avoiding obvious duplication) and combined, via a principal
component analysis, into an index of deprivation. This index consisted of a score for each
ward within the range —2 to +2.
Table V shows the correlation of individual census variables with the overall index.
Variables above the line are included in the analysis — clearly those below the line are also
significantly associated with the index even though they have not been entered into the
analysis - in some cases because they overlap with other items.

FINDINGS
The correlations of the deprivation score with the 'all causes' health indicators appear in
Table VI. The deprived index shows fairly strong associations with the health indicators. The
correlation is higher for deaths (0.686 all ages Glasgow) than for the hospital discharges

Table VI. Correlations of deprivation score with health indicators (all causes) for Edinburgh
and Glasgow wards

Edinburgh Glasgow „
(all ages) (all ages) °~64 65

Deaths 0.657 0.686 0.758 0.526

Discharges 0.472 0.589 0.613 0.441
Bed-days 0.498 0.601 0.647 0.416
Mental hospital admissions 0.447 0.527
Live births < 5.5 Ib 0.570 0.561
Perinatal deaths 0.586 0.104
Post-neonatal mortality 0.492
Infant mortality 0.235 0.348

Table VII. Death, discharge and bed-days rates and mean stay by deprivation class: Glasgow
and Edinburgh data

Deprivation category Death rate Discharge rate Bed-days rate Mean stay

Least severe 1 31.2 298 4600 15.4

2 34.8 340 5097 15.0
3 35.7 321 4776 14.9
4 39.1 330 5492 16.6
5 42.1 373 6622 17.7
6 42.8 381 6409 16.8
7 44.2 375 7820 20.9
r 8 46.9 374 7268 19.4
Most severe 9 50.2 459 8590 18.7

(0.589 all ages) or bed-days (0.601 all ages); the coefficients are slightly lower for Edinburgh
than for Glasgow. As anticipated the correlations are stronger for the age group 0—64 than
for 65+. For all ages and 0—64 the correlation is stronger for bed-days than for discharges,
and the other way round for 65+, although the variation is small for both. The association is
moderately strong for mental hospital admissions (0.527 and 0.447) and low birthweight
(0.561 and 0.570), and surprisingly low for perinatal and infant deaths; the association with
post-neonatal mortality is higher, however, as would be expected. In Table VII the mortality
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Table VIII. Correlations of deprivation scores with deaths, discharges and bed-days for selected causes (all
ages)

Deaths Discharges Bed-days

Glas. Edinb. Glas. Edinb. Glas.

All causes 0.686 0.657 0.589 0.472 0.601

Infective and parasitic N/A 0.697 0.341 0.625
Endocrine and nutritional 0.561 0.297
Respiratory 0.876 0.687 0.538 0.527 0.560
Malignant neoplasms 0.407 0.550 0.250 0.120 0.352
Circulatory 0.352 0.250 0.414
Heart diseases 0.275 0.441
Accidents excluding
adverse reactions 0.684
Fractures 0.560
'Other' accidents
(not M V A ) 0.777
Musculoskeletal 0.105 -0.298 0.155
Infections
Intestinal 0.735
Tuberculosis 0.535
Neoplasms
Ca lung 0.418
Ca breast —0.305
Respiratory
Infections upper and
lower respiratory tract 0.780
Other u.r.t.
(mainly Ts and As) 0.041

and bed-use ratios for the wards are grouped into nine classes of deprivation where the
gradients can be seen to be firm, although not unfaltering, and clearer for the deaths than
the discharges or bed-days. The range is greater for the bed-days than for the other two
measures, and mean stay is longer in the more deprived classes.
Although there are strong correlations overall, there is considerable variation among the
cause groups. Table VIII shows some of these: the correlation coefficient is high for dis-
charges for infective and parasitic diseases, for respiratory disorders for deaths (but only
moderate for hospital discharges), moderate to low for the neoplasms and circulatory
disorders and high for accidents for both deaths and discharges. Further analysis within the
data set shows for discharges that the association is higher for the intestinal infections than
for the group of infective and parasitic diseases, and that the correlations for respiratory
disorders are improved by splitting up the group into its components, when the respiratory
infections display a coefficient which is much more comparable to the deaths. Cancer deaths
are shown to have a slightly higher coefficient for deaths from lung cancer, and cancer of the
breast to have a negative association, which would accord with the known epidemiological
facts.*

DISCUSSION
For much of the data there are fairly strong associations of deprivation with the health
indicators: deaths, discharges, bed-days and low birth-weight, and the results allow us to say

*The data only allowed analysis by the B List of Causes; many specific causes were too small to permit
analysis.
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3-YEAR C l 9 7 0 - 1 9 7 2 )
DISCHARGE RATE

- MAJOR HOSPITAL

Fig. 1. Glasgow ward standardized discharge rate per 1000 population showing location of major hospitals.

fairly confidently that there is good evidence of greater mortality and 'morbidity' in areas of
greater deprivation. The exception is the data on perinatal and infant deaths, which is
contrary to all expectation. Part of the explanation may be that, despite fairly high numbers
overall for Glasgow, the number of events in some wards is quite low and the data may be
insufficient to provide stable rates. For some of the aberrant values, however, the numbers
are not low, and this is a finding for which we do not have an explanation.
Do the data allow us to come to any conclusions about morbidity? It is well known that
morbidity itself is not the only determinant of hospital use. Generous hospital bed provision,
poor primary care services and social factors may all influence the level of use. The differing
levels of bed provision available to different populations mean that the hospital utilization
data cannot normally be used as a measure to indicate differences in morbidity between
populations. However, in this instance we would argue that the high level of provision of
acute beds in Glasgow and Edinburgh effectively means that there is equality of access to the
entire population. The bed-provision data for this period are not analysed at city level, but
we can say that the discharge and bed-use rates for the populations of the two cities used in
this analysis exceed the rates for Scotland as a whole by 17—30 per cent. It can also be
shown that areas of high use are not those in which the hospitals are located (Fig. 1), and
bed provision can probably be ruled out as a determining factor.
We did not attempt to quantify the primary care services available to the population but
Knox has done this, albeit for a later date, in papers published in 1978 and 1979. 14>1S In
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Glasgow, he found that access to primary care services was high in the inner city areas
(which rank among the most deprived) and low in the peripheral zone of public housing
(also deprived). However, he also identifies the inner-city areas as emerging as worst-off in
terms of the quality of primary care services, in the light of a number of factors, and con-
cludes that 'it is not surprising that many patients prefer to seek treatment at the city's
hospital outpatient departments', although he does not provide any data to show that they
do so.
For Edinburgh, Knox finds that the city's worst-served areas (in terms of access only)
correspond with the deprived local authority estates, and that the best-served are the middle-
class owner-occupied areas.
True morbidity is not something which is easy to identify. We have already noted that
people's perceptions will vary, although there is little, if any, evidence of how readiness-to
identify oneself as sick is related to other factors. Even given equal morbidity, people's
needs for care will not be uniform. The capacity of people to cope with or manage their own
illness or that of a member of the family will vary, and social and environmental factors will
also influence the demand for care — hospital use is much higher for instance for the single
than for the married or once-married,16 while working wives and mothers may find difficulty
in providing care for a sick member of the household and the presence or absence of house-
hold amenities will play a part in determining whether a sick person can be nursed at home.
All these factors may influence not only the probability of admission but also the decision
to discharge: Table VII shows that length of stay is longer in the more deprived than in the
lesser deprived categories, and social factors must be considered as a likely influence. Many
factors other than basic morbidity may therefore influence the hospital data. To a lesser
extent they may also affect mortality, but it is arguable that there is a strong morbidity
component in these data, and the finding of a higher mortality also in deprived areas must
encourage us to attribute some of the variation in hospital use to difference in morbidity in
its widest context.
If we accept that these indicators provide some measure of health state, then these data
suggest that more 'need' is demonstrated in areas of deprivation, and the RAWP/SHARE
philosophy would imply that positive discrimination of resources towards areas of depri-
vation is appropriate. Positive discrimination will be relevant both within and between
areas, but in larger areas the overall level of deprivation is likely to be diluted by the presence
of a diversity of types of area, including affluent as well as deprived.
In the development of strategies for delivery of health care some important factors must
be borne in mind.
1. A high proportion of deprived households are to be found outside the deprived areas.13
Our own analysis shows an association of 'morbidity' and mortality with deprived areas and
we have not been able to examine households. A few analyses examine the data for house-
holds, notably Wedge and Prosser, who found increased levels of morbidity in children
from disadvantaged households.17 Further work would be required to identify whether
deprived households in nondeprived areas should also be a target for additional services. In
the meantime, where large areas of deprivation exist, appropriate services directed generally
to these areas would certainly enable large numbers of deprived households to be reached.
2. It has been shown that correlations are not high with some causes of morbidity and
mortality, but there are strong correlations with infections and respiratory disorders and
with accidents, all disorders with a strong preventable component. These findings may have a
particular message for the delivery of services that are believed to affect and modify people's
behaviour or which are preventive in action, and will be relevant to the determination of
particular strategies. It should not be overlooked that other sectors of social policy, housing,
education, employment and Social Security, may have an equally important contribution to
make. History tells us that improvements in standards of living, of nutrition and the environ-
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ment, have played a critical role in the reductions in mortality and morbidity which have
been achieved in the past. A main exponent of this view, however, believes that 'personal
behaviour is now even more important than provision of food and control of hazards'.18
It is clear that low social class is a feature of deprived areas. Table V shows that the
percentage of the population in social class 5 and in classes 4 and 5 correlates highly with the
composite deprivation index. This variable (SC5) also correlates very highly, for the Glasgow
wards, with unemployment, overcrowding and not having a car (all 0.88 or more). It is
worth asking, therefore, whether the concept of deprivation has much to add to our under-
standing of the well known associations between morbidity and social class. Table IX shows
(for ages 0-64) that for deaths the correlation with the urban deprivation index is very
slightly higher than any of the individual census variables, and that the percentage of the

Table IX. Urban deprivation Glasgow ward analysis: correlations of census variables
with health indicators for ages 0—64

All causes

Deaths Discharges Bed-days

(0-64) (0-64) (0-64)

UD factor 0.758 0.613 0.647

Overcrowding 0.686 0.483 0.501
Lacking amenities 0.717 0.520 0.581
SC5 0.636 0.577 0.666*
Seeking work/sick 0.658 0.657* 0.650*
No car 0.748 0.604 0.611
1 —3 rooms 0.740 0.492 0.488
% pop. EA -0.683 -0.508 -0.569

'Exceeds UD factor

population in social class 5 shows the lowest association. For hospital discharges the corre-
lation is highest with unemployment, and social class 5 is very close to the deprivation
index. Similarly, for bed-days, social class 5 and unemployment correlate as highly as the
overall factor. It does not appear from these data that the composite factor has much to
offer over and above the explanatory power of the individual variables.
Correlation measures, nevertheless, do not provide a comprehensive picture of the data.
The question is sometimes raised whether there is an area effect which is over and above that
of social class, i.e. do some areas have an experience which is worse than would be expected,
given their social class composition, which appears to be attributable to deprivation in the
area? So far we have not been able to examine this question fully but it is hoped to do so
when social class populations for the Glasgow wards become available.

Acknowledgements
I would like to thank Derek Young of Information Services Division for work on the basic
organization of the computer file and George Clark (now at Mersey Regional Health
Authority), for statistical advice and computer analysis.

REFERENCES
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Social Trends No. 6. London, HMSO.
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Requests for reprints should be addressed to: Vera Carstairs, Scottish Health Service Common Services
Agency, Information Services Division, Trinity Park House, South Trinity Road, Edinburgh EHS 3SQ.