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Statistical bulletin: Inequality in Disability-free life expectancy by area deprivation: England, 2002–05 and 2006–09

Released: 15 May 2012 Download PDF

Key findings

  • Inequality in life expectancy (LE) and disability-free life expectancy (DFLE) between the least and most deprived neighbourhoods in England grew between 2002-05 and 2006-09 for males and females at birth and at age 65.
  • From birth, the number of years lived with a limiting longstanding illness or disability (LLSI) increased between 2002-05 and 2006-09 in the most deprived neighbourhoods and fell in the least deprived neighbourhoods by one per cent for both males and females.
  • At age 65, the remaining years lived with a LLSI between 2002-05 and 2006-09 increased by around three per cent in the most deprived neighbourhoods but was almost unchanged in the least deprived neighbourhoods.
  • Absolute inequality, taking into account all area deprivation clusters, using the slope index of inequality (SII), fell for males at birth and remained unchanged at age 65 between 2002-05 and 2006-09. For females, absolute inequality as measured by the SII, increased both at birth and at age 65 over this period.

Summary

DFLE adds a dimension of quality of life to LE, providing users with a summary measure of population health which can be used as a high level outcome to monitor health improvement, effects of policy changes and to support service planning across sectors, such as health, benefits and pensions.

This bulletin presents estimates of DFLE and LE along with indices of absolute and relative inequality across quintiles of Lower Super Output Areas (LSOAs) in England, as defined by the Index of Multiple Deprivation (IMD) 2007, for the periods 2002-05 and 2006-09. 

Background

Health expectancies (HEs) provide estimates of the length of life spent in favourable and unfavourable health states adding a quality dimension to LE. DFLE, the focus of this bulletin, divides expected years of life into those spent with and without limiting longstanding illness or disability (LLSI).

DFLE is an important metric in the assessment of health and social care need, the high level monitoring of polices designed to reduce health inequalities, the likely proportion of the working age population fit for work at a given age and the fairness of increases to the state pension age. This measure also supports policy development in the Department of Health, the Department for Work and Pensions and the Department for Environment, Food and Rural Affairs.

The relationship between HEs and measures of socio-economic position, and how the relative advantage of area modifies this relationship, has been investigated previously (White and Edgar 2010). Specifically, a steeper social gradient is observed in more deprived areas demonstrating that the relative advantage conferred by area, or geography, additionally impacts on health expectancy over and above its socio-economic composition. However, while these measures alone can be important predictors of health, the difficulty in accurately recording occupation and/or employment status at death registration for some groups of people and the absence of mid-year population estimates by socio-economic position has restricted analyses to longitudinal data sources.

To overcome the limitations of carrying out analyses of mortality data by socio-economic position, small area deprivation indices have frequently been used as alternative indicators to measure health inequality. Several studies have reported a clear, linear relationship between health and relative deprivation, however defined (Bajekal, 2005; Rasulo et al., 2007; Olatunde et al., 2010; Smith et al., 2010a, 2010b). It is now widely accepted that analyses of health inequality using deprivation indices are as important as analyses based solely on occupation and employment status (MacIntyre et al., 1993; Bajekal, 2005). This is partly because indices, such as the Index of Multiple Deprivation (IMD) in England, take into account both compositional (individual) and contextual (physical and social environment) characteristics in producing a summary measure of the deprivation of an area of residence.

In comparing the least and most deprived areas, the use of the range between the least and most deprived area quintiles can mask the true scale of health inequality that exists across all area clusters of deprivation. The SII better represents the relationship between DFLE and deprivation as it provides an estimate of the absolute health inequality across all areas, reflecting the experience of the entire population, and is also sensitive to changes in the distribution of the population across areas (Low and Low. 2004).

This bulletin updates a previous article  (Smith et al., (2010b) (255.9 Kb Pdf) available on the ONS website which describes the methodology in detail and presents results for the periods 2001-04 and 2005-08.

ONS has produced a range of health expectancy statistics using the IMD and this bulletin represents the second in a series of analyses of inequalities in DFLE across quintiles of relative ecological deprivation in England in the 21st century.
For further information, please visit our website.

Key comparisons: Inequalities at birth

2002-05

Substantial inequalities in health persist between neighbourhoods experiencing differing amounts of deprivation.

In the least deprived areas, males born between 2002 and 2005 could expect to live for 80 years, some 7.8 years, or 10 per cent, longer than their counterparts in the most deprived areas. For females, LE in the least deprived areas was 83.2 years, approximately 5.3 years or 7 per cent more than in the most deprived areas.   

The gap between males and females in terms of LE is substantial, across all levels of deprivation. This gap, however, was narrowest in the least deprived areas (3.3 years) and widest in the most deprived (5.7 years).

For DFLE, the sex specific contrast between the least and most deprived neighbourhoods is greater. DFLE for males in the least deprived areas was 67.3 years in 2002-05, representing an additional 13.2 years (almost 20 per cent) of life free from LLSI compared to males in the most deprived areas. For females, DFLE was 67.8 years in the least deprived neighbourhoods; 10.6 years (around 16 per cent) more disability-free life years than in the most deprived areas.

The gap in DFLE between the sexes was narrower than for LE; just 6 months in the least deprived areas increasing to around 3 years in the most deprived areas.

The absolute inequality in LE and DFLE as measured by the SII exceeded the simple difference between the least and most deprived area groupings. For males, the SII at birth in 2002-05 was 9.4 years for LE and 15.4 years for DFLE. For females these figures were 6.4 years and 12.5 years for LE and DFLE respectively.

2006-09

In general, LE and DFLE increased for males and females at birth in 2006-09 compared with 2002-05. For LE, increases were relatively consistent across areas and there was, therefore, little change in inequality between the least and most deprived areas; 0.2 years for males and 0.3 years for females. DFLE, however, increased unevenly across areas, slightly falling for females in the most deprived neighbourhoods. These changes resulted in more substantial increases in inequality in DFLE between the least and most deprived areas; 1.6 years for males and 2.1 years for females.

The inequality between males and females narrowed slightly for LE between 2002-05 and 2006-09 across all levels of deprivation, consistent with the national trend and as can be seen on the  Interim Life Tables 1980-82 to 2008-10. (41 Kb Excel sheet)   For DFLE however, this narrowing was more pronounced. Previously, in 2002-05, DFLE was significantly lower for males than for females in all but the least deprived areas; however, in 2006-09 this was true only in the most deprived areas.

Interestingly, taking into account change across all levels of deprivation, the SII of LE indicates an equivalent increase of 0.4 years for both males and females between 2002-05 and 2006-09. For DFLE however, the SII fell by 0.7 years for males but increased by 4.1 years for females. This change means that the inequality in DFLE, taking into account all levels of deprivation, was actually greater for females in 2006-09 at 16.6 years compared with 14.7 years for males.

 

Figure 1 Inequality in Life expectancy (LE) and Disability-free life expectancy (DFLE) for males at birth by area deprivation quintile, 2002-05 and 2006-09

England

 Inequality in Life expectancy (LE) and Disability-free life expectancy (DFLE) for males at birth by area deprivation quintile, 2002-05 and 2006-09
Source: Office for National Statistics

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Table 1 Inequality in Life expectancy (LE) and Disability-free life expectancy (DFLE) for males at birth by area deprivation quintile, 2002-05 and 2006-09

England

Years, Percentages
  2002–05 2006–09
LE DFLE Lower 95 per cent CI Upper 95 per cent CI Proportion of life disability free (%) LE DFLE Lower 95 per cent CI Upper 95 per cent CI Proportion of life disability free (%)
1 - Least deprived 80.0 67.3 66.7 68.0 84.2 81.4 69.4 68.7 70.2 85.3
2 78.6 64.3 63.6 64.9 81.7 80.0 66.8 66.0 67.5 83.4
3 77.3 63.4 62.8 64.1 82.0 78.8 64.9 64.0 65.7 82.3
4 75.4 59.7 58.9 60.4 79.2 76.6 61.8 60.9 62.7 80.7
5 - Most deprived 72.2 54.2 53.4 54.9 75.0 73.3 54.6 53.7 55.5 74.4
Range 7.8 13.2 .. .. .. 8.0 14.8 .. .. ..
Ratio 1.1 1.24 .. .. .. 1.1 1.27 .. .. ..
SII 9.4 15.4 .. .. .. 9.8 14.7 .. .. ..
RII* 1.1 1.23 .. .. .. 1.1 1.21 .. .. ..

Table source: Office for National Statistics

Table notes:

  1. * The modified relative index of inequality (RII) represents the ratio of the predicted SII value to the LE or DFLE value of the least deprived areas with 1 added to this value. For the period 2002-05 in the table above, this shows a DFLE value of 1.23; as the value exceeds 1 and the outcome measure is desirable (i.e. more disability-free life years than fewer) this shows a relative 1.23 fold inequality gradient between the least and most disadvantaged areas. When examining the difference in the health gap between discrete time periods, the RII is not sensitive to underlying changes in the prevalence of LLSI and mortality rates and therefore represents a more reliable measure of the health gap.

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Figure 2 Inequality in Life expectancy (LE) and Disability-free life expectancy (DFLE) for females at birth by area deprivation quintile, 2002-05 and 2006-09

England

Inequality in Life expectancy (LE) and Disability-free life expectancy (DFLE) for females at birth by area deprivation quintile, 2002-05 and 2006-09
Source: Office for National Statistics

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Table 2 Inequality in Life expectancy (LE) and Disability-free life expectancy (DFLE) for females at birth by area deprivation quintile, 2002-05 and 2006-09

England

Years, Percentages
  2002–05 2006–09
LE DFLE Lower 95 per cent CI Upper 95 per cent CI Proportion of life disability free (%) LE DFLE Lower 95 per cent CI Upper 95 per cent CI Proportion of life disability free (%)
1 - Least deprived 83.2 67.8 67.1 68.5 81.4 84.5 69.6 68.7 70.4 82.3
2 82.3 65.7 65.0 66.3 79.8 83.4 67.7 66.9 68.5 81.2
3 81.5 64.9 64.2 65.6 79.7 82.6 65.3 64.4 66.2 79.1
4 80.1 61.8 61.0 62.5 77.1 81.1 62.6 61.8 63.5 77.2
5 - Most deprived 77.9 57.2 56.4 58.0 73.4 78.9 56.9 55.9 57.9 72.1
Range 5.3 10.6 .. .. .. 5.6 12.7 .. .. ..
Ratio 1.07 1.19 .. .. .. 1.07 1.22 .. .. ..
SII 6.4 12.5 .. .. .. 6.8 16.6 .. .. ..
RII* 1.08 1.18 .. .. .. 1.08 1.24 .. .. ..

Table source: Office for National Statistics

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Key comparisons: Inequalities at age 65

2002-05

At age 65, men in the least deprived areas in 2002-05 could expect to live for a further 18.3 years, some 3.6 years or around 20 per cent longer than their counterparts in the most deprived areas. For women, LE in the least deprived areas at age 65 was 20.8 years; 2.9 years or around 14 per cent longer than in the most deprived areas.

As at birth, inequality in DFLE at age 65 between the least and most deprived areas was much greater than in LE. For men, DFLE in the least deprived areas was 11.8 years, approximately 4.6 years or 39 per cent longer than in the most deprived areas. For women, DFLE in the least deprived areas was 12.0 years, some 2.9 years or 29 per cent longer than in the most deprived areas. 

The gap between males and females at age 65 showed a similar pattern to figures at birth. The inequality in LE was greater than the inequality in DFLE and differences were greatest in the most deprived areas.

Taking into account deprivation across all levels, the SII in LE for males was 4.3 years and for DFLE was 5.3 years. For females these figures were 3.4 years (LE) and 4.3 years (DFLE). As at birth, these figures reveal a greater scale of inequality across the whole distribution than seen by simply comparing the least and most deprived areas.

2006-09

Inequalities in LE between the least and most deprived neighbourhoods were greater for men and women in 2006-09 than in 2002-05, increasing by around half a year in each case; to 4.1 years in 2006-09 for men, and to 3.4 years for women.

DFLE also increased over time for men in all but the most deprived areas, where it remained essentially unchanged. For women however, DFLE increased in quintiles 1 (least deprived), 2 and 4, but fell in quintiles 3 and 5 (most deprived).

The gap in LE and DFLE between men and women narrowed over time between 2002-05 and 2006-09. The narrowing of LE was relatively small (around 0.1 of a year on average) however the narrowing of the gap in DFLE was more pronounced, (between 0.2 and 1.1 years) removing the significant difference between men and women in this measure in the least deprived areas. 

The SII of LE increased by around 0.4 of a year for both men and women in 2006-09 to 4.7 and 3.8 years respectively. For DFLE the SII remained constant for men at 5.3 years in 2006-09 but increased for women by 1.7 years to 6.0 years. As at birth then, inequality in DFLE, taking into account all levels of deprivation, was greater for women than men in 2006-09.

Figure 3 Inequality in Life expectancy (LE) and Disability-free life expectancy (DFLE) for men at age 65 by area deprivation quintile, 2002-05 and 2006-09

England

 Inequality in Life expectancy (LE) and Disability-free life expectancy (DFLE) for men at age 65 by area deprivation quintile, 2002-05 and 2006-09
Source: Office for National Statistics

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Table 3 Inequality in LE and DFLE for males at age 65 by area deprivation quintile, 2002-05 and 2006-09

England

Years, Percentages
  2002–05 2006–09
LE DFLE Lower 95 per cent CI Upper 95 per cent CI Proportion of life disability free (%) LE DFLE Lower 95 per cent CI Upper 95 per cent CI Proportion of life disability free (%)
1 - Least deprived 18.3 11.8 11.4 12.3 64.6 19.6 12.6 12.2 13.1 64.6
2 17.5 10.3 9.9 10.8 59.2 18.7 11.1 10.6 11.6 59.3
3 16.9 9.9 9.5 10.4 58.6 18.1 10.9 10.4 11.4 60.1
4 15.9 8.6 8.1 9.0 53.9 16.9 9.1 8.5 9.7 53.7
5 - Most deprived 14.7 7.2 6.7 7.7 49.1 15.5 7.2 6.6 7.7 46.3
Range 3.6 4.6 .. .. .. 4.1 5.5 .. .. ..
Ratio 1.25 1.64 .. .. .. 1.26 1.76 .. .. ..
SII 4.3 5.3 .. .. .. 4.7 5.3 .. .. ..
RII* 1.23 1.45 .. .. .. 1.24 1.41 .. .. ..

Table source: Office for National Statistics

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Figure 4 Inequality in Life expectancy (LE) and Disability-free life expectancy (DFLE) for women at age 65 by area deprivation quintile, 2002-05 and 2006-09

England

Inequality in Life expectancy (LE) and Disability-free life expectancy (DFLE) for women at age 65 by area deprivation quintile, 2002-05 and 2006-09
Source: Office for National Statistics

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Table 4 Inequality in Life expectancy (LE) and Disability-free life expectancy (DFLE) for women at age 65 by area deprivation quintile, 2002-05 and 2006-09

England

Years, Percentages
  2002–05 2006–09
LE DFLE Lower 95 per cent CI Upper 95 per cent CI Proportion of life disability free (%) LE DFLE Lower 95 per cent CI Upper 95 per cent CI Proportion of life disability free (%)
1 - Least deprived 20.8 12.0 11.5 12.5 57.7 22.0 12.6 12.0 13.3 57.5
2 20.1 11.5 11.0 12.0 57.1 21.1 12.0 11.4 12.5 56.6
3 19.7 11.1 10.6 11.6 56.4 20.6 11.0 10.4 11.6 53.4
4 18.9 9.5 9.0 10.1 50.3 19.8 9.7 9.0 10.3 48.7
5 - Most deprived 17.9 8.5 8.0 9.0 47.4 18.6 8.2 7.6 8.8 44.2
Range 2.9 3.5 .. .. .. 3.4 4.4 .. .. ..
Ratio 1.16 1.42 .. .. .. 1.18 1.54 .. .. ..
SII 3.4 4.3 .. .. .. 3.8 6.0 .. .. ..
RII* 1.16 1.35 .. .. .. 1.17 1.47 .. .. ..

Table source: Office for National Statistics

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In conclusion, disproportionate improvements in health and longevity in less deprived neighbourhoods appear to be driving the increase in inequalities in LE and DFLE, particularly amongst females. In part this may be influenced through the operation of an ‘inverse care law’ where the benefits of health programmes ‘..accrue to the more advantaged groups who have awareness and knowledge of how to use the system’ and ‘..the reach of public services can be weaker in disadvantaged areas’  (Dept. of Health 2009).  

But why is the gap widening more for females than for males? Significant risk factors to good health and longevity include smoking, drinking and obesity (Marmot 2010). Changes in the incidence and prevalence of these factors may be contributing to the results presented in this bulletin. In recent years there has been a greater decline in patterns of smoking and drinking for men compared to women; although these behaviours remain more prevalent in men (GLF 2011). It is also notable that obesity is more prevalent in women than men in low income households. This suggests the national trend of increasing obesity prevalence (HSE 2009) will be proportionately greater among women in the most deprived areas, and this population will therefore be more likely to experience obesity related health problems now and in the future.

Methods

Calculating Disability-free life expectancy

The data used in calculating the prevalence of self-reported limiting long-standing illness or disability  were obtained from the General Lifestyle Survey (GLF), formerly known as the General Household Survey (GHS). The data were aggregated over two four-year periods (2002–05 and 2006–09) in order to achieve sufficiently large sample sizes to enable meaningful statistical comparison. The prevalence of limiting long-standing illness or disability among males and females resident in private households in England was compared across LSOA quintiles of relative deprivation and over time. DFLE was then calculated using the Sullivan method which combines these prevalence data with mortality and mid-year population estimates (MYPE) over the same periods to calculate estimates of LE and DFLE at birth and at age 65 by sex for each deprivation quintile (Jagger, 1996). MYPEs were adjusted to match the private household population by subtracting numbers resident in communal establishments; however, the mortality data represents the entire population of England.

To obtain the quintiles of relative deprivation, each survey data record was first mapped to an LSOA level geographical boundary using a postcode identifier look-up table. The records were then ranked by the IMD 2007 scores for each LSOA and grouped into fifths for subsequent analyses.

Slope Index of Inequality for DFLE

Slope and Relative indices of inequality (SII and RII respectively) were used to assess the absolute and relative inequality in DFLE between the least and most deprived quintiles. These indicators measure the gap in DFLE by taking into account the inequality across all adjacent quintiles of relative deprivation, rather than focusing only on the extremes.

To calculate the slope and relative index of inequality:

Quintiles were ordered by decreasing area deprivation, that is, from the most to the least deprived. The fraction of the total population in each quintile (f) was calculated. The cumulative frequency (ci), that is the cumulative sum of the population in successively less deprived quintiles, was also obtained and the relative deprivation rank (x) for each quintile was calculated as:

The SII (slope of the regression line) was then estimated by regressing DFLE for each quintile against the relative deprivation rank (x), weighted by the population in each quintile.

The RII was calculated using the method described by Mackenbach and Kunst (1997). First, the predicted value of DFLE (y) for the least deprived areas, taking into account its relative deprivation rank, was estimated using a linear regression model. Then the SII was divided by the predicted DFLE value, (SII / y). The result obtained represents the ratio of the DFLE of the most deprived areas to that of the least deprived. This was then expressed as a rate ratio by adding 1 to it, giving the modified RII:

 

Results on the Office for National Statistics website

The results in this bulletin, including equivalent results for 2001-04 and 2005-08 can be found on the ONS website (54.5 Kb Excel sheet) .

Interpretation of DFLE

DFLE at a given age for an area in a given time period for a specified population, such as England, is an estimate of the average number of years a person would live without a limiting long-standing illness or disability if he/she experienced the specified population’s particular age-specific mortality and health status rates for that time period throughout the rest of his/her life.

The figures reflect mortality and health status of the entire specified population in each time period rather than those born in each area. It is not therefore the number of years that a person will actually expect to live in the various health states, both because the death rates and health status rates of the specified population are likely to change in the future and because some of those in the specified population may live elsewhere for part of their lives.

Health expectancies are indicators of health status that take into account differences in the age structures of populations. Results are comparable by age, sex and between specified populations. 

References

Bajekal M (2005) ‘Healthy life expectancy by area deprivation: magnitude and trends in England, 1994–1999.’ Health Statistics Quarterly 25 pp 18–27.

Department of Health (2009) ‘Tackling Health inequalities: 10 years on. A review of tackling health inequalities in England over the last 10 years’ available on the Dept of Health website.

General Lifestyle survey overview report 2010, (2011) available on the ONS website.

Health Survey for England 2009 Volume 1, Health and Lifestyles (2010) available on the NHS IC website.

Jagger C (1996) ‘Health Expectancy Calculation by the Sullivan Method: A Practical Guide’, NUPRI Research Paper Series No 68, Toyko.

Low A and Low A (2004) ‘Measuring the gap: quantifying and comparing local health inequalities.’ Journal of Public Health 26 pp 388-395.

Marmot M (2010) ‘Fair Society, Healthy Lives; The Marmot Review. Strategic review of Health Inequalities in England post–2010’. The Marmot Review

MacIntyre S, MacIver S and Sooman A (1993) ‘Area, class and health: should we be focusing on places or people?’ Journal of Social Psychology 22 pp 213–234.

Mackenbach JP and Kunst AE (1997) ‘Measuring the magnitude of socio-economic inequalities in health: An overview of available measures illustrated with two examples from Europe.’ Social Science and Medicine 44 pp 757-771.

Olatunde O, White C, Smith MP (2010) ‘Life expectancy and disability–free life expectancy estimates for middle super output areas; England, 1999–2003.’ Health Statistics Quarterly 50 pp 33–65.

Smith MP, Olatunde O and White C (2010a) ‘Monitoring inequalities in health expectancies in England – small area analyses from the Census 2001 and General Household Survey 2001–05’ (145.1 Kb Pdf) Health Statistics Quarterly 46 pp 53–70

Smith MP, Olatunde O and White C (2010b) ‘Inequalities in disability-free life expectancy by area deprivation: England, 2001-04 and 2005-08’ (255.9 Kb Pdf) Health Statistics Quarterly 48 pp 36–57.

White C and Edgar G (2010) ‘Inequalities in healthy life expectancy by social class and area type: England, 2001–03’ (749 Kb Pdf) Health Statistics Quarterly 45 pp 28–56.

Background notes

  1. From 2008, the GLF began to include proxy responses for adults; this subset of the survey population represents less than 10 per cent of the total sample for Great Britain and is included in these analyses.

  2. From 2005, the GHS began to follow a four year rotating panel design in which around three-quarters of the survey panel are re-interviewed in each year. From 2008, when the design became fully established, this ‘re-interviewed sample’ accounted for around three quarters of the total survey population. Potentially confounding effects in the data; issues such as ‘non-response bias’ or attrition of a particular subset of the survey population are corrected for in the survey weighting. As this weighting sufficiently accounts for bias in self-reported limiting long-standing illness (ONS 2009 unpublished data) the complete GLF datasets are used in this study. Further information about the GLF can be found on the ONS website.

  3. The GLF survey data includes respondents from private households only and no adjustment is made here to include residents of communal establishments such as nursing homes. This means that the data is likely to underestimate levels of limiting long-standing illness in the population of England as a whole. Differences in communal establishment populations that may exist across clusters of area deprivation are, therefore, not reflected in this analysis.

  4. A summary quality report for ONS health expectancies (165.5 Kb Pdf) is available on the ONS website. 

    Summary Quality Reports are overview notes which pull together key qualitative information on the various dimensions of statistical quality as well as providing a summary of the methods used to compile the particular output.   

  5. Enquiries relating to these statistics should be made to:
    Disability and Health Measurement team
    Health and Life Events Division
    Office for National Statistics
    Cardiff Road
    Newport
    Wales
    NP10 8XG

    Tel: 01633 455925
    E-mail: hle@ons.gov.uk

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