Criteria for Evaluating Evidence on Public Health Interventions

Drawing on and critically appraising varying levels and sources of data, perform a health needs assessment of a defined population. Select a health need and identify a strategy to address this need. Using the data you have collated, provide a rationale for your strategy that could be used to influence potential funders. This report is about the population of the practice base, Cove and Southwood Ward in Farnborough, Rushmoor District . Rushmoor is a local government district and borough in Hampshire, South East England.

The Health need assessment will profile the ward and compare it with Rushmoor local authority, Hampshire, South East region and England. The report is expected to present an independent overview of one of the key health issues affecting the population identified as alcohol. Profiling will focus on five data sets: Demography, Ethnicity, Socio-economic, Mobidity and Mortality.

Rushmoor Borough Council occupies the north-east part of Hampshire and is part of the commuter belt into London(Figure 1). It covers the towns of Aldershot and Farnborough(Figure2) It is one of thirteen districts in Hampshire( Figure3) used for comparisons in South East Region.

FIGURE 1: A MAP OF HAMPSHIRE WITH RUSHMOOR BOROUGH HIGHLIGHTED (CONTAINS ORDNANCE SURVEY DATA © CROWN COPYRIGHT AND DATABASE RIGHT Figure 2 Rushmoor Borough. (Contains Ordnance Survey data © Crown COPYRIGHT AND DATABASE RIGHT) SOURCE: ORDNANCE SURVEY DATA 2012 Health is defined by WHO (1946) as a state of complete physical, mental and Figure.

3. Map of Hampshire Showing the 13 Districts including Rushmoor 1. GOSPORT 2. FAREHAM 3. WINCHESTER 4. HAVANT 5. EAST HAMPSHIRE 6. HART 7. RUSHMOOR 8. BASINGSTOKE AND DEANE 9. TEST VALLEY 10. EASTLEIGH 11. NEW FOREST 12. SOUTHAMPTON (UNITARY) 13. PORTSMOUTH (UNITARY)

social well-being and not merely the absence of disease or infirmity. Given the dynamic concepts of health and well- being, there is variation in interpretation or perception on individually as it is influenced by life experiences amongst other factors(Donaldson and Scally 2009). Factors that affect health are identified with a particular focus on medicine and inequalities in health( Tones and Green 2010. According to Naidoo and Willis (2010) Health is holistic and encompass the social economic and cultural factors that affect behaviour.

Therefore, improvement of public health involves the promotion of mental, physical, and social well-being as well as the prevention of disease and injury(Cowley 2002). However, Acheson (1998) emphasize that the population in general have a potential to impact positively or negatively on health and well-being. The Mermot report (2010), highlights that inequalities reflect social and economic inequalities in society evident in the individuals environment where they are born, live, grow, work and age and there is a strong association between poverty poor health and health inequalities.

As these disadvantages begin before birth and continues through a lifetime, theoretically, the cycle should be tackled early enough to break the cycle. However this is not always as easy. In a community study, Hog and Henley (2008), reported that there is a potential conflict between the ethos of community development and the aims of the national policy-driven public health agenda whereby health professionals feel they are required to manipulate people in order to focus on policy-driven priorities.

TheHealthylivesHealthypeopledocument(DoH2010)emphasizeonthe integration and innovative ways to empower people and communities to make healthier choices. Notably choice , in so as it exists, in relation to health is largely influenced by a multitude of financial , social, environmental and cultural constraints (Naidoo and Willis 2010).

Hence, poverty and its associated health inequalities have been less readily resolved, a fact highlighted in the Black Report (Black et al, 1980), and reiterated by Acheson (1998) and Wanless (2004). However, some aspects of children’s health are beyond children’s control yet can have a large influence on whether they will survive infancy and may determine the quality of life they enjoy in adulthood such as smoking and drinking during pregnancy, preterm births and low birth weight.

Indeed, it is recognized by the government’s White paper Healthy Lives, Healthy People: our Strategy for Public Health in England (DoH 2010) and Health and Social Care Act 1990(DoH 1990) that public health specialists who are trained in core public health skills play a key role in narrowing the inequality gaps in health needs.

Health visitors are specialist community public health nurses(SCPHN)nurses trained TO WORK AT COMMUNITY, FAMILY AND INDIVIDUAL LEVEL. SCPHN) ARE SEEN AS INSTRUMENTAL IN HELPING TO REDUCE INEQUALITIES IN HEALTH, PROMOTE SOCIAL INCLUSION AND IMPROVE PEOPLE’S LIFESTYLES AND CIRCUMSTANCES

(SCOTTISH EXECUTIVE, 2001, DOH 2001A) The Acheson report (Do H 1998) concluded that the shortcomings of public health were to some degree attributable to the failure of strategic management as the health authorities did not prioritise public health and the responsibilities in this area was not clearly defined. In response, current UK public health policy incorporates strategies to meet targets rather than just addressing specific diseases and significantly focuses on tackling inequalities such as in monitoring child development by SCPHN.

The NHS Operating Framework 2011/12 includes the requirement that Primary Care Trusts(PCT’S) should ensure they develop effective health visiting services, with sufficient capacity to deliver the new service model set out in “Health Visitor Implementation Plan 2011 – 2015 – “A Call to Action”.

The government’s vision for service provision is to link community and public health with individual health. This includes identifying collective health needs, working collaboratively with other agencies to influence policies affecting health (D0H, 2010) and facilitating behaviour changes, which is pertinent given the clear links between ill health and lifestyles such as smoking((Bailey et al 2005)

The National Institute for Clinical Guidelines(NICE 2005) define Health needs assessment as a systematic method of identifying unmet health and health care needs, and making changes to meet these unmet needs. Sykes (2005) definition of health needs assessment includes identification of the actions needed to address the agreed needs and allocation of resources effectively. A health needs assessment can also include the wider determinants of health (Robotham and Frost 2005).

The Dahlgren and Whitehead mode(199l) is widely used to depict these and draws attention to factors which have significant impacts on health, but at first glance, may not be seen to be under the remit of health or the health service(Bailey et al 2005).

The influences of such interactions allow the assessment of need and risk to be comprehensive both at individual and at population level (Whitehead (2010), Laverack( 2007), Scriven and Ewles 2010). Figure4 Dahlgren and Whitehead model The concept of “need” used in this document is based on Bradshow’s taxonomy of need(Naidoo and Willis 2010) whereby, a “need” moves beyond the concept of demand and takes into account people’s capacity to benefit from health care and public health programmes.

This definition incorporates those needs felt and expressed by local people as well as those defined by professionals on global or national level (Figure 5) Figure 5. Bradshow’s taxonomy of need. (Adopted from from Naidoo and Willis 2010) Global Physical Emotional Spiritual Environmental Societal Mental Social Sexual Health needs assessment is a key activity in public health epidemiology (Orme et al, 2005). Public Health is defined as the science and art of preventing disease, prolonging life and promoting health through the organized efforts of society (Naidoo 2010).

Wanless (2004) and (Butt, 2007) definitions adds that informed choice should be incorporated into public health, demonstrating recognition that it should be underpinned by knowledge. Perhaps the most comprehensive definition is that offered by the United Kingdom Public Health Association (UKPHA) (Table 6) which encompasses the themes of health improvement, health protection and health services , but also provides much more specificity and clarity as it highlights that public health is multifaceted and requires a specialist workforce to undertake this role such as the health visitor.

Figure 6 . The New public health approach Responsive – owned by communities and shaped by their needs; Resourced – with ring-fenced funding and incentives to improve; Rigorous – professionally-led and focused on evidence; efficient and effective; and Resilient – strengthening protection against current and future threats to health Demography According to Jones and Douglas (2012), demography provides a framework for studying different aspects of a population.

In profiling ,it is important to be aware of the various levels at which census data is available in order to determine the appropriate level of data presentation. Less common events such as suicides will be better represented at a district level while common events such as school performance allow for better focus on super output area. SOA’s . There can be sharp contrasts within a community and ward level data may not reveal significant issues for a relatively small group of people within a given population. Below is a map of Cove and Southwood Ward(Figure 7 Figure 7 shows Rushmoor’s comparative wards.

Cove and Southwood ward, a SOA is shown on Figure 7 Rushmoor 005 ONS Super-Output Area Highlighting 005B , Southwood Clinic Figure 8 Map of Rushmoor Borough Council showing electoral wards and SOAs . Source: Ordnance Survey data 2012 The population in Southwood community (Middle Layer Super Output Areas) is 8,173 compared to 93, 807 in Rushmoor, 1297000 in Hampshire and South East region, 8634750 region compared to the 53,012456 in England and the total of 63. 2 million in the united Kingdom (UK, Census 2011).

More definitive figures are shown in the local health profile(Appendix 1). Hampshire is the third largest county in England behind Kent and Essex The population has a balance male to female ratio(Figure 10 ). Figure 9. Percentage of people Cove and Southwood Ward, March 2011:

Source office for national statistics 005A Bybroadageband,Rushmoorhasthehighestpropotionof0-15yearsof 19. 3 percent( Figure 11) compared to Hampshire 18. 7 and South East 18. 9 and England 18. 7 while Hart has the highest 20. 3 percent(Figure 12). The likely working group propotion of ages 16-64 years in Rushmoor was 67. 5 percent, highest in comparison to, Hampshire, 62. 8 percent, 63. 9 percent in the South East region and 64. 8 percent in England and some of the other districts in the region(Figure 12).

Hampshire County had a bigger proportion of persons over 65 years, 18. 5%, than the South East region 17. 2%, England 16. 5% and Rushmoor 13. 2% while New Forest has the highest 24. 9%(Figure 12). Ages between 25 and 44years is the highest in Rushmoor 44. 8%(Figure 13), a potentially fertile population followed by Basingstoke 38. 4%(Figure 14). The relatively younger population in Rushmoor is reflected in Figure(15) in comparison to England.

However, fertility in this age group has not been reflected in the population growth(Figure 16). According to the general fertility rate(GFR) statistics, in 2008, Rushmoor had a general fertility rate of 67. 1 live births per 1,000 women aged 15-44, a lower rate compared to 69. 3 in 2006.

The national figure in 2008 was 63. 9 per 1,000 women aged 15-44(Figure 17) ONS 2011). Respectively, Rushmoor births per year is projected to decrease by 7. 7% in the period 2010 to 2031, (Figure 18). Figure 19 shows a growing population of people over 60 years in England and Wales and Rushmoor will not be exceptional. Figure 18 shows a 15. 1%,significant increase in older people which could result in a higher level of healthcare resource utilisation if proactive action is not taken to reduce risk factors for illness such excess alcohol consumption. FIGURE 16. THE FIGURE BELOW SHOWS THE TREND IN THE GFR, IN RUSHMOOR.

FIGURE 17 Figure 18 The percentage of children aged 0 to 5 and adults aged 60 and over, selected Census years England and Wales Thereisasignificantmilitarypresenceinlocalauthority. Rushmooris connected by three railway stations and two motorway junctions shown in the transport network of the borough(Figure 20) with London city other commercial boroughs mainly Reading and Basingstoke.

Rushmoor is one of the most densely districts in Hampshire with an estimated 2356 people occupying 36 hectares in comparison to Hampshire where 352 people occupy 3679 hectres as demonstrated in Figure 21 and 22. Emperical evidence suggests that the amount of industry within the borough and the transport connectivity are contributing factors to population density.

In Rushmoor, 40% of the land is owned by the Ministry of Defence and 17% is occupied by Farnborough Airfield(Ordance survey 2012). Gosport is the only District with a higher population density than Rushmoor in South East region apart from Southampton and Portsmouth which are unitary authorities(Figure 23).. Figure 20. Map of transport network in Rushmoor. Source Ordance Survey 2012. Rushmoor Borough Council has extrapolated population growth to 94,600 a change of 6.1% from the base in 2010. Figure 15 shows change in population 2001-mid 2010.

The forecasting method used 2011 Census as a base differs from the ONS method of calculation because it also takes account of new housing developments. The population of Hampshire is projected to increase to 1,471,200 an increase of 13. 4%from the base in 2010(Figure 24).

While using this data it is important to bear in mind that the UK borders are open to European economic and therefore migration may be unpredictable especially because of the area’s proximity to London. Overall, the population is growing steadily and therefore the health needs will equally be more in a bigger population. Also the young population in Rushmoor poses a high risk of excessive alcohol use as more than 1 in 10 of deaths of people in their 40s are from liver disease, most of them from alcoholic liver disease.

Alcoholic liver disease disproportionately affects younger age groups as it is reported that 90% of people who die from liver disease are under 70 years old and it accounts for well over a third (37%) of liver disease deaths. Health needs services need to be tailored with resources allocation bearing in mind such growth and anticipated demand.

ETHNICITY

The most common ethnicity in this ward is white making it 94. 9 percent of the local population compared with 91. 4% nationally there is only 5. 1 % other ethnicity groups. Other data has been sourced from the Black and Minority Ethnic (BME) composition of Rushmoor CD is comprised for the total population and for the population aged 15 years or under in 2007(Office for National Statistics).

The categories used in census for ethnicity, some small community groups may be overlooked when allocating resources as when percentage is so small that they are classified under an umbrella ethnicity such as the Nepalese who are categorised as Asians in the local profiling . Below are categories used to identify ethnic groups. Figure( 26) Figure 27 : Black and Minority Ethnic (BME) composition of Rushmoor CD.

Total population and for the population aged 15 years or under in 2007(Source: Office for National Statistic) Source: Office for National Statistics (ONS) Source: Office for National Statistics (ONS) In 2008 there was an estimated 6000 Nepali residents in Rushmoo(Casey 2010). Despite the significant size of this community little was known about its specific health needs. 7% (35) of notified cases of TB in Hampshire from 2006-2009 were in Nepali individuals. The majority of those cases (82% or 29 cases) in Nepali individuals were in Rushmoor.

Appendix 2 shows health inequalities in ethnicity, shows the increased number of hospital emergencies by ethnic groups. This may reflect poor access or receiving care most suited to managing their health conditions. The health profile for Grange and Mayfield ward in Cherrywood ,where the Nepali community is highly concentrated(Casey 2010) demonstrates further the inequalities as it is siginficantly worse than England average in education , child development, substance misuse and self harm(Appendix 3).

Neighbourhood Renewal Strategy(2009-2014) which highlights significant pockets of multiple deprivation in the wards, evidencing a need for targeted intervention listed in Figure 26. . Itisclearthateveninoneareaatoneparticulartime,thefrequencyof disease can be highly variable as demonstrated in a case study of the Figure 26. Identified needs in Joint Strategic Planning The wider determinants of health: The main issues identified were: 1 A public perception that the community carry knives Racism and bullying in the Rushmoor community Cultural and language barriers (particularly in elderly and women).

Different educational system here compared with Nepal. Lack of understanding of the British justice system and fear of police Drug use in young Nepali males (heroin) Limited knowledge on how to access public services like the fire service Deprivation and overcrowding in housing Domestic violence being a taboo subject in the Nepali community Difficulty in gaining employment if in possession of poor English language skills Reluctance of Nepali to access benefits and administrative barriers when they do so.

Although alcohol is not an identified in the Nepali community, death from liver disease is often associated with stigma. Many but by no means all of the people dying from liver disease come from deprived socioeconomic backgrounds. Those dying of alcoholic liver disease may have mental health problems and/or drug dependence problems which complicate their social circumstances such that they have little family or social support. This area is occupied by ethnic minority group- Nepalese.

A case profile for Grange and Mayfield ward, showed deprivation in housing, employment and older people, skills and training, living environment, child poverty, .child development at under five was worse than England average and in education GCSE rates are reported to be worse than England average and crime is higher than in the borough. (Joint local Strategic Needs Assessment 2011).

Although this was better than the Local authority health profiling in that it had identified a particular population, the population in Grange and Mayfield wards is of mixed ethnicity mainly the Nepalese population. The statistics in local profile do not give the reasons for deprivation but a case study carried out on the Nepalese community had detailed needs. (Casey 2010)as summarised below figure 32. Some of the information is significant in the fact that epidemiological observations may also guide decisions about individuals, but they relate primarily to groups of people.

This fundamental difference in the purpose of measurements implies different demands on the quality of data. On the other hand, target population with this design, the statistical inference from the study sample to the study population is free from systematic sampling error( ), but further extrapolation to the target population remains a matter of judgement.

Wright et al 1998 suggest that a distinction between individual needs such as disability, and the wider needs of the community should be taken into consideration when local health services are being planned. social support.

MORBIDITY AND MORTALITY Life expectancy in the Cove and Southwood ward at birth is significantly better than in Rushmoor, Hampshire and England but similar to the South East Region in general. Life expectancy in the ward is 82. 5 years in males and 89. 7years females(Health Profile, PHO 2006-2010), compared to 79. 6yrs male and 84. 4yrs female in Rushmoor(Appendix 1).

Population in the ward are more likely to live longer than the 79.8years male, 83. 6years female in the Hampshire, 80. 5years, males and 84. years females in South East region as compared to the national average in England of 78. 6yrs male and 82. 6yrs female. In all heath data, women live longer than men. The average life expectancy is shown below in Figure 22 and 23… Trend 3 shows that there is an increasing early death rates from cancer. The data from national statistics is a three year average with the latest estimate used 2008-2010, about two years old and differs from PHO profiling 2006-2010.

Therefore, data should be used with caution to indicate current trends. Also data for number of deaths is obtained from the death register and although it is possible to learn about the individuals sex ,age ,residence and occupation. The social and physical characteristics are not detailed and they are important in aetiological enquiries, or when morbidity or the natural history of disease needs to be assessed . Barker et a(1998) suggests that a survey may be undertaken in small communities on many aspects of disease.

Also diseases like diabetes which is a long life illness may not be indicated as cause of death as the individual may die of diabetes complications such as renal failure or heart failure. Aging is associated with commobidities( and the significant increase in the numbers of older people could result in a higher level of healthcare resource utilisation if proactive action is not taken to reduce risk factors for illness such renal failure and liver cancer caused by excessive alcohol intake. However, the younger population may require health promotion services due to risky behaviour such as sexual health, and smoking cessation.

A qualitative study by Stead et al(1999) reported that poorly resourced and stressful environment, strong community norms isolation from wider society al and limited opportunities for respite and recreation appear to combine not only to foster smoking but also to discourage or undermine cessation. … . The figure below shows the trend in infant mortality in Rushmoor CD. Infant mortality rate in Rushmoor is 2. 9% compared to 3. 2% in Hampshire and 4. 6 %in England .

The age of the mother is also a risk factor for infant mortality. It is reported that infant mortality rates in babies born to mothers aged under 20 years are higher than in other age-groups (7. 1 per 1,000 live births in 2007), the lowest rate being found in mothers aged between 30-34 years (3. 8 per 1,000 live births in 2007), and rising again in mothers of 40 years or over (5. 1 per 1,000 live births in 2007).

This pattern has been seen over the last 25 years, although rates in all age-groups have been falling. Perinatal and infant mortality rates are used for comparisons of the quality of health care(Blair et al 2003) Standardised mortality rates are used to measure are used to compare local information ontotal mortality or mortality from specific causes(Barker et al 1998). Sudden infant death syndrome is associated with excessive use of alcohol( ).

Any birth deffects due due alcohol intake in pregnancy in Rushmoor is ch couldhave implications for children’s services and their capacity to continue todeliver public health interventions The main cause of mortality and premature death in Cove and Southwood is all cancers for population aged over 75 years (Appendix 2 ) 87. 6 percent compared to 91 percent in Rushmoor , 97 percent in Hampshire and 100 percent in England. Mortality and cause of disease of all ages is associated with circulatory diseases, coronary heart disease, stroke and respiratory diseases(Appendix 8).

World Health Organisation (2004)recognised these diseases as the leading causes of death world wide and conclude that lifestyle factors are the main contributing causes of death. the Health Summary shows that Rushmoor has a larger then England average rate for violent crime, self harm, substance misuse, alcohol misuse and obesity. In Rushmoor, a higher population of adults are obese 25. 4%, in comparison to 23. 7% in Hampshire and 24. 2%, 22. 7 South Central region and 24. 2% in England(Appendix 23).

Children in Hampshire have better than average levels of obesity. 8. 4% of children aged 4-5 years and 14. 5% of children aged 10-11 years are classified as obese. 62. 6% of children participate in at least three hours of sport a week which is better than the England average (Appendix 23). There is an increased risk of disease development and premature death in obese population including cancer of the stomach(Baggott, 2011). Obesitity is a global health concern (WHO 2012).

Morbidity data is not as readily available as mortality data available in death registers. The statistics are based on hospital inpatient statisitcs and their primary purpose is to inform hospital services and assisst in planning.

Barker et al(1998) suggests that community records such as in general practitioner(GP) have the merrit of diagnostic accuracy but are grossly unrepresentative. Rushmoor health profile summary 2012(Appendix 21) Trend 2, clearly demonstrates the reduced mortality rates in heart disease and stroke numbers overtime while Trend 1 demonstrates reduction in all age and all causes of mortality. Trend 3, shows the increasing death rates from cancer in Rushmoor.

Occupation in mortality data is not recorded on death certificates of men and women over the age of 75 years and is recorded for married women only if the woman been in paid work for the majority of her life. The alternative measures of social classification such as housing tenure are important as they describe socioeconomic differences in mortality in older people. One of the most pronounced differences in socioeconomic groups are for among others stroke and coronary heart disease and both are associated, excessive alcohol intake( )and in such cases the main cause of death may not be registred as alcohol.

The national registration of deaths and causes of death provide comprehensive mortality information which is not always accurate(Wright et al 1998),. Road injuries and deaths is better in Rushmoor than Hampshire and England average but the rate of violent crimes is higher than England average. According to the 2011/12 Crime Survey for England and Wales (CSEW), victims believed the offender(s) to be under the influence of alcohol in around half (47%) of all violent incidents, or 917,000 offences(Flatley et al. , 2010).

Crime is an important determinant of public health outcomes, including quality of life, mental well-being, and health behavior(Daisuke et 2012). Drug misuse in Rushmoor is worse than Hampshire and England average. Hospital stay for self harm local number per year is 310 worse than 241. 6 in Hampshire and 212, England average. Teenage pregnancy is 29. 5% which is slightly better than England average of 38. 1% and almost the same as Hampshire of 29. 4%.

The rates of statutory homelessness and long term un-employment are lower than England’s average in the Cove and Southwood Ward. Appendix There is a high number of adult smokers in Rushmoor, 20. 1% compared to 20. 7% in England and 17. 2% in Hampshire. Rushmoor is significantly worse than the average in South Central region and similarly Gosport, Portsmouth and Southampton (Appendix 22…). Smoking is one of the major causes of cancer in England(….. )

A high number of smoking related deaths is reported in Rushmoor 225, in comparison to 168 deaths in Hampshire and 211 deaths in England. Hospitalstaysforlocalauthoritypopulationalcoholrelatedharmis2252, worse than 1895 England’s average. In 2010, ? 42. 1 billion was spent on alcohol in England and Wales alone.

Excessive alcohol intake is associated with risky behaviour such as substance misuse, self harm, drink driving and hence road traffic accidents, alcohol liver disease, renal failure , crime and coronary heart disease(Sundquist et al 2006). In 2001 and 2009 In the UK, There has been a 25% increase in liver disease between in the UK. Alcohol-related liver disease accounts for over a third (37%) of all liver disease deaths.

People dying from liver disease often have complex end of life care needs and over 70% die in hospital. The predicted cost to the NHS of managing this could be around ? 1billion per year by 2015(NHS National End of Life Care 2012). It is also reported by the North West Public Health Observatory that, the rate of admission in 2011/12 in England was 1,974 per 100,000 population, up 4% on 2010/11.

In total, the number of admissions for the same period was 1. 2 million; an increase of 4% compared with 2010/11. The admission rate was reportedly highest in the North East (2,712) and North West (2,413); and lowest in South East Coast SHA (1,614) and South Central SHA (1,475). There are three times as many deaths from alcoholic liver disease in the most deprived areas as in the least deprived. (Acheson 1998) ?? Liver disease causes approximately 2% of all deaths. ?? The number of people who die from liver disease in England is rising (from 9,231 in 2001 to 11,575 in 2009). ??

More men than women die from liver disease (60% are men, 40% women). ?? Liver disease disproportionately affects younger age groups: ?? 90% of people who die from liver disease are under 70 years old ?? more than 1 in 10 of deaths of people in their 40s are from liver disease, most of them from alcoholic liver disease. ?? Alcoholic liver disease accounts for well over a third (37%) of liver disease deaths. ?? There are three times as many deaths from alcoholic liver disease in the most deprived areas as in the least deprived. ??

People dying from liver disease often have complex end of life care needs and over 70% die in hospital Socio economics Classification by occupation identifies a group with special risk for most major disorders, such as groups working with industrial chemicals may have unforseable risks such as respiratory diseases and mortality statistics may identify occupational risks(Barker et al 1998) Orme et al(2007) urgues that although the health of the poor has improved over time, it has not improved as fast as the rest of the population and therefore the health inequality gap has widened.

Some of the indicators for this gap are education, housing employment and job seekers allowance and household composition. In 2010 Index of multiple deprivation( Appendix 10 ), unemployment in cove and southwood was 2 percent, equivalent to Hampshire and comparatively lower than 2. 5 percent in Rushmoor and 3. 6 percent in England. Appendix 15 shows the differences in indeprivation levels in Rushmoor highlighting the most deprived areas locally and in England.

In Grange and Mayfield Ward unemployment is higher, 3. 6%(Appendix 12). Income deprivation is 7. 4% in Cove and Southwood in comparison to 8. 6% in Rushmoor , 8. 2% in Hampshire and 14. 7% in England(appendix 12). In South Central, region Harvant and Southampton are the most deprived and significantly worse than England average (appendix 13). However, in regional variation south East 5. 9 % significantly better than England average 0f 19. 9% Some of the worst regions are London 28. 5%, North East 33. 7% and Northwest 31. 8% West Midlands 27. 4%.

The profile for Rushmoor show that deprivation is lower than the national average. However, 2,600 children live in poverty(Appendix. Mayfield and Grange ward in Rushmoor, 24. 6% children are living in poverty compared to 13. 2% in Rushmoor and 12. 1% in England above the 21. 8% in England.

This is a small population which has small pockets of families living in poverty and could be missed out especially when data is generalised in a large population( NICE 2005 ). Higher levels of consumption has been consistently observed in deprived groups such as unempolyed,and the homeless(Forcier 1998, Hammrstroem 1994). Binge drinking is significantly worse than England average in the most deprived regions such as North East(Appendix 12). However, Winchester in South East is one of the most afluent areas but binge drinking is worse than South Central average. (Appendix 12) In2011census,economicactivityinCoveandSouthwood.

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