Commissioning for Equity: Are London’s Stop Smoking Services Equitable?
A review of age, gender, ethnic group and area based deprivation data.
A progress report
Peter J Aspinall Special Adviser, London Health Observatory November 2007
Contents
Introduction 1.
The pan-London review
2.
Why measuring equity of access to stop smoking services is important?
3.
What stops us from assessing equity of access?
4.
Do we know enough about what works?
5.
How we can get around the lack of data
6.
Findings of the north west London pilot
7.
Next steps
Introduction This is a summary of the work in progress on a pan London review into equity of access to stop smoking services in London, carried out by the London Health Observatory (LHO). This work is a part of the LHO’s work programme for 2007/8.
Copies of the summary and the full report are available on the LHO website www.lho.org.uk Report author Peter Aspinall is also happy to receive comments and feedback, which should be sent to
[email protected].
We would also like to thank John Hamm (Public Health, NHS London) and the North West London PCT stop smoking co-ordinators for facilitating the pilot study.
1. The pan-London review Following the LHO pilot study with primary care trusts (PCTs) in the former North West London Strategic Health Authority, the observatory is now carrying out a pan-London review of equity of access to NHS stop smoking services focusing on four equality indicators: •
age
•
gender
•
ethnic group
•
social class/socio-economic position (area-based deprivation).
The review is looking at variations at Local Authority/PCT level, followed by an analysis of person-level data to identify the predictors that influence quitting success and other outcomes.
2. Why measuring equity of access to stop smoking services is important Measuring equity of access to stop smoking services is important because smoking is the single greatest cause of preventable illness and premature death in the UK. To address this, the Government set objectives in the 2004 Public Service Agreement (PSA). The targets are to reduce adult smoking rates to 21% or less by 2010, and to lower prevalence among routine and manual groups to 26% or less.
As implied in the targets, smoking prevalence varies across different segments of the population. While rates are now similar among men and women in the general population, they vary markedly by gender across minority ethnic groups. Bangladeshi and Irish men are more likely to report smoking cigarettes than men in the general population, and Indian men less so. Smoking prevalence is higher among women in the general population than most minority ethnic groups (except Irish and Black Caribbean women). Moreover, while the proportion of cigarette smokers fell in the general population between 1999-2004 (from 27% to 24% for men, and 27% to 23% for women), changes in smoking prevalence across minority ethnic groups showed no consistent pattern. While smoking levels fell in Black Caribbean men from 35% to 25%, in Irish men from 39% to 30% and Irish women from 33% to 26%, no differences were observed in the other minority ethnic groups.
The differences in smoking prevalence, and its reduction in the various population groups, require approaches that address the whole population as well as tailored programmes that target the most disadvantaged communities where smoking prevalence is highest. The National Institute for Health and Clinical Excellence (NICE) has concluded that reducing smoking prevalence among people in routine and manual groups, some minority ethnic groups and disadvantaged communities will help reduce health inequalities more than any other public health measure. A better understanding of equity of access will help with Local Area Agreements (LAAs) planning and health commissioning.
3. What stops us from assessing equity of access? Equity of access is a key objective for all NHS services in the UK. However, equity is not a straightforward concept, and is not the same as inequality. Inequity takes into account the need (i.e. differential smoking rates) that ought to affect use of health care together with the non-need variables (e.g. language need) that do not1.. There is inequality in use when different individuals consume different amounts of care. There is horizontal inequity when use is affected by non-need variables, so that people with the same needs consume different amounts of care. Most of the analysis of equity of access to health care is based on horizontal inequity. At the very least, equity of access to stop smoking services requires information on service users where smoking prevalence is indicated as a measure of need for stop smoking services. Therefore, we have grouped the four equality indicators (age, gender, ethnic group
1
Morris S, Sutton M, Gravelle H. Inequity and inequality in the use of health care in England: an empirical investigation. Social Science & Medicine 2005; 60: 1251-1266.
and social class/socio-economic position) and compatible denominator data (the population at risk).
Difficulties in deciding how to determine the smoking quit rate over which population makes it difficult to assess equity of access to stop smoking services properly. Data is routinely collected on service users by age, gender, and ethnic group. However, the collection of ethnic group data using a 16-category census classification (ONS, 2001 Census) only became mandatory in 2004/5. Earlier data only took into account pan-ethnic groups (White, mixed, Asian, Black, other and not known). The considerable diversity in smoking prevalence in groups such as Asian makes the data of only limited value in investigations of equity of access and use2. Another major drawback with ethnic group data is that data on outcomes successful quitting at four weeks - is reported for age and gender only. The only data for ethnic groups is a measure of intermediate outcome or process: the number of people setting a quit date at four weeks. However from 2007/08 the outcome data is now being collected for ethnic groups but data for this has only started to be returned centrally to the Strategic Health Authority. There is no routine data collection on social class or socio-economic group. Therefore, analysis is dependent on area deprivation measures such as the Indices of Deprivation 2004 (DCLG, 2004). Incorporating need by using community level figures on smoking prevalence is equally problematic, particularly for ethnic groups. There is no reliable data on the variations in smoking prevalence at PCT and local authority level. Estimates derived from The Health Survey for England (DH, 2004) probably offer the best solution. Even when reliable data is found for one or more of the equality indicators, it only provides a starting point to begin exploring why access and outcome rates differ. Some explanations might include:
2
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differences in the motivation to give up smoking
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the inclination to use and sustain use of NHS services
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knowledge of quit-smoking services
An attempt was made to assess equity of access to smoking cessation services across ethnic groups in: Fitzpatrick J, Jacobson B and Aspinall PJ (2005) Indications of Public Health in the English Regions. Vol. 4: Ethnicity and Health, York: APHO pp.31-33. Quit data was used for 2002-3 and 2003-4 and smoking prevalence data from the General Household Survey (2001-3) as denominator. This provided indicative evidence that Asian, black and mixed groups have lower rates than the white group of setting a smoking quit date for both males and females and that females are more likely to set a quit date than males in every ethnic group.
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ease of access, including affordability such as travel costs
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convenience such as the time of day clinics are held
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perceived cultural competency of the services (including the ethnic and gender mix of clients and professionals, language and communication issues etc)
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issues relating to racism and discrimination
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intensity of treatment (use of the stop-smoking aid buproprion, ethnically-tailored interventions etc).
4. Do we know enough about what works? The evidence base on what works to stop smoking in different ethnic groups is poor. The Cochrane Collaboration has provided systematic review evidence on a wide range of types of intervention to stop smoking such as nicotine replacement therapy (NRT) or counselling, but little relates to minority ethnic communities. Where such evidence has been published in the peer-reviewed journal literature, it is based almost exclusively on “ethno-racial” groups in the US. This is a problem because the longer-term historical processes that have influenced and shaped the nature of ethnic relations – and consequently how groups are defined – differ between the two countries.
According to the latest NICE guidance: “Smoking cessation interventions tailored for people from minority ethnic or disadvantaged groups may be slightly more effective than generic interventions aimed at these groups. However, it is not known whether these tailored interventions would make any impression on the social gradient in smoking prevalence.”3
There is little robust evaluation of smoking cessation programmes aimed at minority ethnic groups in the UK. Only three studies have been identified, all of which indicate some degree of success. 4.1 The Turkish Study The first is a community smoking cessation project aimed at the Turkish community in the London boroughs of Camden and Islington. It aimed to highlight the dangers of smoking and to reduce levels of smoking and the number of smokers though a play, poster, purpose-
National Institute for Health and Clinical Excellence (2007) Public health programme draft guidance. Smoking cessation services, including the use of pharmacotherapies, in primary care, pharmacies, local authorities and workplaces, with particular reference to manual working groups, pregnant women who smoke and hard to reach communities. NICE public health programme guidance 2, London: NICE. 3
designed leaflets and media campaigns4. The follow-up found a net reduction in smokers of 6.4% (95% CI 0 to 13.6% in responders, or 2.9% in all study subjects, CI 0 to 6.3%). Most quitters were light smokers to start with. Over half (51%) of the respondents recognised at least one of the Turkish language interventions used. The estimated cost-effectiveness of the campaign was £105 (range £33-£391) per life gained. This led the investigators to suggest that targeted campaigns at groups with high smoking prevalence may be more cost-effective than general population campaigns. However, as Secker-Walker et al.5 point out, the cost per life-year gained without discounting did not take into account potential changes in smoking prevalence in the absence of an intervention. 4.2 The London Ramadan Campaign The second study was an impact evaluation on attitudes, knowledge and behaviour of the London-wide Ramadan Campaign, a programme of tobacco cessation activities aimed at Muslim communities6. Knowledge of where to get help to stop smoking significantly increased from 27% to 58%. Self-reported quit rates were 61% for those with a last attempt to give up since the beginning of Ramadan, and 23% for those with a last attempt to give up before Ramadan. Success was associated with the amount of help received. 4.3 The Bangladeshi Stop Tobacco Project The third programme we looked at is the Bangladeshi Stop Tobacco Project in Tower Hamlets. This study had success rates ranging from 63% to 68%7 for the three years 2003/04 to 2005/06. The figures were based on four week carbon monoxide (CO) validated quit rates. This is well above the national average. However, Bangladeshi women in this project have been less successful in quitting smoking than men, although well represented (female participants, n=415; male participants, n=552; quit success, females 61.9%; males, 68.8%).
5. How can we get around the lack of data? Some estimates of access and outcome for age, gender and deprivation can be produced at a small-area level, but they are likely to be indicative rather than robust. The routinely reported 4
Stevens W, Thorogood M and Kayikki S (2002) Cost-effectiveness of a community anti-smoking campaign targeted at a high risk group in London, Health Promotion International, 17(1), pp.43-50. 5 Secker-Walker RH, Holland RR, Lloyd CM, Pelkey D and Flynn BS (2005) Cost effectiveness of a community based research project to help women quit smoking, Tobacco Control,14, pp.37-42. 6 Taket A, Kotecha M and Belling R (2003) Evaluation of London-wide Ramadan Campaign, London: South Bank University. 7 Begum S (2006) Bangladeshi Stop Tobacco Project, Quarterly Monitoring Reports. London: Tower Hamlets Bangladeshi Stop Tobacco Project, cited in Bell K, McCullough L, Greaves L, Mulryne R, Jategaonkar N, DeVries K and Bauld L (2006) NICE rapid review. The Effectiveness of National Health Service Intensive Treatments for Smoking Cessation in England, London: NICE.
data on ethnic groups is limited to analysis of people who set a quit date for years previous to 2007/08, although four week cessation rates are being reported from this year. We can overcome some of these measurement problems by looking at individual level data. This will make it possible to assess quit success at four weeks across all the equality indicators. There will be some outcome measures such as the proportion of people: •
who successfully quit at four weeks out of those who set a quit date
•
quitting with the help of NRT, buproprion etc.
There is sufficient additional information in the person-level data to undertake modelling on what predicts successful quitting. However, it is likely that estimates of smoking prevalence for ethnic groups will need to be specially derived for the project using pooled data from The Health Survey for England. All this depends on every London PCT being willing and able to share its person-level data with the LHO.
6. Findings of the North West London pilot PCTs in NW London agreed to undertake a pilot with us. This revealed a poor level of ethnic coding on smoking cessation data. Among the PCTs in the former North West London Strategic Health Authority, a fifth of the 50,000 records covering the period 2003/4 to 2005/6 had missing ethnicity data (see table 1). Six PCTs had high rates of missing data (20% to 32%), and two had low rates (4% to 6%). LHO found that data quality deteriorated over the three years in four PCTs, remained stable in three others and improved in only one PCT. Data is currently being assessed across London.
Missing ethnicity data is problematic because there is no means of attributing uncoded cases to the range of ethnic groups. As a result, a substantial number of cases are lost. In the individual level analysis, it is possible to profile the uncoded records in terms of age, gender, and deprivation and assess this profile alongside ethnically-coded records.
In addition to this, in order for a complete evaluation and more detailed population-based study, PCTs have been contacted regarding gaining access to their person-level data. By
analysing this data population groups who are accessing the services can be identified and a particular focus on ethnicity success rates obtained.
Table 1: Completeness of ethnicity coding on returns 2003/4 – 2005/6 Ethnicity % NS Total uncoded Brent
2003-4 2004-5 2005-6 03/4-05/6 Ealing 2003-4 2004-5 2005-6 03/4-05/6 H&F 2003-4 2004-5 2005-6 03/4-05/6 Harrow 2003-4 2004-5 2005-6 03/4-05/6 Hillingdon 2003-4 2004-5 2005-6 03/4-05/6 Hounslow 2003-4 2004-5 2005-6 03/4-05/6 K&C 2003-4 2004-5 2005-6 03/4-05/6 Westminster 2003-4 2004-5 2005-6 03/4-05/6 NWL 03/4-05/6 Note: NS = not stated.
186 345 1060 1591 426 685 818 1929 43 507 977 1527 73 146 170 389 3 18 192 213 216 455 815 1486 170 420 337 927 117 511 1034 1662 9724
1072 2329 4418 7819 1566 2351 2828 6745 366 1901 2545 4812 1438 2179 2578 6195 707 1641 2757 5105 1179 1667 2804 5650 536 1319 1932 3787 599 2179 4204 6982 47095
17.4 14.8 24.0 20.3 27.2 29.1 28.9 28.6 11.7 26.7 38.4 31.7 5.1 6.7 6.6 6.3 0.4 1.1 7.0 4.2 18.3 27.3 29.1 26.3 31.7 31.8 17.4 24.5 19.5 23.5 24.6 23.8 20.6
7. Next steps •
LHO has invited every PCT under Caldicott cover, to share its person level study data with the LHO. So far 27 out of 31 have responded with a willingness to share this
data with only 19 actually providing the data at this time. 5 PCTs have shown difficulties with their databases which could hinder their ability to provide this data. •
LHO is currently analysing the routinely collected data for the whole of London and will analyse the London wide person level data once this has been collected by most if not all PCTs.
•
LHO is taking advice on how to get a better measure of the population denominator.
