We know cancer incidence is linked to socio-economic status, but that this differs according to types of cancer. In the second of three blogs on research using the ONS-LS to explore cancer and social status, Charlotte Sturley has examined diagnoses of bowel cancer, and found some clear evidence of a social effect.

Bowel cancer – also known as colorectal cancer – is the fourth most common cancer in the UK. Over 42,000 people are diagnosed with it in the UK each year so it is a major public health problem. 

Cancer incidence varies between different groups of people, and differences have been found based on gender, age, ethnicity and where people live.   

In England, for most cancer types, incidence is higher in the most deprived areas compared with the least deprived. The deprivation gap is largest for lung cancer, reflecting the fact that more deprived groups are more likely to smoke. Conversely some cancer types, such as breast cancer in females and prostate cancer in males, are more common in the least deprived areas.

The association between colorectal cancer and deprivation is less clear, and findings from previous studies have been inconsistent. In the 1980s, affluence was associated with an increased risk of colon and rectal cancer in Europe. But more recently, evidence has emerged of links between this type of cancer and living in a deprived area.  

Understanding the causes

Given this apparent shift in the relationship between socio-economic deprivation and colorectal cancer, it is important for researchers to monitor recent data to see if the patterns are changing. We also need to understand the extent to which inequalities are associated with both individual and area-level factors to better target their underlying causes.

Most research on inequalities in cancer incidence has focussed on indicators of deprivation at area level, largely because cancer registries do not collect data on indicators of socio-economic position, such as the patient’s level of education or occupation.

Using Census Data to dig deeper

The Office for National Statistics Longitudinal Study (ONS LS) offers the opportunity to investigate variations in cancer incidence using information gathered in the census on individuals’ socioeconomic positions. My study used measures of educational attainment, occupational social class and housing tenure, along with an area-based measure of deprivation called the Townsend deprivation score. 

My sample were LS members who were present at the 2001 Census and were aged 50 years or over, as incidence of colorectal cancer is very low among people aged under 50. 

Among the study sample of 178,116 individuals present at the 2001 census, there were 4,418 cases of colorectal cancer recorded by the end of 2015. Because the ONS LS links census responses to cancer diagnoses, we could measure the average length of time between the 2001 census and the diagnosis.

Results

The study found evidence of socio-economic inequalities in colorectal cancer incidence and that these differences varied by indicator of socio-economic position. LS members with a degree were less likely to have a colorectal cancer diagnoses compared to those without a degree, after accounting for differences by age, sex, ethnicity and area deprivation. A statistically significant association was also observed between housing tenure and colorectal cancer incidence, but only for those in social rented housing, who were at an increased risk of colorectal cancer compared to owner-occupiers.

Those employed in manual occupations were more likely to have a colorectal cancer diagnosis, compared to those in non-manual occupations – however this association was not statistically significant when adjusted for other variables. There was no statistically significant difference in colorectal cancer risk among study members in private rented accommodation compared to those in owner-occupied housing. No significant variation in colorectal cancer incidence was found by the level of area deprivation.

So, we can say individual measures of socio-economic position based on educational attainment and housing tenure are associated with colorectal cancer. My finding that there is not a link with area-level deprivation differs from other recent research which reported an emerging association between this type of cancer and deprivation, measured at the area-level. But these other studies used a different measure of deprivation which means comparisons are more difficult. The longitudinal nature of the LS data and the long-follow up period enabled time-to-event analysis to be employed in my study, whereas previous studies have tended to be more of a snapshot.

Not all individuals living in deprived areas will experience the same level of deprivation, and that could explain why I did not find area effects even though I did find individual ones.

Risk factors

One explanation for an association between colorectal incidence and socio-economic position could be different levels of exposure to risk factors such as poor diet or smoking. There is strong evidence to link socio-economic disadvantage with such behaviours.

My study highlights the complexity of the relationship between socio-economic circumstances and health outcomes and the need to investigate socio-economic inequalities by a range of different indicators in order to implement targeted policy interventions to reduce cancer incidence.

Future work

An interesting next step using the LS would be to investigate if and how change in individual socio-economic position and area deprivation over a person’s lifetime might influence their risk of having a colorectal cancer diagnosis. Linking the LS to data from the bowel cancer screening programme to investigate the impact of screening on colorectal cancer incidence and socioeconomic inequalities would also provide valuable insight.

Further information

Charlotte Sturley, who carried out this study as part of her PhD research, presented the work at the 19^th International Medical Geography Symposium 2022, which is being held at the Royal College of Surgeons of Edinburgh from 19^th-24^th June

Her presentation is available here: (PDF) Contrasting socio-economic influences on colorectal cancer incidence and survival (researchgate.net)

Read the full paper

 

by Fran Abrams

Three pieces of research using the ONS Longitudinal Study were cited in the recent report of the Independent Review of Children’s Social Care. The findings from the Looked After Children Grown Up project played a key part in providing evidence to the review – and were reflected in its report and the Government’s response.

The government’s 2019 Manifesto included a commitment to a review of the care system, and in March 2021 the independent review of children’s social care, led by Josh MacAlister, was given a year to produce a report.

The Looked After Children Grown Up project, which was funded by the Nuffield Foundation and led by Professor Amanda Sacker with colleagues at the UCL Institute of Epidemiology and Health Care and Kings College London, had already begun in February 2018 and was able to provide important evidence to the review.

The adverse consequences of being looked after as a child were already well recognised, but this research project was set up to address a lack of evidence on what happened to looked-after children later in life. Studies tended to follow them into early adulthood and no further, but using census data from the ONS Longitudinal Study the researchers were able to explore outcomes for those who experienced care from the 1970s onwards, up to the age of 50.

The study allowed researchers to track those who were children at the time of each census, and to identify whether they were living in residential care,  as an unrelated member of an individual household, as a biological or adopted child in a parental household or as a child in a relative’s household.

By tracking care-experienced children into mid-life, the project was able to look at their later outcomes from a variety of different angles: it was able, for instance, to look at their likelihood of long-term illness, their employment, their education, their housing tenure, the type of family relationships they had and even whether they were at greater risk of dying early.

A fuller picture

The research, which was shared with Josh MacAlister at an event last July, was also able to drill deeper into the later experiences of children who experienced different types of care: it compared the outcomes of those who experienced residential and foster care with those who remained living with relatives, both parental and other.

Findings from the project were shared in an earlier Linking our Lives blog, and were welcomed by Josh MacAlister at the event last Summer.

In his report he focused on many aspects of the research, both citing it explicitly and reflecting its findings in his narrative.

The review

In particular, he focused on a 2021 report from the study which showed lower rates of long term illness and higher rates of employment for adults with a history of kinship care compared to those that grew up in foster or residential care.

He also highlighted  a second report from the team which showed that care leavers who were in residential care had the highest prevalence of limiting long term illnesses (around 32 per cent on average), followed by adults who lived in foster care (around 16 per cent on average) and adults who lived in kinship care (12 per cent on average). This was significantly higher than the average prevalence of limiting long term illnesses amongst individuals who had not been in care (7 per cent) , he said.

The review report also focused on mortality rates among care leavers from different types of care, and cited a 2020 report which used the ONS Longitudinal Study to link childhood out-of-home care status with all-cause mortality up to 42-years later.

It highlighted findings which showed adults who spent time in care between 1971-2001 were 70 per cent more likely to die prematurely than those who did not, and were also more likely to experience an unnatural death through self-harm, accident, mental or behavioural causes.

The review report made a number of recommendations which chimed with the research findings, including:

• Support for families to cut down referrals and help to keep children in their family homes or with relatives – £2 billion over five years.
• Unlocking wider family support networks including payments for relatives to act as foster carers.
• Support for a ‘new deal’ with foster carers to help larger numbers of children to be cared for in families rather than in residential care – 9000 new carers over three years.

The response

In his response for the Government, the Education Secretary Nadim Zahawi promised more support for family hubs which offer early help and intervention. This would add seven new areas to an existing network of centres in 75 areas that receive a £302 million pot of funding for family hubs. A further 5 areas would receive part of a £12 million investment to deliver on a manifesto commitment to a network of family hubs around the country, he said.

Addressing concerns about the educational outcomes of children who had been in care – the research found those in parental care had a 28 per cent chance of achieving an NVQ level 3 qualification compared with just 11 per cent for those in residential care – Mr Zahawi promised funding for local authorities to help them keep vulnerable children in education.

Funding would be provided to local authorities for continued delivery of the Social Workers in Schools and designated safeguarding lead supervision programmes, which launched in September 2020, he added.

An evidence-based approach

In both the review report and in the Government’s response, there was a strong focus on the need for reforms to be underpinned by evidence.

The review suggested the Office for National Statistics should collect and report data on the mortality rate of care leavers and care leaver health outcomes, and that the Government should also launch a new cohort study which tracks the health outcomes of care experienced people and helps to gather other missing data on housing, education and employment outcomes.

In his response, Mr Zahawi promised support to help the most at-risk families to stay safely together, and a focus on early help, preventing them from reaching crisis point.

As part of this, he said, the government would set up a new National Implementation Board of sector experts and people with experience of leading transformational change and the care system. This would boost efforts to recruit more foster carers, increase support for social workers including on leadership, recruitment and retention, improve data sharing, and implement a new evidence-based framework for all the professionals working in children’s social care.

“Everything we do to raise the outcomes for children and families must be backed by evidence,” he said. “This report will be central in taking forward our ambition to ensure every child has a loving and stable home and we will continue working with experts and people who have experienced care to deliver change on the ground.”

The Looked After Children project involved Professor Amanda Sacker, Dr Emily Murray, Professor Barbara Maughan and Dr Rebeccca Lacey. 

by Fran Abrams

Adults who have reached higher levels of education have parents who live longer – even when comparing families from similar social backgrounds. But is this a consequence of education? A study using Census data sheds new light on the issue.

Those with better education have better health and live longer – this has been known for a long time. A more recent finding is that this extends across generations: those with better education also have healthier parents. And in times of ageing population and stark generational divides, policies with intergenerational benefits are urgently needed. Improving the education of a younger generation at the same time as enabling an older generation to live longer and healthier lives: if this was possible, it would be very attractive for policymakers.  Moreover, framing education as a family resource could help convince older generations that such investments in young generations are beneficial even for them.

There is a big question about this, however: Is it really adult children’s education that improves parental health, or is it just that healthier parents have better-educated children?  Research using the ONS Longitudinal Study addresses this key question.

Two data sets

The researchers used two sets of UK data to examine the question: the 1958 birth cohort called the National Child Development Study (NCDS) and the ONS Longitudinal Study (ONS-LS) based on English and Welsh census data.

First, using the NCDS, a birth cohort data set of all British children born in one week in 1958, they established that in Great Britain, better-educated adult children do have parents who live longer.  The results of this first analysis were striking: Even when comparing parents of similar social class and education, parents whose children stayed in education until age 21 lived two years longer, on average, than the parents of children who left school at age 16.

Other studies have shown similar results: Parents of better-educated children are less likely to suffer depression, for instance, and have fewer disabilities. But few studies have used natural experiments, i.e. constellations that mimic a random assignment of individuals into treatment and control groups in this case, pairs of parents and children, where the children  were born just before or just after the cut-off date at which the school-leaving age was raised.

The ONS Longitudinal Study thus allowed the researchers to answer the crucial question as to whether parental longevity was a consequence of children’s education rather than just a correlate. They used census information from 1971 to analyse the health and longevity of 56,000 mothers and 49,000 fathers whose children were born between 1949 and 1965 and whose children therefore benefited from the educational reform  which raised the mandatory school-leaving age from 15 to 16 years in 1972.  The ONS-LS, which links the census to the civil registration system, the NHS registration systems, and the cancer registries, meaning researchers knew when the parents observed in 1971 died and what their cause of death was.

Six causes of death

Researchers examined six causes of death linked to behaviours: lung cancer, accidents and self-harm, liver disease, ischaemic heart disease, mental and behavioural causes of death, and causes generally deemed preventable. Researchers could thus ask if those parents whose children stayed in education lived heathier lives due to possible changes in health behaviours.

Generally, parents whose children stayed in education longer due to education reform were not found to be healthier than those who didn’t. The study concludes no overall causal link exists between adult children’s education and parental health. This result differed from research in developing countries such as Tanzania, where a causal link had been found.

So why was a link between adult children’s education and parental health not found in England and Wales? Researchers suggest three possible reasons: First, universal health care provided by the NHS might have helped those whose children had fewer years of education. Second, the UK’s strongly class-based society might have benefited those from middle class homes more than educational changes. And third, the focus on the raising of the school-leaving age from 15 to 16 years cannot identify whether going to university, for instance, might have had a more direct effect on ones’ parents’ health behaviour.

Future studies should look at how other factors and educational transitions might affect parents, the researchers say. These might focus on whether having male or female children affects parents’ health, and on whether reforms which enable more young people to go to university might lead to a healthier older generation in those families.

In other words, they conclude, it is too early to dismiss the notion that children’s education can have a direct causal effect on the health and longevity of their parents, yet the evidence for England and Wales so far does not support the notion.

• Does Children’s Education Improve Parental Health and Longevity? Causal Evidence from Great Britain is a working paper by Cecilia Potente, Patrick Präg and Christiaan Monden.

by Fran Abrams

Where you grow up still has a significant effect on your life chances, according to new research using Census data. Evidence from the 1971 to 2011 censuses shows that those who moved out of poorer areas were more likely to move up the social ladder than those who stayed – but, for later cohorts, those from the North or Wales were more likely to thrive  in their own region than in London.

A major study of social mobility confirms that not only who your parents are, but also where you grow up, substantially influences subsequent life chances. But there have been significant changes in recent decades, it says – suggesting that some long-standing assumptions about social mobility chances across the country may need to change.

The government’s ‘levelling up’ agenda is based on the notion that deep divides exist between the North and South of Britain. The study, by researchers at the University of Westminster and the London School of Economics, shows this still holds true.

But within regions there are big variations in social mobility, the study confirms. And while those who leave their birthplace to live and work elsewhere tend to do better as a result, heading for the Capital does not confer the same advantages as it did in the past.

Census data

The study focuses on three cohorts who were aged between eight and 18 in 1971, 1981 and 1991, and who were followed up after 20 years when they were aged between 28 and 38. The data is a particularly rich source, the researchers say, because it enables them to link people’s occupations to those of their parents.  The sample covers a total of almost 170,000 people over a fifty year period and reveals both where they lived as adults and what they and their parents did for a living.

Mobility

In general, upward social mobility in Britain increased between the mid-1950s and the early 1980s. But some regions had higher rates of mobility than others during that time, and the upward trend tailed off for those born later. So while there were small increases in mobility in every region over time, there were persistent and substantial inequalities. 

In all regions of England and Wales, children born to managerial and professional parents were at least two and a half times more likely to end up in those occupational groups than children from working class backgrounds.

For those born between the late 1950s and the early 1980s, there was a clear advantage to starting out in London for upward social mobility. For the first cohort, the West Midlands had the next highest upward mobility followed by the North East, Wales, the North West, and Yorkshire and Humberside.

Stayers and leavers

The study compares those who moved away with those who stayed close to their birthplace and finds that overall, those born outside London and the South East did better if they moved away. 

The study divided those born in the North or Wales into four groups according to where they lived later in life: those who stayed in the same region in the North or Wales, those who moved a new region within the North or Wales, those who moved to a different region outside London and those who moved to London. 

Three quarters of those in the study stayed in their region of origin, while the remaining quarter moved.  And in all regions outside London and the South East, movers had higher rates of upward mobility compared to stayers. 

There were significant changes in these patterns over time, though. Among those who were children in the early 1970s and 1980s, social mobility was highest among those who moved to London. But for those born a decade later a move to the capital was not associated with any greater upward mobility when compared to people who stayed in their region of origin.

The highest level of upward mobility for this latter group was among those who moved to a different region within the North or Wales or who moved to another region outside of London.

Regional effects

Overall, London stands out as the most socially mobile region. But when the figures are broken down to the more fine-grained level of local authority areas, a more nuanced picture emerges: within London, there are areas with both very high and very low levels of social mobility. Indeed, most authorities in London have a border with a district whose social mobility is substantially different. Similarly, for all areas in England and Wales there is substantial variation in social mobility both within as well as between regions.  

What should politicians do?

So what does this mean for the Government’s ‘levelling up’ agenda? The study suggests that while some redistribution of resources from London and the South East to post-industrial areas in Wales, the Midlands and the North is justified, a more fine-tuned approach is needed.

This research shows patterns of social mobility are changing over time, and also that they are greater within regions and cohorts than between them.

And while it confirms that people who move out of their region of origin tend to advance higher up the social ladder, it also highlights the other side of the same coin: those who are born in low-mobility areas but who stay there have lower chances of occupational attainment. 

Incentivising people to move is one approach  – but that will not solve the problem of ‘left-behind’ towns and cities. An alternative solution would be both to improve opportunities for salaried jobs in those areas, and also to improve the working conditions —autonomy, employment rights and security— of those lower down the class structure.

Spatial and social mobility in England and Wales: A sub-national analysis of differences and trends over time is research by Franz Buscha, Emma Gorman and Patrick Sturgis and is published in the British Journal of Sociology.

by Fran Abrams

Across the developed world, populations are ageing and policy makers are wondering how to keep people in work for longer. But at the same time, greater numbers of older people are claiming sickness benefits. So what can the Census tell us about the true picture, and about the types of policy interventions that might help? 

Heated debate has raged for years around the issue of disability and sickness benefits. More people are claiming them – and a key response from the UK Government has been the use of ‘Nudge’ techniques to encourage the reluctant to return to work.

But a range of studies which use data from the ONS Longitudinal Study suggest popular assumptions on the topic may be flawed.

One such study challenges the assumption that the number of people claiming sickness benefits is growing because they are becoming available to people whose conditions are less serious: that claiming has become easier and that those with milder illnesses are doing so.

Bola Akinwale from Public Health England and colleagues from the ESRC International Centre for Lifecourse Studies at University College London compared Census data from 1971 to 2001. 

There had been big changes in the labour market positions of 60-64 year-old men, they found:

• Working – 78.4 percent v 47.5 percent
• Retired – 7.2 percent v 24.7 percent
• Permanently sick – 9 percent v 19.7 percent

The proportion of permanently sick men had doubled in 30 years, but the trend was even more striking among women:  12.4 percent of 55-59 year-old women described themselves as permanently sick in 2001 compared with 3.4 percent in 1971.

And yet in the last 30 years of the 20^th century, life expectancy for those aged 65 increased more than it did in the previous 70 years, and the risk of dying just before State Pension Age decreased substantially – by more than 60 percent for men and by more than 50 percent for women. This increase in life expectancy benefited the permanently sick as much as those in work, with both  living longer than their counterparts 30 years previously.

Are sick people less sick nowadays?

 But the researchers found that statistic did not tell the whole story: yes, people were living longer and healthier lives by the turn of the century. But if the ‘permanently sick’ were in fact less sick than in the previous generation, the gap between their chances of dying prematurely and that of someone in work would have got smaller over the 30-year period. It didn’t.

Permanently sick men aged 65-69 were three times more likely to die prematurely than their working peers in 2001 – an increase on the 1971 figure. For women, the figure was between four and five times higher.

The  life expectancy of the permanently sick increased in line with others’ as medical and social advances were made. But their likelihood of dying when compared to working people if anything, increased slightly.

So, Census data confirms the United Kingdom has an ageing population that contains more people with long-term and life-limiting illnesses. It also gives us a richer picture of who those people are, and where they live.

Dr Emily Murray and colleagues* used census data to look at who lives longest after leaving work, and they found wide disparities in health and life expectancy between different social classes. 

They compared data on people who were aged 50-75 at the time of the 2001 census and who had stopped work by 2011 – the average age of stopping was 58 for women and 60.2 for men. 

The study showed those in professional occupations could expect to live and enjoy good health for longer than those in manual jobs: the average 50 year-old man in a professional job could expect 25 years of good health, while a man in a manual occupation could expect only 18: a seven-year difference. And that explains why lower social class groups are more likely to find themselves on disability benefit.

Among the sample group of 50-75 year-olds from 2001,  14.6 per cent of the women and 25.1 per cent of the men died within 10 years. For both genders, those in lower social classes tended to die younger – professional women lived two years longer than unskilled women, and professional men three years longer than unskilled men.

But despite these longevity gaps, those from lower social groups faced more years between leaving work and being able to draw their state pensions – because they left work earlier.

The researchers estimated that if two women were 65 in 2001, the woman who had worked in an unskilled occupation would live five years longer after leaving work than the professional woman with good health – because the unskilled woman would have left at a younger age. Two men in the same circumstances would live on average 25.0 and 19.5 years from stopping work to death.

Poor health

The most likely explanation, they said, is that poor health has a greater impact on the ability of manual workers to continue working than it does on non-manual workers.

There is a clear message for policymakers: a uniform state pension age disproportionately affects the poorest because they must wait longer between stopping work and qualifying for their state pension, at a time when they are likely to be in poor health: over half of women and two-fifths of men  fall out of the labour market before state pension age.

A two-year earlier pension age may be more appropriate for individuals who work in manual occupations, the researchers say, in order to improve the financial security and health of the most vulnerable in society. Such occupation-specific pensions already exist in some other countries, along with pensions based on duration of employment – people in manual occupations generally start work earlier so they work more years if they retire at same time. The issue was raised in the Cridland review on the state pension age.

A third paper addresses Government responses to these issues, which have tended to focus on behavioural techniques for encouraging older people to stay in work. It asks whether official publications, which have suggested there may be resistance to continuing in work among some groups, are correct in their assumptions.

Census data

Nicola Shelton and colleagues* used census data to look at what happened in 2011 to adults aged between 40 and 49 in 2001 and found significant regional differences: men in the North East were significantly less likely to extend their working lives than others, for instance, while women in all regions apart from London and Wales were significantly more likely to stay in work than those in the North East.

But further analysis showed that for men at least, other social factors could explain these differences. Put bluntly, men in the North East leave work earlier because they tend to have fewer qualifications and less favourable employment status – both of which are associated with shortened working lives.

For women, some additional factors affected the likelihood of staying in work. Those in lower-skilled jobs were less likely still to be in work by 2011, but those working for larger employers, for long hours or away from home were also more likely to have left.

Working conditions

So, what can governments do? Given a good work environment, choosing to remain in work may have positive benefits such as maintaining good health and functioning and providing a sense of purpose- so working conditions are important, the researchers suggest.

The biggest single factor in determining whether workers stay on for longer is prior employment – and that is not likely to be changed by behavioural approaches such as the ‘nudge’ theory of behavioural economics, which is popular with policy makers, they say.

Policies that do not address issues such as low levels of education and high levels of unskilled employment can only be partially successful in enabling people to work for longer. Indeed, some groups who may have the most financial need to remain in work are most likely to leave earlier. This is particularly an issue for women.

Policies that increase skills and education in later life, rather than simply targeting those ‘receptive’ to extended working, will be more likely to make a difference, they conclude.