Underprivileged areas and health care planning: implications of use of Jarman indicators of urban deprivation.

OBJECTIVE--To analyse critically the use of the Jarman underprivileged area index in health care planning and distribution of resources. DESIGN--The original derivation of the score was examined and evidence to support criticisms of the use of underprivileged area scores examined. MAIN OUTCOME MEASURES--Discrepancies between areas classified as deprived according to the index and areas known to require government funding; the extent of the bias towards family practitioner areas in London; and how the results of using the Jarman index compared with those when another deprivation index based on different indicators was used. RESULTS--The use of electroal wards as geographical areas for which deprivation payments are made is unsatisfactory as the wards vary considerably in size. Of the 20 district health authorities with the highest underprivileged area scores in England, 12 were in London, and four of the six family practitioner committee areas with the highest scores were in London. No health authority or family practitioner committee area in the Northern region had one of the top 20 or 10 scores respectively. When an alternative deprivation index was used to determine the allocation of resources to doctors there was considerable variation compared with the Jarman index. CONCLUSION--The Jarman index underprivileged area score is an inappropriate measure to use for health care planning and distribution of resources. There is a need for a revised measure for allocating deprivation payments to general practitioners.     

Water fluoridation,tooth decay in 5 year olds,and social deprivation measured by the Jarman score: analysis of data from British dental surveys.

OBJECTIVE: To examine the effect of water fluoridation, both artificial and natural, on dental decay, after socioeconomic deprivation was controlled for. DESIGN: Ecological study based on results from the NHS dental surveys in 5 year olds in 1991-2 and 1993-4 and Jarman underprivileged area scores from the 1991 census. SETTING: Electoral wards in three areas: Hartlepool (naturally fluoridated), Newcastle and North Tyneside (fluoridated), and Salford and Trafford (non-fluoridated). SUBJECTS: 5 year old children (n = 10,004). INTERVENTION: Water fluoridation (artificial and occurring naturally). MAIN OUTCOME MEASURE: Ward tooth decay score (score on the "decayed, missing, and filled tooth index" for each electoral ward). RESULTS: Multiple linear regression showed a significant interaction between Jarman score for ward, mean number of teeth affected by decay, and both types of water fluoridation. This confirms that the more deprived an area, the greater benefit derived from fluoridation, whether natural or artificial (R2 = 0.84, P < 0.001). At a Jarman score of zero (national mean score) there was a predicted 44% reduction in decay in fluoridated areas, increasing to a 54% reduction in wards with a Jarman score of 40 (very deprived). The area with natural fluoridation (at a level of 1.2 parts per million-higher than levels in artificially fluoridated areas) had a 66% reduction in decay, with a 74% reduction in wards with a Jarman score of 40. CONCLUSION: Tooth decay is confirmed as a disease associated with social deprivation, and the more socially deprived areas benefit more from fluoridation. Widespread water fluoridation is urgently needed to reduce the "dental health divide" by improving the dental health of the poorer people in Britain.     

Designing a deprivation payment for general practitioners: the UPA(8) wonderland.

OBJECTIVE--To analyse critically the deprived area payment introduced in the new general practitioner contract. The payment formula is based on the Jarman underprivileged area index (UPA(8)) and aims at compensating general practitioners for increases in workload. DESIGN--Evaluation of the deprived area payment against the stated policy objective with a set of criteria for developing resource allocation formulas. MAIN OUTCOME MEASURES--The degree to which the components of the Jarman index predict the workload of general practitioners; whether construction of the index is sensible and comprehensible; and how the formula incorporates the index and is likely to work in practice. RESULTS--The fact that the index relies on census data and the way the weighting was derived means that the formula will not accurately reflect the workload. The use of statistical transformations obscures the original policy intent. There has been no validation to support the application of the index as part of a national policy. The payments are not linked to the quality of service provided and may have the perverse effect of increasing list size. CONCLUSION--The formula used as the basis of the deprived area payments is poorly suited to the policy objective of compensating general practitioners for increases in workload. More research is urgently needed to enable the effect of the payment to be monitored and a more empirically sound set of incentives to be developed.     

Socio-economic disparities in the burden of seasonal influenza: the effect of social and material deprivation on rates of influenza infection

Background

There is little empirical evidence in support of a relationship between rates of influenza infection and level of material deprivation (i.e., lack of access to goods and services) and social deprivation (i.e. lack of social cohesion and support).

Method

Using validated population-level indices of material and social deprivation and medical billing claims for outpatient clinic and emergency department visits for influenza from 1996 to 2006, we assessed the relationship between neighbourhood rates of influenza and neighbourhood levels of deprivation using Bayesian ecological regression models. Then, by pooling data from neighbourhoods in the top decile (i.e., most deprived) and the bottom decile, we compared rates in the most deprived populations to the least deprived populations using age- and sex-standardized rate ratios.

Results

Deprivation scores ranged from one to five with five representing the highest level of deprivation. We found a 21% reduction in rates for every 1 unit increase in social deprivation score (rate ratio [RR] 0.79, 95% Credible Interval [CrI] 0.66, 0.97). There was little evidence of a meaningful linear relationship with material deprivation (RR 1.06, 95% CrI 0.93, 1.24). However, relative to neighbourhoods with deprivation scores in the bottom decile, those in the top decile (i.e., most materially deprived) had substantially higher rates (RR 2.02, 95% Confidence Interval 1.99, 2.05).

Conclusion

Though it is hypothesized that social and material deprivation increase risk of acute respiratory infection, we found decreasing healthcare utilization rates for influenza with increasing social deprivation. This finding may be explained by the fewer social contacts and, thus, fewer influenza exposure opportunities of the socially deprived. Though there was no evidence of a linear relationship with material deprivation, when comparing the least to the most materially deprived populations, we observed higher rates in the most materially deprived populations.     

Deprivation and general practitioner workload.

OBJECTIVES--To examine general practitioner consultations by demographic and socioeconomic variables and to derive a method of measuring the impact of relative deprivation on general practitioner workload. DESIGN--The study was based on general practitioner consultations reported in the general household surveys of 1983-7, covering a sample of 129,987 individuals in Great Britain. Odds ratios for general practitioner consultations were obtained for selected variables among children (0-15 years), men (16-64), women (16-64), and elderly people (greater than or equal to 65). These were then used to derive deprivation indices specific to electoral wards for use in general practice. SETTING--Great Britain, with particular findings illustrated by English electoral wards and the conurbations of London, Manchester, Merseyside, and the West Midlands. RESULTS--Council tenure increased the likelihood of consultation significantly in all four groups. Odds ratios were raised in children, men, and women with no access to a car. Birth in the New Commonwealth or Pakistan yielded high odds ratios in men, women, and elderly people but not in children. Marginally increased consultation rates were evident in the manual socioeconomic groups in women, elderly people, and children with a single parent mother. The deprivation indices for general practice derived using these odds ratios varied substantially among English electoral wards with, for example, anticipated general practitioner consultations in the electoral ward of Hulme, Manchester, being 24% higher than the average ward in England as a result of local attributes, and consultations in the Cheam South ward of Sutton, London, 11% lower than average. CONCLUSION--This deprivation index for general practice overcomes several shortcomings expressed about the underprivileged area score, which has been adopted in the 1990 contract as a basis for allocating deprivation supplements to general practitioners. The proposed index can be applied nationwide.     

Where Are Socioeconomically Deprived Immigrants Located in Chile? A Spatial Analysis of Census Data Using an Index of Multiple Deprivation from the Last Three Decades (1992-2012)

Introduction and Purpose of the Study

Immigrants in Chile have diverse characteristics and include socioeconomically deprived populations. The location of socioeconomically deprived immigrants is important for the development of public policy intelligence at the local and national levels but their areas of residence have not been mapped in Chile. This study explored the spatial distribution of socioeconomic deprivation among immigrants in Chile, 1992–2012, and compared it to the total population.

Material and Methods

Areas with socioeconomically deprived populations were identified with a deprivation index which we developed modelled upon the Index of Multiple Deprivation (IMD) for England. Our IMD was based upon the indicators of unemployment, low educational level (primary) and disability from Census data at county level for the three decades 1992, 2002 and 2012, for 332, 339 and 343 counties respectively. We developed two versions of the IMD one based on disadvantage among the total population and another focused upon the circumstances of immigrants only. We generated a spatial representation of the IMD using GIS, for the overall IMD score and for each dimension of the index, separately. We also compared the immigrants´ IMD to the total population´s IMD using Pearson´s correlation test.

Results

Results showed that socioeconomically deprived immigrants tended to be concentrated in counties in the northern and central area of Chile, in particular within the Metropolitan Region of Santiago. These were the same counties where there was the greatest concentration of socioeconomic deprivation for the total population during the same time periods. Since 1992 there have been significant change in the location of the socioeconomically deprived populations within the Metropolitan Region of Santiago with the highest IMD scores for both the total population and immigrants becoming increasingly concentrated in the central and eastern counties of the Region.

Conclusion

This is the first study analysing the spatial distribution of socioeconomic deprivation among international immigrants and the total population in a Latin American country. Findings could inform policy makers about location of areas of higher need of social protection in Chile, for both immigrants and the total resident population in the country.     

Out-of-hours visits in a group practice.

In one year 1644 out-of-hours calls were undertaken by a partnership of eight doctors working in a deprived inner urban area and a deprived large council housing estate; of these calls 332 were performed between the hours of 11 pm and 7 am. The number of calls required in the housing estate, 1077, was about twice as many as in the inner urban area, although the same doctors were using the same criteria for a visit. The rate of visits of 107 per 1000 patients in the housing estate was much higher than in other published series. The reasons for this difference appeared to be related to the comparative youth of parents and the number of young children.     

Recovery from monocular deprivation in the monkey. III. Reversal of anatomical effects in the visual cortex

Transneuronal autoradiography was used to study the effects of visual deprivation on the ocular dominance stripes in layer IVc of the striated cortex of Erythrocebus patas (Old World) monkeys. The animals were studied after: (a) 21-28 days of monocular deprivation starting at, or within, a few days of birth; (b) the same treatment followed by a further 3, 6, 15 or 126 days of monocular vision through both eyes (reopening). One other monkey was monocularly deprived from birth to 1890 days. In most cases the behaviour of the ocular dominance stripes formed by the initially closed eye was studied. After 24 days of monocular deprivation from birth, the input from the normal eye was distributed uniformly within layer IVc, with no periodicity evident. After 21 days of deprivation, the deprived eye's input formed narrow stripes occupying about 38% of layer IVc in the operculum. Seven months of monocular deprivation reduced this to about 29%. Opening the closed eye after the deprivation produced no change in the area innervated: when periods of 15 or 96 days of binocular vision followed the deprivation, the areas innervated by the initially deprived eye were 26 and 30% respectively. However, in both cases the deprived eye's input formed blobs and spots, rather than uniformly narrow stripes. In contrast to reopening, reverse suturing increased the fraction of layer IVc occupied by input form the initially deprived eye. In the operculum, the effects of reverse suturing appeared to be fully developed after only 6 days of reversal: the initially deprived eye's stripes having expanded to occupy about 50% of layer IVc. A further 9 days' reversal produced little change in this. In the visual cortex in the calcarine fissure, the effect of the initial deprivation ws more severe, and the expansion induced by reverse suturing more pronounced. The initial deprivation caused the stripes to shrink to occupy 24% of layer IVc; after 6 days of reverse sulture the proportion increased to 52%, while after 15 days of reverse suture about 88% of IVc was occupied. These results show that reverse suturing can cause fresh growth of afferent axons in regions of layer IVc from which they had been at least partially removed, either by the normal process of segregation, or as a consequence of monocular deprivation. Taken in conjuction with the findings of the accompanying two papers (Blackemore et al...     

Unemployment rate as predictor of rate of psychiatric admission.

OBJECTIVE--To examine the relation between rates of psychiatric admissions and both the rate of unemployment and the underprivileged area score within small areas. DESIGN--Calculation of correlation coefficients and explanatory power by using data on psychiatric admissions from April 1990 to March 1992. Crude and age standardised rates were used based on all admissions and also on the number of people admitted regardless of the number of times each person was admitted. SETTING--Sectors with an average population of 45,000 consisting of aggregations of neighbouring wards in Bristol and District Health Authority and electoral wards with an average population of 9400 in the city of Bristol. RESULTS--Unemployment rates explained 93% of the variation in the crude person based admission rates standardised for age for those aged under 65 in the sectors. Person based rates correlated more strongly with unemployment than did rates based on all separate admissions. Inclusion of people aged 65 and over weakened the relation. Within electoral wards unemployment rates explained only about 50-60% of the variation but were still more powerful than the underprivileged area score. There was a significant negative correlation between average length of stay and readmission rates--that is, sectors with short lengths of stay were more likely to have patients readmitted (r = -0.64, 95% confidence interval -0.25 to -0.85). CONCLUSIONS--Unemployment rates are an extremely powerful indicator of the rates of serious mental illness that will need treatment in hospital in those aged under 65. This should be considered in the process of resource allocation, particularly to fundholders in general practice, or people with serious mental illness living in areas of high unemployment could be considerably disadvantaged.     

Re‐Feeding Food‐Deprived Male Meadow Voles Affects the Sperm Allocation of Their Rival Males

An individual's nutritional status affects the manner in which same‐ and opposite‐sex conspecifics respond to that individual, which may affect their fitness. Male meadow voles, Microtus pennsylvanicus, increase their sperm allocation if they encounter the scent mark of an unfamiliar male that is not nutritionally challenged. If, however, the scent mark comes from a male that has been food deprived for 24 h, stud male voles do not increase their sperm allocation. Food‐deprived males may be viewed as being lower quality and a reduced risk of sperm competition by rival males. We hypothesized that stud males in promiscuous mating systems tailor their sperm allocations depending on whether rival males have been food deprived and then re‐fed. We predicted that newly re‐fed males will be considered a strong risk of sperm competition because of the potentially high fitness and survival costs associated with food deprivation in males, and that they will cause stud males to increase their sperm allocation. Our results, however, showed that the recovery period from 24 h of food deprivation was a relatively slow process. It took between 96 and 336 h of re‐feeding male scent donors that were food deprived for 24 h to induce stud males to increase their sperm allocation to levels comparable to when scent donors were not food deprived. Stud male voles may be conserving the amount of sperm allocated until the male scent donors have recovered from food deprivation and subsequent re‐feeding.     

Family doctors and innovation in general practice

Family doctors have been presented with changes in government policies and incentives in a recent white paper on primary care. Little work has been done, however, to find out how general practitioners respond to such measures. The response of general practitioners to professional and economic incentives was examined in relation to the location of the practice and the characteristics of the practitioners in seven different areas of England. The areas represented urban, rural, affluent, and deprived communities. The overall response rate was 74%, but the response varied among the areas, being poorest (64%) in an inner city area. Practices were subdivided as innovative, traditional, or intermediate, according to whether they employed a nurse and participated in the cost rent scheme and the vocational training scheme. Innovative practices were defined as fulfilling two of these criteria and traditional practices as fulfilling none; the remainder were classed as intermediate. The results showed that these three types of practice had distinct strategies that were related to financial constraints and the local population. Innovative practices had more partners and were often located in rural or affluent suburban areas; traditional practices had fewer partners and were more common in urban and working class areas. Innovative practices seemed to be in the best position to increase their services, and hence their incomes, in response to the recent proposals in the white paper. Practices in areas of developmental difficulty (predominantly urban but not necessarily inner city areas) had been less able to respond to existing incentives and had a smaller margin available for developing their services.In view of the effect of local constraints of economics and population on the strategy of practices, concentrating resources for primary care in local budgets for working class and urban areas may be preferable to extending the system of charging fees for services provided by family doctors.     

Deprivation,low birth weight,and children's height: a comparison between rural and urban areas.

OBJECTIVE--To compare proportions of low birthweight babies and mean heights of schoolchildren between rural and urban areas at different levels of social deprivation. DESIGN--Cross sectional population based study classifying cases by Townsend material deprivation index of enumeration district of residence and by rural areas, small towns, and large towns. SETTING--Northumberland Health District. SUBJECTS--18,930 singleton infants delivered alive during January 1985 to September 1990 and resident in Northumberland in October 1990; 9055 children aged 5 to 8 1/2 years attending Northumberland schools in the winter of 1989-90. MAIN OUTCOME MEASURES--Odds ratios for birth weight less than 2800 g; difference in mean height measured by standard deviation (SD) score. RESULTS--Between the most deprived and most affluent 20% of enumeration districts the odds ratio for low birth weight adjusted for rural or urban setting was 1.71 (95% confidence interval 1.51 to 1.93) and the difference in mean height -0.232 SD score (-0.290 to -0.174). Between large towns and rural areas the odds ratio for low birth weight adjusted for deprivation was 1.37 (1.23 to 1.53) and the difference in mean height -0.162 SD score (-0.214 to -0.110). Results for small towns were intermediate between large towns and rural areas. CONCLUSIONS--Inequalities in birth weight and height exist in all rural and urban settings between deprived and affluent areas. In addition, there is substantial disadvantage to living in urban areas compared with rural areas which results from social or environmental factors unrelated to current levels of deprivation.     

The influence of social deprivation on bone donation: a 10 year retrospective study

An audit identifying all surgical bone donors over a 10 year period was conducted. Postcodes were used to link data from the index of multiple deprivation (IMD) 2007 to give each donor a deprivation score. An audit from 2000 to 2010 of primary total hip replacement (THR) patients was also conducted, and similarly a deprivation score was identified for each patient. IMD scores are split into quintiles. A high IMD score indicates a high degree of social deprivation. Conversely low IMD scores indicate a more affluent community. The mean IMD 2007 score was 13.36 (95 % CI 13.12–13.60). The national mean IMD score is 21.7 (CI 21.52–21.88). The difference is significant (p < 0.0001). The mean IMD 2007 score of primary THR patients identified in the arthroplasty database was 19.19 (CI 19.00–19.38). The difference between the mean arthroplasty score and the mean score of donors is significant (p < 0.0001). The donation rate increases as social deprivation decreases from quintile to quintile in both: the older patients (CI 1.08–1.14; p < 0.0001) and the general population (CI 1.20–1.25; p < 0.0001). Bone donors are substantially less deprived than their donor pool of THR patients. Donor rates are consistently lower in quintiles which are more deprived.     

Relation between socioeconomic deprivation and pathological prognostic factors in women with breast cancer.

OBJECTIVE--To investigate the relation between socioeconomic deprivation and pathological prognostic factors in women with breast cancer as a possible explanation for socioeconomic differences in survival. DESIGN--Retrospective analysis of data from cancer registry and from pathology and biochemistry records. SETTING--Catchment areas of two large teaching hospitals in Glasgow. SUBJECTS--1361 women aged under 75 who had breast cancer diagnosed between 1980 and 1987. MAIN OUTCOME MEASURES--Tumour size, axillary lymph node status, histological grade, and oestrogen receptor concentration in relation to deprivation category of area of residence. RESULTS--There was no significant relation between socioeconomic deprivation and four pathological prognostic factors: 93 (32%) women in the most affluent group presented with tumours less than 20 mm in size compared with 91 (31%) women in the most deprived group; 152 (48%) of the most affluent group presented with negative nodes compared with 129 (46%) of the most deprived group; 23 (22%) of the most affluent group presented with grade I tumours compared with 12 (17%) of the most deprived group; and 142 (51%) of the most affluent group had a low oestrogen receptor concentration at presentation compared with 148 (52%) of the most deprived group. None of these differences was statistically significant. CONCLUSIONS--Differences in survival from breast cancer by socioeconomic deprivation category could not be accounted for by differences in tumour stage or biology. Other possible explanations, such as differences in treatment or in host response, should be investigated.     

Difficult Life Events,Selective Migration and Spatial Inequalities in Mental Health in the UK

ObjectiveResearch has indicated that people moving towards neighbourhoods with disadvantaged socio-economic status have poor health, in particular mental health, but the reasons for this are unclear. This study aims to assess why people moving towards more socio-economically deprived areas have poor mental health. It focuses upon the role of difficult life events that may both trigger moves and damage mental health. This study investigates how mental health and socio-spatial patterns of mobility vary between people moving following difficult life events and for other reasons.MethodsLongitudinal analysis of British Household Panel Survey data describing adults’ moves between annual survey waves, pooled over ten years, 1996-2006 (N=122,892 observations). Respondents were defined as ‘difficult life event movers’ if they had experienced relationship breakdown, housing eviction/repossession, or job loss between waves. Respondents were categorised as moving to more or less deprived quintiles using their Census Area Statistic residential ward Carstairs score. Mental health was indicated by self-reported mental health problems. Binary logistic regression models of weighted data were adjusted for age, sex, education and social class.ResultsThe migration rate over one year was 8.5%; 14.1% of movers had experienced a difficult life event during this time period. Adjusted regression model odds of mental health problems among difficult life event movers were 1.67 (95% CI 1.35-2.07) relative to other movers. Odds of difficult life events movers, compared to other movers, moving to a less deprived area, relative to an area with a similar level of deprivation, were 0.70 (95% CI 0.58-0.84). Odds of mental health problems among difficult life event movers relocating to more deprived areas were highly elevated at 2.40 (95% CI 1.63-3.53), relative to stayers.ConclusionDifficult life events may influence health selective patterns of migration and socio-spatial trajectories, reducing moves to less deprived neighbourhoods among people with mental illness.     

高山垫状植物团状福禄草开花面积与方位随海拔的变化及其适应性

作为高山生态系统中的奠基种(foundation species), 垫状植物自身种群的繁殖与扩张, 对高山生态系统功能稳定性起着关键作用。但是, 垫状植物如何在极端环境条件下实现资源的有效利用与分配, 达到繁殖最优化, 至今鲜为人知。该研究在滇西北白马雪山沿海拔梯度选择具有不同坡度及坡向的5个团状福禄草(Arenaria polytrichoides)种群, 调查、比较种群内、种群间以及具有不同性系统的植株个体之间的开花面积比、开花方位, 并分析不同生态因子对其开花特性的影响。结果表明: 随着海拔的升高, 团状福禄草个体变小, 其分配到开花的资源比例总体上随海拔上升呈现下降的趋势, 说明团状福禄草的繁殖分配受到由海拔所引起的生态因子的调控。但是, 部分低海拔种群内植物个体的繁殖分配显著低于部分高海拔种群, 说明海拔并非控制植物繁殖分配的唯一因素。此外, 植株开花总面积随植株个体增大而增加, 但开花面积比却随个体增大而变小, 说明植株分配到开花的资源增长速率可能低于植株个体的增长速率。在性别差异方面, 两性植株对开花的资源分配比例要显著高于雌性植株, 但是, 其差异程度受到海拔因素的影响。最后, 在同一种群内, 团状福禄草在冠层表面不同方位上的开花面积比存在显著差异性, 这种差异性在不同种群之间又具有不同的表现形式。     

THE EFFECT OF SLEEP DEPRIVATION UPON THE IN VIVO AND IN VITRO INCORPORATION OF TRITIATED AMINO ACIDS INTO BRAIN PROTEINS IN THE RAT AT THREE DIFFERENT AGE LEVELS

Abstract— The effect of sleep deprivation on the in vivo and in vitro tritiated amino acid incorporation into brain proteins was studied in the rat at three age levels. Sleep deprivation was induced either by water tank or handling methods. Three experimental groups of animals were used: control, sleep deprived and post deprivation sleeping rats.
A significant decrease of protein synthesis was found in the cerebellum, telencephalon and in crude subcellular fractions of brainstem of adult rats selectively deprived of paradoxical sleep. However, no alteration of protein synthesis was observed either in vivo or in vitro , in the same brain regions or in the liver after the rebound of paradoxical sleep following deprivation.
In four crude subcellular protein fractions a specific increase of the in vitro labelled amino acid incorporation was observed in the brain stem of 24-day-old rats allowed to recuperate after sleep deprivation as compared with the deprived rats. No significant changes were seen in the telencephalon.
No alteration of incorporation was found in 7-day-old rats deprived of sleep.
The possible functional significance of these results is discussed in relation to stress and to variations in the size of the precursor pool for protein synthesis.     

Altitudinal variation in flowering area and position and their ecological significances of an alpine cushion Arenaria polytrichoides,a gynodioecious herb

Aims As foundation species in the alpine ecosystems, the reproduction and recruitment of alpine cushion plants are very important for sustaining the alpine ecosystem functions. However, it still remains unclear that how cushion plants effectively allocate resources to optimize reproductive fitness.Methods Here we selected five populations of a gynodioecious herb Arenaria polytrichoides with different exposures and slopes along an altitudinal gradient on the Baima snow mountain in northwest Yunnan, southwest China, to investigate and compare flowering area and positions, within and among populations and between female and hermaphroditic morphs. By doing so, we further discuss how the environmental stresses affect the cushion’s flowering attributes thus the population-level reproduction.Important findings The results showed that, individual plant size and resources allocated to flowering (flowering area %) both decreased with increasing elevation, indicating that the reproductive allocation strategy was significantly affected by elevation. However, a population at lower elevation showed lower reproductive investment than higher populations, suggesting that elevation was not the only factor affecting the cushion’s reproductive allocation. In addition, absolute flowering area increased with increasing individual size, but the flowering area ratio decreased, indicating that the increases in reproductive allocation are fewer than that in vegetative allocation. Hermaphroditic individuals invested more resources to flowering than females did, but again, such effect was affected by elevation. Moreover, within a single population, the flowering areas were significantly different among the four directions (east, south, west and north) within one single individual canopy, but such differences varied in different populations.     

The effect of deprivation on variations in general practitioners' referral rates: a cross sectional study of computerised data on new medical and surgical outpatient referrals in Nottinghamshire.

OBJECTIVE: To determine the effect of deprivation on variations in general practitioners'' referral rates using the Jarman underprivileged area (UPA(8)) score as a proxy measure. DESIGN: Cross sectional survey of new medical and surgical referrals from general practices to hospitals (determined from hospital activity data). SETTING: All of the 183 general practices in Nottinghamshire and all of the 19 hospitals in Trent region. MAIN OUTCOME MEASURES: The relation between the referral rates per 1000 registered patients and the practice population''s UPA(8) score (calculated on the basis of electoral ward), with adjustment for the number of partners, percentage of patients aged over 65 years, and fundholding status of each practice. RESULTS: There was a significant independent association between deprivation, as measured by the UPA(8) score, and high total referral rates and high medical referral rates (P < 0.0001). The UPA(8) score alone explained 23% of the total variation in total referral rates and 32% of the variation in medical referral rates. On multivariate analysis, where partnership size, fundholding status, and percentage of men and women aged over 65 years were included, the UPA(8) score explained 29% and 35% of the variation in total and medical referral rates respectively. CONCLUSION: Of the variables studied, the UPA(8) score was the strongest predictor of variations in referral rates. This association is most likely to be through a link with morbidity, although it could reflect differences in patients'' perceptions, doctors'' behaviour, or the use and provision of services.