CONTENTS TABLE OF FIGURES... 4 FOREWORD... 8 EXECUTIVE SUMMARY... 9 CHAPTER 1: DEMOGRAPHIC PROFILE Population structure...

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CONTENTS TABLE OF FIGURES... 4 FOREWORD... 8 EXECUTIVE SUMMARY... 9 CHAPTER 1: DEMOGRAPHIC PROFILE... 10 1.1 Population structure... 11 1.2 Population projections by local authority and year... 11 1.3 Ethnicity... 13 1.4 Life expectancy... 14 1.5 All cause mortality... 16 1.6 Deprivation... 18 1.7 Childhood deprivation... 20 CHAPTER 2: CHRONIC CONDITIONS... 22 2.1 Cardiovascular disease... 23 2.2 Stroke... 25 2.3 Diabetes... 26 2.4 Respiratory disease... 28 2.5 Cancer... 29 CHAPTER 3: WIDER DETERMINANTS... 32 3.1 Income... 33 3.2 Housing... 35 3.3 Economic activity... 36 3.4 Education... 37 CHAPTER 4: LIFE STAGES AND LIFESTYLE... 41 4.1 EARLY YEARS, CHILDREN & YOUNG PEOPLE... 42 4.1.1 Childhood health surveillance... 42 Page 2 of 74

4.1.2 Low birth rates... 45 4.1.3 Babies breast fed at birth... 46 4.1.4 Immunisations... 47 4.1.5 Healthy eating... 49 4.1.6 Physical activity... 50 4.1.7 Overweight and obesity... 51 4.1.8 Smoking... 52 4.1.9 Alcohol... 54 4.1.10 Sexual health... 55 4.1.11 General health & well being... 58 4.1.12 Cancer... 59 4.1.13 Oral health... 61 4.2 ADULT AND OLDER POPULATIONS... 63 4.2.1 Smoking... 63 4.2.2 Physical activity... 65 4.2.3 Obesity... 66 4.2.4 Alcohol... 68 4.2.5 Excess winter deaths in residents aged 65 and over... 70 CHAPTER 5: LINKS TO LOCAL SINGLE INTEGRATED PLANS... 71 5.1 Carmarthenshire... 72 5.2 Ceredigion... 73 5.3 Pembrokeshire... 74 Page 3 of 74

TABLE OF FIGURES Figure 1: Population pyramid percentage by age and sex in Hywel Dda UHB and Wales, 2014.... 11 Figure 2: Projected population counts by age group, Hywel Dda UHB, 2013-2036.... 12 Figure 3: Population by ethnic group percentage, Wales, 2011.... 13 Figure 4: Percentage of population who do not define themselves as White British or Irish, by local authority, 2011.... 14 Figure 5: Measures in life expectancy in males and females, 2012.... 15 Figure 6: Healthy life expectancy at birth, Wales, 2012.... 15 Figure 7: All cause mortality, EASR per 100,000, count and crude rate, female and male aged under 75 years, Wales, Wales local authorities and health boards, 2012-14... 16 Figure 8: Mortality in males under 75 years, EASR per 100,000 population.... 16 Figure 9: Mortality in females under 75 years, EASR per 100,000 population.... 17 Figure 10: Welsh Index of Multiple Deprivation, Wales 2014.... 18 Figure 11: Welsh Index of Multiple Deprivation, Hywel Dda UHB, 2014.... 19 Figure 12: Welsh Index of Multiple Deprivation, Child Index, 2011.... 20 Figure 13: Percentage LSOA s in the most deprived tenth, Welsh Index of Multiple Deprivation, Child Index 2011.... 21 Figure 14: Emergency admissions for cardiovascular disease by primary condition (ICD-10 100-199), persons, all ages, Wales, 2011-12.... 23 Figure 15: Cardiovascular disease emergency hospital admissions, EASR per 100,000, persons, all ages, Wales local authorities, financial year 2013-14.... 24 Figure 16: Cardiovascular disease emergency hospital admissions, EASR per 100,000, persons, all ages, Wales health boards, financial years 2013-14.... 24 Figure 17: Emergency hospital admissions with primary diagnosis of cerebrovascular disease (stroke), EASR per 100,000 persons, Hywel Dda UHB and Wales, 2008-10.... 25 Figure 18: Emergency hospital admissions with primary diagnosis of cerebrovascular disease (stroke) EASR per 100,000 persons, Wales local authorities, 2008-2010.... 25 Figure 19: Diabetes prevalence rate, QOF disease registers, 2014.... 26 Figure 20: Age and gender of patients with Type 1 diabetes, Hywel Dda UHB, 2014.... 27 Page 4 of 74

Figure 21: People admitted to hospital with a primary diagnosis of chronic obstructive pulmonary disease*, count, crude and EASR per 100,000, persons aged 35+, Wales local authorities, financial year 2013-14... 28 Figure 22: People admitted to hospital with a primary diagnosis of chronic obstructive pulmonary disease*, count, crude and EASR per 100,000, persons aged 35+, Wales health boards, financial year 2013-14.... 29 Figure 23: Incidence of all malignant cancers (excluding non-melanoma skin cancer), Hywel Dda UHB, 2012.... 30 Figure 24: Proportion of cancers by site in men, Hywel Dda UHB 2012.... 30 Figure 25: Proportion of cancers by site in women, Hywel Dda UHB 2012.... 31 Figure 26: Percentage of households living in poverty, 2007-08... 34 Figure 27: Percentage of all people living in households with no central heating, 2001.... 35 Figure 28: Percentage of all residents aged 16-74 years who have never worked or are longterm unemployed, Wales, England and English regions, March 2011.... 36 Figure 29: Percentage of all Welsh residents aged 16-74 years who have never worked or are long term unemployed, Wales and local authorities, March 2011.... 37 Figure 30: Percentage of all residents aged 16 to 74 years who have academic or professional qualifications, Wales, England and English regions, March 2011.... 38 Figure 31: Percentage of all Welsh residents aged 16 to 74 years who have no academic or professional qualifications, Wales and local authorities, March 2011.... 38 Figure 32: Residents aged 16-74 years who have no academic or professional qualifications, Hywel Dda UHB, March 2011.... 40 Figure 33: Childhood health surveillance for Carmarthenshire, 2016.... 42 Figure 34: Childhood health surveillance for Ceredigion, 2016.... 43 Figure 35: Childhood health surveillance for Pembrokeshire, 2016.... 44 Figure 36: Singleton live births, low birth weight (less than 2500g), percentage, Hywel Dda UHB and Wales, 2005-14.... 45 Figure 37: Percentage of babies breast fed at birth, 2011.... 46 Figure 38: Percentage of children up to date with routine immunisations by 4 years of age, 2012.... 47 Figure 39: Percentage of children up to date with immunisations by 4 years of age, Wales MSOA's, 2012.... 48 Page 5 of 74

Figure 40: Percentage of persons aged 11-16* years who reported eating at least one piece of fruit, daily, 2013-14.... 49 Figure 41: Percentage of persons aged 11-16* years, who reported eating vegetables every day, 2013-14.... 49 Figure 42: Persons aged 16-24 years who reported eating breakfast five days a week, 2013-14.... 50 Figure 43: Percentage of children aged 11-16 years who reported undertaking physical activity for an hour or more every day, 2013-14.... 50 Figure 44: Proportion of children aged 4 to 5 years who are a healthy weight or underweight, Child Measurement Programme, Wales and local authorities, 2012-13.... 51 Figure 45: Proportion of children aged 4 to 5 years who are overweight or obese, Wales and local authorities, Child Measurement Programme, 2012-13.... 51 Figure 46: Percentage of 11-16 year olds who were reported as being overweight / obese, 2013-14.... 52 Figure 47: Percentage of persons aged 11-16 years who reported smoking at least once a week, stratified by Family Affluence Scales (FAS), Wales, 2009-10.... 52 Figure 48: Percentage aged 16-24 years who reported currently being a smoker (daily or occasionally), 2008-11.... 53 Figure 49: Percentage of 11-16 year olds who reported they smoke at least once a week, 2013-14.... 53 Figure 50: Percentage of persons aged 11-16* years who reported being drunk the last 30 days, 2013-14.... 54 Figure 51: Percentage of persons aged 11-16 years who reported brushing their teeth more than once a day, 2013-14.... 62 Figure 52: Smoking prevalence in Hywel Dda UHB, 2003/04-14.... 63 Figure 53: Percentage of adults reporting to be a current smoker, age-standardised percentage, persons, Hywel Dda UHB and Wales, 2003/04-14.... 63 Figure 54: Percentage currently smoking, Hywel Dda UHB 2007-2012.... 64 Figure 55: Average number of days of 30 minutes moderate or vigorous physical activity (capped) reported by adults, age-standardised, Wales and local authorities, 2013-14.... 65 Figure 56: Percentage of adults reporting to be physically active on no days in the past week, age standardised percentage, persons, Hywel Dda UHB and Wales, 2003/04-14.... 65 Page 6 of 74

Figure 57: Percentage of adults reporting to be physically active on 5+ days in the past week, age-standardised percentage, persons, Hywel Dda UHB and Wales, 2003/04-14.... 66 Figure 58: Number of survey respondents (weighted) and observed percentage with a BMI of 30 and over 35 and over, persons aged over 16, Wales health boards, 2013-14... 66 Figure 59: Number of survey respondents (weighted) and observed percentage with a BMI of 40 and over and 50 and over, persons aged over 16, Wales health boards, 2009-14.... 67 Figure 60: Percentage of adults reporting to be overweight or obese, age group, all persons, Hywel Dda UHB and Wales, 2012.... 67 Figure 61: Percentage of adults reporting to be obese, age group, all persons, Hywel Dda UHB and Wales, 2012.... 68 Figure 62: Percentage of adults reporting drinking above guidelines (males over 4 units, females over 3 units) on the heaviest drinking day in the past week, age-standardised percentage*, persons, Wales health boards, 2011-12.... 68 Figure 63: Percentage of adults reporting drinking above guidelines (males over 4 units, females over 3 units) on the heaviest day in the past week, Hywel Dda UHB 2008-12.... 69 Figure 64: Excess Winter Deaths (EWD) index, Wales health boards, residents aged 65 and over, 2007-10.... 70 Page 7 of 74

FOREWORD We are delighted to present the Hywel Dda UHB Health Needs Assessment. This is the first Health Needs Assessment document to be developed for the Health Board and should be referred to as a transitional report, as it is anticipated more sophisticated tools and interactive methods will be developed over the coming years, in conjunction with the Public Health Wales Observatory. It is anticipated that this document will help inform the Public Service Board and will support the development of the Integrated Medium Term Plan for 2016/17. This document is a shortened version of a more detailed technical document, which covers a range of key health issues and is set out as follows: Chapter One: Describes the demographic profile of residents living in the Hywel Dda locality. It provides detailed information on the population structure by age, sex and gender, ethnicity, fertility, births and mortality rates, deprivation and life expectancy. Chapter Two: Highlights the incidence and prevalence of various chronic conditions such as cardiovascular disease, diabetes, respiratory disease, cancer, liver disease and neurology. Chapter Three: Briefly describes the wider determinants of health and highlights the impact of income, housing, economic activity, employment and education. Chapter Four: Provides an overview of the various lifestyle risk factors and life stages from early years to older people. Chapter Five: Provides links to the local Single Integrated Plans for Carmarthenshire, Ceredigion and Pembrokeshire. We are most grateful to Ms Kerry Morgan for leading on the production of this document, and also members from the Public Health Wales Observatory and the Public Health Team for their contributions and support. We hope you find this document informative and useful. Teresa Owen Director of Public Health Dr Michael Thomas Consultant in Public Health January 2016 Page 8 of 74

EXECUTIVE SUMMARY This Health Needs Assessment (HNA) has been produced by the Public Health Directorate to provide evidence about our population in order to plan services and address health inequalities amongst our local communities. The purpose of this HNA is to gather the information required to bring about changes beneficial to the health of the population. It is generally accepted that this occurs within the context of finite resources. The subjects of this HNA are the populations and patients who are healthcare recipients or potential beneficiaries of health care within Hywel Dda UHB. Hywel Dda UHB provides healthcare services to a total population of around 384,000 people across the three counties of Carmarthenshire, Ceredigion and Pembrokeshire. Approximately 13% of the total population of Wales live in Hywel Dda, although the area covers roughly a quarter of the landmass of Wales. Within the Hywel Dda area almost 47.9% of the population live in Carmarthenshire, just over 20.7% in Ceredigion and just over 31.4% in Pembrokeshire. The table below outlines some key statistics for Wales and Hywel Dda UHB: Key Statistics Wales HDUHB Total population 3,092,000 384,000 Population aged 75 and over (%) 8.9 10.3 Life expectancy at birth males (years) 78.1 78.9 Life expectancy at birth females (years) 82.2 82.7 Adults who are overweight or obese (%) 58.1 58.5 Adults who smoke (%) 20.9 19.7 Adults who drink above guidelines (%) 41.1 39.1 MMR uptake (%) 95.8 94.9 Live birth per 1,000 women aged 15-44 59.1 56.8 Emergency hospital admissions (European age 112.4 105.3 standardized rate per 1,000 population) http://www.wales.nhs.uk/sitesplus/922/home When assessing health needs it s important to be able to draw upon epidemiological, comparative and corporate information. This document provides detailed public health data on various health needs, however it must be noted that some data sources have more comprehensive data collection methods and are easier to access. This document is a shortened version of a more detailed technical document which provides further data on a wide range of public health issues. Page 9 of 74

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CHAPTER 1: DEMOGRAPHIC PROFILE 1.1 Population structure Hywel Dda UHB covers three local authority areas: Carmarthenshire, Ceredigion and Pembrokeshire. The population of Hywel Dda is estimated 384,000. Hywel Dda UHB, covering a quarter of the landmass of Wales 1, is the second most sparsely populated health board area. 47.9 per cent, 20.7 per cent and 31.4 per cent of the population live in the local authority areas of Carmarthenshire, Ceredigion and Pembrokeshire respectively. There are, however, notable differences with fewer people aged 25-44 and more people aged 50-79. In rural Ceredigion and Pembrokeshire there are relatively high numbers of older people. With 13% of Wales population the area s age and sex profile is similar to that of Wales as a whole, as shown in Figure 1: Figure 1: Population pyramid percentage by age and sex in Hywel Dda UHB and Wales, 2014. 1.2 Population projections by local authority and year Current population projections suggest that the total population of Hywel Dda will rise to 425,400 by 2033, with a rise in those aged over 65 years from 88,200 in 2013 to 127,700 by 2033. 1 Office of National Statistics, 2007 geography Page 11 of 74

It is important to highlight the predicted rise in the number of older people over the next 20 years. Projections suggest by 2030, the population of over 65 year olds will increase by 60% in Hywel Dda. In particular the number of the very elderly (85+) will increase by 6%. Current projections see a rise in the older population (75 years and over) from 35,000 (10% of the total population) in 2006 to 70,000 (16% of the total population) in 2031. These estimates are based on assumptions about births, deaths and migration. In the current economic climate, the relative (and absolute) increase in economically dependent and, in some cases, care-dependent populations will pose particular challenges to communities. The increase in the number of older people is likely to lead to a rise in chronic conditions such as circulatory and respiratory diseases and cancers. Meeting the needs of these individuals will be a key challenge for the Health Board and its local authority partners. Figure 2: Projected population counts by age group, Hywel Dda UHB, 2013-2036. Page 12 of 74

1.3 Ethnicity The total population of Wales at the time of the 2011 Census was 3,063,456, with the greatest percentage of the population (93.7%) reporting to be White British or Irish. The White British or Irish population in Wales is 2,869,536. Of the populations excluding White British or Irish, the Asian/Asian British population has the highest number of people, representing 2.3% (70,128) of the total population. The White other group, including White Gypsy or Irish Traveller, represents 1.9% of the population with 58,717 persons reporting as belonging to this group. The mixed/multiple ethnic group represents 31,521 people, which corresponds to 1.0% of the population. The Black/African/Caribbean/Black British population is made up of 18,276 people, representing 0.6% of the population of Wales. Finally, the Other ethnic group has a population of 15,278, approximately 0.5% of the total population. Figure 3: Population by ethnic group percentage, Wales, 2011. Page 13 of 74

Figure 4: Percentage of population who do not define themselves as White British or Irish, by local authority, 2011. Cardiff (19.0%) and Newport (12.5%) have the highest percentage defining themselves as not being White British or Irish followed by Swansea, Wrexham and Ceredigion (8.1%, 6.6% and 6.2%, respectively). 1.4 Life expectancy Life expectancy is the number of years a person can expect to live, on average, in a given population. The length of people s lives will differ substantially and life expectancy can be used to measure or compare death rates between and within communities and other countries over time. It is also important to consider quality of life, which can now be calculated using the Healthy Life Expectancy (HLE) measure. The HLE at birth represents the number of years a person can expect to live in good health. It is perhaps a better indicator of overall health, since it looks at the period lived in good health and excludes the period when quality of life may be poor. National data suggests that whilst there are increases in overall life expectancy, the increases in the measures relating to quality of life experienced are falling behind. Life expectancy has therefore improved more than the quality of life and health. Page 14 of 74

Life expectancy at birth is a statistical measure of the average expected years of life for a newborn based on currently observed mortality rates and is a measure of mortality across all ages. Figure 5: Measures in life expectancy in males and females, 2012. Figure 6: Healthy life expectancy at birth, Wales, 2012. Page 15 of 74

1.5 All cause mortality Figure 7: All cause mortality, EASR per 100,000, count and crude rate, female and male aged under 75 years, Wales, Wales local authorities and health boards, 2012-14. Males: Females: Males in Ceredigion and Pembrokeshire have statistically lower all cause mortality than the Welsh average. Whereas, females in Carmarthenshire and Ceredigion have statistically lower all cause mortality than the Welsh average. All-cause mortality, under 75, males, European age-standardised rate (EASR) per 100,000, Hywel Dda HB and Wales, 2001-09 Figure 8: Mortality in males under 75 years, EASR per 100,000 population. Produced by Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD 2008 (WG) 700 600 500 400 300 200 Most deprived within Hywel Dda (95% CI) Least deprived within Hywel Dda Wales EASR Hywel Dda overall 100 0 Rate Ratio - most deprived divided by least deprived 1.8 1.7 1.7 1.8 1.8 1.8 1.9 2001-03 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 Produced by the Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD 2008 (WG) Page 16 of 74

Figure 8 shows the mortality trend between 2001-03 and 2007-09 for all causes of death in males under 75 in Hywel Dda UHB. The mortality rate in the most and the least deprived fifths is shown together with the rates for Wales and the Health Board as a whole as a comparison. All-cause mortality, under 75, females, European age-standardised rate (EASR) per 100,000, Hywel Dda HB and Wales, 2001-09 Figure 9: Mortality in females under 75 years, EASR per 100,000 population. Produced by Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD 2008 (WG) 450 400 350 300 250 200 150 100 50 0 Most deprived within Hywel Dda (95% CI) Wales EASR Least deprived within Hywel Dda Hywel Dda overall Rate Ratio - most deprived divided by least deprived 1.6 1.6 1.5 1.7 1.7 1.8 1.6 2001-03 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 Produced by the Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD 2008 (WG) Figure 9 shows the mortality trend between 2001-03 and 2007-09 for all causes of death in females under 75 in Hywel Dda UHB. The mortality rate in the most and the least deprived fifths is shown together with the rates for Wales and the Health Board as a whole as a comparison. Page 17 of 74

1.6 Deprivation The Welsh Index of Multiple Deprivation (WIMD) is the official measure of relative deprivation for small areas in Wales. The Index was developed as a tool to identify and understand deprivation in Wales so that funding, policy and programmes can be effectively focussed on the most disadvantaged communities. The following indicators are included in this measure: employment, income, education, health, community safety, geographical access to services, housing and physical environment. Figure 10: Welsh Index of Multiple Deprivation, Wales 2014. Page 18 of 74

Local deprivation fifths for Hywel Dda UHB have been produced by ranking all Lower Super Output Areas (LSOAs) within the area and grouping them into fifths, based on the Welsh Index of Multiple Deprivation (2008). Each Health Board therefore has its own local fifths depending on the deprivation distribution within that area, which is shown below. The association between deprivation and health is clearly apparent. Many health outcomes are statistically significant worst than Wales as a whole in the following areas of high deprivation: Carmarthenshire: Glanymor, Tyisha, Lliedi Pembrokeshire: Parts of Pembroke, Pembroke Dock and Haverfordwest. Ceredigion is not significantly worst than the Welsh Average. Figure 11: Welsh Index of Multiple Deprivation, Hywel Dda UHB, 2014. Page 19 of 74

1.7 Childhood deprivation Deprivation is part of a wider notion of poverty than measures of income alone. The Welsh Index of Multiple Deprivation 2011 Child Index is a measure of relative deprivation for small areas in Wales for children. It is constructed of 7 domains: income, health, education, geographical access to services, community safety, physical environment and housing. These domains included in the Child Index are focused on the child population and the types of deprivation which might be expected to affect them. Figure 12: Welsh Index of Multiple Deprivation, Child Index, 2011. Page 20 of 74

Figure 13: Percentage LSOA s in the most deprived tenth, Welsh Index of Multiple Deprivation, Child Index 2011. % LSOAs in the most deprived tenth, Welsh Index of Multiple Deprivation 2011 Child Index Produced by Public Health Wales Observatory, using WIMD 2011 (WG) Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan 5.6 0.0 3.9 12.4 17.4 16.0 10.3 Wales =10.0% Number 24 0 9 40 49 30 38 Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pembrokeshire Carmarthenshire Swansea Neath Port Talbot Bridgend Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monm outhshire Newport 4.5 4.0 4.2 10.3 4.3 7.1 0.0 0.0 7.0 3.6 14.3 9.9 11.8 5.1 22.2 15.8 16.7 10.9 10.6 6.7 0.0 18.1 2 3 3 6 4 6 0 0 5 4 21 9 10 4 45 24 6 12 5 4 0 17 The percentage of LSOAs in the most deprived tenth in Hywel Dda UHB ranges from 2 in Ceredigion, 8 in Pembrokeshire to 11 in Carmarthenshire. Page 21 of 74

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CHAPTER 2: CHRONIC CONDITIONS 2.1 Cardiovascular disease Cardiovascular disease (CVD) is a major cause of ill-health and death in Wales. It is caused by disorders of the heart and blood vessels, and includes coronary heart disease (heart attacks), cerebrovascular disease (stroke), raised blood pressure (hypertension) and heart failure. CVD has a substantial impact on the health service. Over 7% of all inpatient hospital admissions in Wales are for CVD. There were nearly 33,000 emergency admissions for CVD in 2011/12, around 9% of all emergency admissions. Figure 14 shows the number of emergency admissions by primary condition. Around a third of these admissions for CVD are for coronary heart disease (CHD) and another third for other forms of heart disease. Figure 14: Emergency admissions for cardiovascular disease by primary condition (ICD-10 100-199), persons, all ages, Wales, 2011-12. Page 23 of 74

Figure 15: Cardiovascular disease emergency hospital admissions, EASR per 100,000, persons, all ages, Wales local authorities, financial year 2013-14. Both Ceredigion and Pembrokeshire were statistically lower than the Welsh average, Carmarthenshire however showed no statistical difference. Figure 16: Cardiovascular disease emergency hospital admissions, EASR per 100,000, persons, all ages, Wales health boards, financial years 2013-14. Hywel Dda UHB is statistically lower than the Welsh average. Page 24 of 74

2.2 Stroke Figure 17: Emergency hospital admissions with primary diagnosis of cerebrovascular disease (stroke), EASR per 100,000 persons, Hywel Dda UHB and Wales, 2008-10. Ceredigion had the lowest average annual deaths of 120, followed by 288 in Pembrokeshire and 403 in Carmarthenshire. Ceredigion was considered statistically lower than the Welsh average, whereas there was no statistical difference with Pembrokeshire and Carmarthenshire. Figure 18: Emergency hospital admissions with primary diagnosis of cerebrovascular disease (stroke) EASR per 100,000 persons, Wales local authorities, 2008-2010. Page 25 of 74

2.3 Diabetes Within Hywel Dda UHB we are aware that there are significant differences in the prevalence of diabetes. This is reflected in our hospital data that shows we have approximately 20% of in-patients in Llanelli with diabetes, whereas in Aberystwyth the figure is closer to 15%. This is likely to reflect the differences in overall health and levels of social deprivation of people in these areas. In the financial year of 2013-14 the prevalence of diabetes in Hywel Dda UHB was 5.8 % (n = 22,877), in comparison to Wales, which was 5.6% (n = 177,212). Figure 19: Diabetes prevalence rate, QOF disease registers, 2014. National Paediatric Diabetes Audit (NPDA) 2013-2014 Page 26 of 74

Figure 20: Age and gender of patients with Type 1 diabetes, Hywel Dda UHB, 2014. National Paediatric Diabetes Audit (NPDA) 2013-2014 Figure 21 identifies that Type 2 Diabetes is also more prevalent in males in Hywel Dda UHB. Figure 21: Age and gender of patients with Type 2 diabetes, Hywel Dda UHB, 2014. National Paediatric Diabetes Audit (NPDA) 2013-2014 Page 27 of 74

2.4 Respiratory disease People admitted to hospital with a primary diagnosis of chronic Figure 21: People admitted to hospital with a primary diagnosis of chronic obstructive pulmonary disease*, count, crude and European obstructive pulmonary disease*, count, crude and EASR per 100,000, persons age-standardised rate (EASR) per 100,000, persons aged 35+, aged 35+, Wales local authorities, financial year 2013-14. Wales local authorities, financial year 2013/14 Count Crude rate Isle of Anglesey 134 306 274 (229-324) Gwynedd 243 341 304 (267-345) Conwy 222 298 249 (217-284) Denbighshire 191 328 302 (260-348) Flintshire 262 288 300 (264-338) Wrexham 281 360 370 (327-416) Powys 209 243 215 (186-246) Ceredigion 85 195 168 (134-208) Pembrokeshire 207 271 243 (211-278) Carmarthenshire 292 259 239 (212-268) Swansea 373 278 270 (244-299) Neath Port Talbot 287 343 342 (303-384) Bridgend 264 318 324 (286-365) Vale of Glamorgan 206 271 269 (233-308) Cardiff 468 276 309 (281-338) Rhondda Cynon Taf 593 445 453 (417-491) Merthyr Tydfil 168 506 529 (451-615) Caerphilly 467 456 482 (439-528) Blaenau Gwent 190 469 480 (414-553) Torfaen 204 386 378 (328-434) Monmouthshire 126 213 200 (167-238) Newport 278 347 359 (318-404) Wales 5,750 322 314 (306-323) *IC D-10 codes J40-J44 EASR per 100,000 (95% confidence interval) Produced by Public Health Wales Observatory, using PEDW (NWIS) & MYE (ONS) Ceredigion received the lowest count of 85 people admitted to hospital with a primary diagnosis of chronic obstructive pulmonary disease, followed by 207 for Pembrokeshire and 292 for Carmarthenshire. Page 28 of 74

Figure People 22: People admitted admitted to hospital to hospital with a with primary a primary diagnosis diagnosis of chronic of chronic obstructive obstructive pulmonary pulmonary disease*, disease*, count, count, crude and crude EASR and European per 100,000, agestandardised rate (EASR) per 100,000, persons aged 35+, Wales persons aged 35+, Wales health boards, financial year 2013-14. health boards, financial year 2013/14 Count Crude rate Betsi Cadwaladr UHB 1,333 320 298 (282-315) Powys thb 209 243 215 (186-246) Hywel Dda UHB 584 251 226 (208-246) Abertawe Bro Morgannwg UHB 924 307 304 (285-325) Cardiff and Vale UHB 674 275 295 (273-318) Cwm Taf UHB 761 457 467 (434-502) Aneurin Bevan UHB 1,265 378 382 (362-404) Wales 5,750 322 314 (306-323) Produced by Public Health Wales Observatory, using PEDW (NWIS) & MYE (ONS) *IC D-10 codes J40-J44 EASR per 100,000 (95% confidence interval) Hywel Dda UHB was statistically lower than the EASR per 100,000 for Wales. 2.5 Cancer Non-surgical oncology treatment modalities include radiotherapy and systemic therapies. Radiotherapy includes conventional external beam and electron radiotherapy, proton radiotherapy, brachytherapy, and molecular radiotherapy (unsealed source therapy). Systemic therapies include chemotherapy, endocrine therapy and targeted biological therapies (such as antibodies, small molecules including tyrosine kinase inhibitors and immunotherapy). (Ref: Joint Collegiate Council for Oncology). There were 1389 new cancers registered in Hywel Dda male residents in 2012, and 1226 in females. Figure 23 shows the crude registered incidence for cancers in 2012. Page 29 of 74

Figure 23: Incidence of all malignant cancers (excluding non-melanoma skin cancer), Hywel Dda UHB, 2012. Allowing for different age structures across the population, the European Aged Standardised Rate per 100,000 population in 2012 across Hywel Dda was 463.0 for males (Lower 95% CI: 437.8; Upper 95% CI 489.8) and 396.6 for females (Lower 95% CI: 372.6; Upper 95% CI 422.2). Figure 24: Proportion of cancers by site in men, Hywel Dda UHB 2012. Other 35.3% Prostate 30.7% Colorectal 13.5% Urinary Tract exc Bladder 4.3% Head & Neck 4.8% Lung 11.5% Welsh Cancer Intelligence and Surveillance Unit (WCISU), April 2014 Both graphs represent the proportion of cancers by site. 30.7% of males suffer from prostate cancer, whereas 28.1% of females suffer from breast cancer. Page 30 of 74

Figure 25: Proportion of cancers by site in women, Hywel Dda UHB 2012. Other 35.8% Breast 28.1% Colorectal 13.5% Ovary 4.3% Uterus 5.5% Lung 12.8% Welsh Cancer Intelligence and Surveillance Unit (WCISU), April 2014 Page 31 of 74

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CHAPTER 3: WIDER DETERMINANTS Health is affected, positively and negatively by many factors. At an individual level there are fixed biological factors, such as age, sex and genetic (or inherited) makeup and potentially modifiable lifestyle factors, such as smoking, diet and exercise. The society within which individuals live can influence their health, with involvement in social and community networks, including friendships, contact with relatives and supportive community interaction, playing an important role in maintaining health. Then at a higher level again, are the wider determinants of health, or the causes of the causes, the environment, income and housing all influence health both directly and indirectly. Many of these wider determinants of health are both inter-related and beyond the direct control of individuals. For example, an individual with few qualifications is more likely to be unemployed or to have a low income, which in turn limits their housing choice. Similarly, there is evidence of a link between unemployment and health whereby ill health may be caused by, or result from, unemployment 2. All of these circumstances may act to influence what is often wrongly perceived as solely a personal lifestyle choice. For example, whilst smoking may appear to be an individual s lifestyle choice, it is possible that their decision to smoke is pushed by the effects of the context of their lives and is in effect a response to those stresses 3. It follows then that any attempt to tackle poor health must address the wider contextual factors, rather than simply looking to influence individuals and their specific behaviours in isolation. As such, building health into all policies and all policies into health is rightly the first of seven action areas of Fairer Health Outcomes for All, the Welsh Government s strategic action plan to reduce inequalities in health 4. 3.1 Income Low income and poor health are strongly associated, with low income leading to poor health, and poor health leading to low income. A low income is likely to reduce the household s ability to access or maintain key aspects such as healthy food and warm accommodation. Low income is also likely to reduce societal participation and 2 Bambra C et al. Tackling the wider social determinants of health and health inequalities: evidence from systematic reviews. J Epidemiol Community Health 2010; 64:284-91 3 Layte R, Whelan C. Explaining social class differentials in smoking: the role of education. Working paper No.12. Dublin: Economic and Social Research Institute, University College Dublin; 2004. 4 Welsh Assembly Government. Fairer health outcomes for all: reducing inequalities in health strategic action plan. Cardiff: Welsh Assembly Government; 2011 Page 33 of 74

limit access to enabling resources and choices. Those on low incomes are more likely to engage in health damaging behaviours such as smoking and eating high calorie foods, as coping mechanisms or short term fixes. Whilst it must be remembered that these are model based estimates, across the health board there was almost a two-fold difference in the proportion of households estimated to be living in poverty from 18.5% (Ceredigion MSOA 004) to 32.8% (Pembrokeshire MSOA 013). Estimates at local authority level were not available but the median MSOA percentages suggest Pembrokeshire to be slightly higher than the rest and Carmarthenshire to be slightly lower. It can be seen from the map that four of the five highest percentages occurred in Pembrokeshire around the towns of Pembroke, Pembroke Dock, Milford Haven and Haverfordwest. The remaining highest percentage occurred in Carmarthenshire around the town of Llanelli. Figure 26: Percentage of households living in poverty, 2007-08. Page 34 of 74

3.2 Housing The percentage of people living in households with no central heating was markedly higher than the Welsh average in two of the three local authorities within Hywel Dda. This was to such an extent that all 26 MSOAs in Ceredigion and Pembrokeshire were above the Welsh average. Across Wales as a whole the highest percentages were seen in the more rural areas, in the areas that were without access to mains gas. Within the health board, there was substantial variation at the MSOA level, ranging from just 1% in Swiss Valley / Llangennech (Carmarthenshire MSOA 019) to 20% in parts of Milford Haven (Pembrokeshire MSOA 012). The below map shows a very clear difference between the north and south with the majority of the lower percentages occurring in the southern most part of the health board. Figure 27: Percentage of all people living in households with no central heating, 2001. Page 35 of 74

3.3 Economic activity Unemployment puts health at risk and has been shown to increase effects on mental health and self-reported ill health 5. Financial problems, distress, anxiety and depression and poor health behaviours such as smoking and excessive drinking are all related to unemployment 6. The 2011 Census in England and Wales found that 5.6% of working age residents in England and Wales have never worked or are long-term unemployed. In the regions of England and in Wales, the highest proportion of residents who have never worked or are long term unemployed is in London at 8.3%. Figure 28: Percentage of all residents aged 16-74 years who have never worked or are long-term unemployed, Wales, England and English regions, March 2011. In Wales 5.4% of the working age population have never worked or are long-term unemployed. In Hywel Dda UHB all three constituent local authorities are below the Welsh average. In Welsh local authorities, Blaenau Gwent had the highest proportion of the population who have never worked or are long-term unemployed at 8.7% compared to Ceredigion which had the lowest percentage at 3.1%. 5 Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization, 2008. Available at: http://www.who.int/social_determinants/thecommission/finalreport/en/index.html [Accessed 20th March 2013] 6 Marmot M. Fair society, healthy lives: The Marmot Review. London: University College London; 2010. Available at: http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-themarmot-review [Accessed 20th March 2013] Page 36 of 74

Figure 29: Percentage of all Welsh residents aged 16-74 years who have never worked or are long term unemployed, Wales and local authorities, March 2011. At the LSOA level the percentage of residents who have never worked or are longterm unemployed range from 0.85% in the Faenor area of Ceredigion (Ceredigion LSOA 011A) to 14.1% in the Tyisha area of Carmarthenshire (Carmarthenshire LSOA 026E). It is important to note that these are crude percentages only and do not take into account the age structure of the population. The areas with the highest percentages are found in the Llwynhendy and Tyisha areas of Carmarthenshire and in the Pembroke: Monkton and Pembroke Dock: Llanion areas of Pembrokeshire. 3.4 Education Educational outcomes affect physical and mental health, as well as income, employment and quality of life. The relationship between socioeconomic position and qualifications has implications for other social determinants such as income and living standards which have an impact on health. This indicator measures all usual residents aged 16 and over and under 74 years who have no academic or professional qualification. No academic or professional qualification is derived from the question asking people to indicate all types of qualifications held. The 2011 Census in England and Wales found that over one-fifth (22.7%) of working age residents in England and Wales have no academic or professional qualifications. In the regions of England and in Wales, the highest proportions of residents who have no academic and professional qualifications are contained in the West Midlands at 26.6%, followed by Wales at 25.9%. London has the lowest proportion of people having no qualifications at 17.6%. Page 37 of 74

Figure 30: Percentage of all residents aged 16 to 74 years who have academic or professional qualifications, Wales, England and English regions, March 2011. Figure 31: Percentage of all Welsh residents aged 16 to 74 years who have no academic or professional qualifications, Wales and local authorities, March 2011. In Welsh local authorities the proportion of working age residents with no academic or professional qualifications ranged from 1 in 3 people in Blaenau Gwent and Merthyr Tydfil to just under 1 in 5 people in Ceredigion, the Vale of Glamorgan, Page 38 of 74

Cardiff and Monmouthshire. Both Ceredigion and Pembrokeshire were below the Welsh average, while Carmarthenshire was above the Welsh average at 26.8%. Blaenau Gwent had the highest proportion of people with no qualifications at 36% compared to Ceredigion which had the lowest at 19.8%. There is considerable variation at the LSOA level within Hywel Dda UHB. However these are crude percentages only and do not take into account the age structure of the population. The proportion of residents who have no academic or professional qualifications ranged from 5.3% in the Aberystwyth Bronglais area of Ceredigion (Ceredigion LSOA 002A) to 42.2% in the Tyisha area of Carmarthenshire (Carmarthenshire LSOA 026E). The areas with the highest percentages are found in the Tyisha and Bigyn areas of Carmarthenshire and the Pembroke Dock: Llanion area of Pembrokeshire. Page 39 of 74

Figure 32: Residents aged 16-74 years who have no academic or professional qualifications, Hywel Dda UHB, March 2011. Page 40 of 74

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CHAPTER 4: LIFE STAGES AND LIFESTYLE 4.1 EARLY YEARS, CHILDREN & YOUNG PEOPLE 4.1.1 Childhood health surveillance The childhood health surveillance focuses on the health of children. It comprises of a suite of childhood indicators, presented at local authority level, as highlighted in Figures 33, 34 and 35. Figure 33: Childhood health surveillance for Carmarthenshire, 2016. Page 42 of 74

Carmarthenshire scored lower than the Welsh average for children in need, teenage conceptions, percentage of 4 year olds up to date with immunisations and 5 year olds with dmft (decayed, missing and filled teeth). Figure 34: Childhood health surveillance for Ceredigion, 2016. Ceredigion scores higher than the Welsh average for the percentage of 4 year olds up to date with immunisations and emergency admissions for injury. It also scored lower than the Welsh average for live births to females under 20 years. Page 43 of 74

Figure 35: Childhood health surveillance for Pembrokeshire, 2016. Pembrokeshire scores higher than the Welsh average for the percentage of 4/5 year olds classed as either overweight or obese. It was also scored lower than the Welsh average for children in need. Page 44 of 74

4.1.2 Low birth rates Figure 36: Singleton live births, low birth weight (less than 2500g), percentage, Hywel Dda UHB and Wales, 2005-14. In 2014 there were 165 (4.7%) cases of live births / low birth rates for Hywel Dda UHB. There is no statistical difference between Hywel Dda UHB and Wales. Page 45 of 74

4.1.3 Babies breast fed at birth Figure 37: Percentage of babies breast fed at birth, 2011. % of babies breastfed at birth, 2011 Produced by Public Health Wales Observatory, using NCCHD (NWIS) Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan 0.0 50.0Wales = 55.5% 100.0 58.7 77.6 65.3 45.6 71.6 51.0 38.0 Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pembrokeshire Carm arthenshire Swansea Neath Port Talbot Bridgend Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monmouthshire Newport 59.0 62.4 62.6 57.6 52.6 59.1 77.6 79.6 62.5 62.7 45.6 30.7 59.3 69.7 72.2 53.6 40.2 33.0 28.2 35.6 57.6 41.9 Carmarthenshire, Ceredigion and Pembrokeshire are all above the Wales average percentage score of 55.5% for percentage of babies breast fed at birth. Page 46 of 74

4.1.4 Immunisations Figure 38: Percentage of children up to date with routine immunisations by 4 years of age, 2012. % of children up to date with routine immunisations by 4 years of age, 2012 Produced by Public Health Wales Observatory, using CDSC and VPDP (PHW) Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pem brokeshire Carm arthenshire Swansea Neath Port Talbot Bridgend Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monm outhshire Newport 85.2 84.3 80.8 82.4 79.8 84.9 80.7 82.7 87.0 82.2 82.6 85.6 88.3 84.3 85.2 78.2 81.1 82.4 82.1 82.9 84.8 78.0 85.3 83.3 81.0 81.8 81.7 83.8 78.1 Wales=82.4% In Hywel Dda UHB the number of children up to date with routine immunisations was 3124, in Ceredigion it was 513, Pembrokeshire 998 and Carmarthenshire 1613. Page 47 of 74

Figure 39: Percentage of children up to date with immunisations by 4 years of age, Wales MSOA's, 2012. The map above shows the areas, with the greatest uptake of immunisations for 4 year olds. Page 48 of 74

4.1.5 Healthy eating Figure 40: Percentage of persons aged 11-16* years who reported eating at least one piece of fruit, daily, 2013-14. There were more girls (36%) than boys (30%) aged 11-16 years, in Hywel Dda UHB who reported eating at least one piece of fruit daily. Figure 41: Percentage of persons aged 11-16* years, who reported eating vegetables every day, 2013-14. There were more girls (49%) than boys (36%) aged 11-16 years in Hywel Dda UHB who reported eating vegetables every day. Page 49 of 74

Figure 42: Persons aged 16-24 years who reported eating breakfast five days a week, 2013-14. There were more boys (70%) than girls (56%) aged 11-16 years in Hywel Dda UHB who reported eating breakfast five days a week. 4.1.6 Physical activity Figure 43: Percentage of children aged 11-16 years who reported undertaking physical activity for an hour or more every day, 2013-14. 16% of children aged 11-16 years reported undertaking phyical activity for an hour or more everday within Hywel Dda UHB. Boys (21%) were more active than girls (11%). Page 50 of 74

4.1.7 Overweight and obesity Figure 44: Proportion of children aged 4 to 5 years who are a healthy weight or underweight, Child Measurement Programme, Wales and local authorities, 2012-13. The above show the information at local authority and health board level for children with a BMI classified as healthy weight or underweight. Figure 45: Proportion of children aged 4 to 5 years who are overweight or obese, Wales and local authorities, Child Measurement Programme, 2012-13. 26.2% of children measured in 2012/13 in Wales were either overweight or obese. This proportion varies by local authority health board. The prevalence for overweight or obesity was lower in Ceredigion, than in Carmarthenshire and Pembrokeshire. Page 51 of 74

Figure 46: Percentage of 11-16 year olds who were reported as being overweight / obese, 2013-14. 20% of 11-16 year olds were classified as overweight / obese. The boys were reported higher at 26% in comparison to the girls at 14%. 4.1.8 Smoking Figure 47: Percentage of persons aged 11-16 years who reported smoking at % of persons aged 11-16 who reported smoking at least once a week, least once a week, stratified by Family Affluence Scales (FAS), Wales, 2009-10. stratified by Family Affluence Scale (FAS), Wales, 2009/10 Produced by Public Health Wales Observatory, using HBSC (WG) Males Females Persons FAS 1 (low) FAS 2 (med) FAS 3 (high) 7 5 4 11 8 6 9 7 5 Year 7 Year 8 Year 9 Year 10 Year 11 1 1 3 11 9 <0.5 <0.5 2 2 6 5 14 13 14 11 Boys and girls in Year 10 had the highest rates reported for smoking at least once a week. The greatest percentage was amongst those from the lower family affluence scales. Page 52 of 74

Figure 48: Percentage aged 16-24 years who reported currently being a smoker (daily or occasionally), 2008-11. 25.1% (n=11,600) of young people aged 16-24 in Hywel Dda UHB reported as being current smokers. There is no statistical difference between Hywel Dda UHB and Wales. Figure 49: Percentage of 11-16 year olds who reported they smoke at least once a week, 2013-14. 3% of 11-16 years olds within Hywel Dda reported they smoked at least once a week. Page 53 of 74

4.1.9 Alcohol Figure 50: Percentage of persons aged 11-16* years who reported being drunk the last 30 days, 2013-14. More girls (9%) than boys (8%) aged 11-16 years reported being drunk in the last 30 days. Figure 46: Persons aged 16-24 years who reported drinking above the recommended guidelines on at least one day in the previous week, 2008-11. 44.9% (n= 20,600) of persons aged 16-24 years reported drinking above the recommended guidelines on at least one day in the previous week, withinin Hywel Dda UHB. Page 54 of 74

Figure 47: Percentage of persons aged 11-16 years who reported using any illicit drug (even if only once), 2013-14. 9% boys and 7% girls from Hywel Dda UHB reported using any illicit drug. Hywel Dda reported similar score to the all Wales percentage. 4.1.10 Sexual health Figure 48: Conception rates in females aged under 18 years, Hywel Dda UHB, 2010-11. Page 55 of 74

Figure 48 highlights the geographical areas within each of the Health Board counties with the highest conception rates. Figure 49: Conception rate per 1,000 female aged under 18* years, local authorities within Hywel Dda UHB, 2003-12. The above shows the change in conception rates from 2003-2012. Carmarthenshire seems to have a steady decline, whereas Ceredigion and Pembrokeshire seem to have an increase in 2011, followed by a decline in 2012. Figure 50: Conception rates per 1,000 female under 18* years, health boards within Wales, 2003-12. Page 56 of 74

Figure 51: Tests for gonorrhoea and Chlamydia in persons aged 15-24 years by area of residence, rate per 1,000 population, 2007-11. Tests for gonorrhoea and chlamydia in persons aged 15-24 by area of residence, rate per 1,000 population Produced by Public Health Wales Observatory, using SWS data provided by CDSC (PHW) & MYE (ONS) Betsi Cadwaladr Powys Hywel Dda* ABM Cardiff & Vale Cwm Taf Aneurin Bevan Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pembrokeshire* Carmarthenshire* Swansea Neath Port Talbot Bridgend Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monmouthshire Newport Gonorrhoea (annual Positive test (%) average 2007-2011) Gonorrhoea Chlamydia Wales* = 32.1 42.8 5.6 3.8 33.9 35.4 25.6 42.3 38.2 32.6 51.7 55.4 19.3 67.0 5.6 4.0 1.4 5.3 39.7 31.6 23.9 25.7 37.8 27.5 18.3 32.1 28.1 45.5 25.8 67.1 0.7 1.3 0.5 1.5 1.8 1.3 2.1 0.3 0.4 0.5 1.0 0.8 0.8 1.3 0.0 0.0 0.9 1.4 1.6 1.8 1.8 1.8 1.4 0.7 2.0 3.0 2.1 1.6 2.1 17.5 11.9 9.2 12.8 11.8 13.7 12.4 18.8 15.6 16.7 14.3 15.2 22.1 11.9 8.0 9.1 13.5 13.0 11.3 13.6 10.2 12.0 13.2 16.2 13.1 15.9 13.9 9.6 11.2 Chlamydia (2011) 50.1 9.2 8.0 18.7 17.3 21.9 62.8 0.0 43.6 31.3 77.7 68.7 26.7 66.1 9.2 19.8 3.1 3.4 20.4 14.0 19.9 12.9 18.3 22.8 18.3 46.1 42.1 67.4 41.0 99.5 Wales* = 31.4 * Data from clinics in Carmarthenshire and Pembrokeshire are not 1.4 currently 14.0 available via SWS so the figures presented represent only residents who have visited clinics elsewhere. Please note that completeness on reporting of area of residence and coding of diagnosis is variable across clinics and so res ults should be interpreted with caution Although there are some queries about the data for Carmarthenshire and Pembrokeshire, Hywel Dda UHB has the lowest trends in Wales. Page 57 of 74

4.1.11 General health & well being Figure 54: Percentage of persons aged 11-16 years had a long-term illness, disability or medical condition (such as, diabetes, arthritis, allergy or cerebral palsy) that had been diagnosed by a doctor 2013-14. Hywel Dda UHB reported similar score to the all Wales percentage. Figure 55: Percentage of persons aged 11-16 years who rated their health as fair / poor, 2013-14. 13% of boys and 22% of girls reported their health as being fair / poor within Hywel Dda UHB. Page 58 of 74

4.1.12 Cancer % of patients on primary care chronic conditions register with asthma, persons % patients agedon under chronic 25, conditions February % patients 2012 register on with chronic asthma, conditions males register with asthma, Produced aged under by Public 25 years, Health Wales February Observatory, 2012 using Audit+ (NWIS) females aged under 25 years, February 2012 Produced by Public Health Males Wales Observatory, Produced using by Public Audit+ Health (NWIS) Females Wales Observatory, using Audit+ (NWIS) Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan 5.9 5.7 5.6 6.0 5.6 5.2 5.5 Wales = 5.7 Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan 5.2 5.2 4.8 5.3 4.8 4.2 4.7 Wales = 4.9 Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pem brokeshire Carm arthenshire Swansea Neath Port Talbot Bridgend Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monm outhshire Newport 7.7 6.4 5.8 5.3 5.3 5.7 5.7 5.0 6.2 5.6 5.6 6.6 6.1 6.1 5.5 5.2 5.2 5.4 5.0 5.8 5.7 5.4 Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pem brokeshire Carm arthenshire Swansea Neath Port Talbot Bridgend Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monm outhshire Newport 6.3 5.6 4.9 4.7 5.1 5.1 5.2 4.5 5.2 4.8 5.1 5.8 5.1 5.1 4.7 4.1 4.7 4.4 4.3 5.6 4.9 4.5 Ceredigion is statistically lower and Pembrokeshire is statistically higher than the Wales rates in males. Whereas the females in each of the locality areas showed no statistical difference to Wales. Page 59 of 74

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Rate per 1 million population Figure 56: Incidence of cancer*, persons aged 0-24 years, EASR per 100,000 population, 2007-2011. In Hywel Dda UHB there are on average 18 new cases of cancer per year. Figure 57: Cancer registration rates by cancer site for persons aged 0-24 years, Wales, 1998-2011. Cancer registration rates by cancer site for persons aged 0-24, Wales, 1998-2011 Produced by Public Health Wales Observatory, using MYE (ONS) & cancer registrations (WCISU) 60 Testis (males only)* Brain & central nervous system 50 40 30 20 10 0 60 50 40 30 20 10 0 60 50 40 30 20 10 0 Thyroid & endocrine Hodgkin's lymphoma Non-Hodgkin's lymphoma Leukaemia *Denominator for cancer of testis is males aged 0-24 years Page 60 of 74

4.1.13 Oral health Figure 58: Average decayed, missing and filled teeth (dmft) for 5 year olds, Welsh local health boards, 2007/08 compared with 2011/12. Hywel Dda, Betsi Cadwaladr and Abertawe Bro Morgannwg University Health Boards experienced statistically significant reductions. In Hywel Dda the averages were 2.0 (95%CI 1.8-2.2) and 1.2 (95%CI: 1.0-1.4) respectively. The 2011/12 Hywel Dda average was statistically lower when compared with the Welsh average for the same year (1.6, 95%CI: 1.5-1.7) Figure 59: Average dmft for 5 year olds, in unitary authorities within Hywel Dda UHB, 2007/08 compared with 2011/12. During 2007/08 average dmft values for all 3 Hywel Dda unitary authorities were within the average range when compared with the Welsh average for that same year. For Carmarthenshire UA there was a statistically significant reduction in average dmft between 2007/08 and 2011/12, from 2.2 to 1.0. There were reductions in the average dmft for Ceredigion (2007/08: 1.6 2011/12: 1.2) and Pembrokeshire (2007/08: 1.8 2011/12: 1.6) between the survey years. Neither of these changes was statistically significant. Page 61 of 74

Figure 51: Percentage of persons aged 11-16 years who reported brushing their teeth more than once a day, 2013-14. Page 62 of 74

Percent 4.2 ADULT AND OLDER POPULATIONS 4.2.1 Smoking Figure 52: Smoking prevalence in Hywel Dda UHB, 2003/04-14. Smoking Prevalence in Hywel Dda University Health Board (2003/4-2013/14). Source: Welsh Health Survey 30 25 20 20% Target (2016) 15 16% Target (2020) 10 5 Ceredigion Pembrokeshire Carmarthenshire Hywel Dda Wales 0 2003/04 & 2004/05 2004/05 & 2005/06 2005/06-2007 2007&08 2008&09 2009&10 2010&11 2011&12 2012&13 2013&14 Smoking prevalence in the area covered by Hywel Dda UHB continues to decline and is currently in line with the 2016 Tobacco Control Action Plan target (20% smoking prevalence by 2016). Figure 53: Percentage of adults reporting to be a current smoker, agestandardised percentage, persons, Hywel Dda UHB and Wales, 2003/04-14. Page 63 of 74

The map below shows that smoking prevalence by Upper Super Output Area varies considerably across Hywel Dda UHB. Darker shading represents areas with a higher proportion of people who currently smoke. Smoking prevalence in the most deprived areas is higher than in the least deprived areas, with the highest level seen in the Llanelli area of Carmarthenshire (26.3%-28.3%) and Pembroke Dock in Pembrokeshire (24.1%-26.3%). Figure 54: Percentage currently smoking, Hywel Dda UHB 2007-2012. Page 64 of 74

4.2.2 Physical activity Figure 55: Average number of days of 30 minutes moderate or vigorous physical activity (capped) reported by adults, age-standardised, Wales and local authorities, 2013-14. All three of the local authorities within Hywel Dda UHB are significantly higher than the all Wales average. Figure 56: Percentage of adults reporting to be physically active on no days in the past week, age standardised percentage, persons, Hywel Dda UHB and Wales, 2003/04-14. Page 65 of 74

Adults in Hywel Dda UHB reported being more active on 5+ days in the past week than the percentage reporting for all Wales. There is a statistical difference as highlighted in the table below: Figure 57: Percentage of adults reporting to be physically active on 5+ days in the past week, age-standardised percentage, persons, Hywel Dda UHB and Wales, 2003/04-14. 4.2.3 Obesity Figure 58: Number of survey respondents (weighted) and observed percentage with a BMI of 30 and over 35 and over, persons aged over 16, Wales health boards, 2013-14. Page 66 of 74

Wales Hywel Dda UHB Within Hywel Dda UHB 740 respondents reported a BMI of 30+ and 223 reported a BMI of 35+. Figure 59: Number of survey respondents (weighted) and observed percentage with a BMI of 40 and over and 50 and over, persons aged over 16, Wales health boards, 2009-14. Figure 60: Percentage of adults reporting to be overweight or obese, age group, all persons, Percentage Hywel of adults Dda reporting UHB and to be Wales, overweight 2012. or obese, by broad age group, all persons, Hywel Dda UHB and Wales Produced by Public Health Wales Observatory, using Welsh Health Survey (WG) 95% confidence interval 2004/05-2008 2009-2012 65+ 57 58 45-64 68 68 16-44 48 49 65+ 58 60 45-64 66 67 16-44 48 49 Page 67 of 74

Wales Hywel Dda UHB Figure 61: Percentage of adults reporting to be obese, age group, all persons, Hywel Dda Percentage UHB and Wales, of adults 2012. reporting to be obese, by broad age group, all persons, Hywel Dda UHB and Wales Produced by Public Health Wales Observatory, using Welsh Health Survey (WG) 95% confidence interval 2004/05-2008 2009-2012 65+ 19 21 45-64 24 29 16-44 16 19 65+ 18 20 45-64 25 27 16-44 17 19 4.2.4 Alcohol Figure 62: Percentage of adults reporting drinking above guidelines (males over 4 units, females over 3 units) on the heaviest drinking day in the past week, age-standardised percentage*, persons, Wales health boards, 2011-12. Percentage of adults reporting drinking above guidelines (males over 4 units, females over 3 units) on the heaviest drinking day in the past week, age-standardised percentage*, persons, Wales health boards, 2011-2012 Produced by Public Health Wales Observatory, using Welsh Health Survey (WG) 95% confidence interval Wales = 42.7 Betsi Cadwaladr UHB Powys thb Hywel Dda UHB ABM UHB Cardiff & Vale UHB Cwm Taf UHB Aneurin Bevan UHB 42.6 39.2 38.7 44.4 43.7 44.8 43.2 * Using aggregated weightings from the 2013 European Standard Population Hywel Dda UHB is significantly lower (38.7%) than the all Wales score of 42.7%. Page 68 of 74

Females Males Figure 63: Percentage of adults reporting drinking above guidelines (males over 4 units, Percentage females of adults over reporting 3 units) drinking on above the guidelines heaviest (males day over in the 4 units, past week, Hywel Dda UHB females 2008-12. over 3 units) on the heaviest drinking day in the past week, Hywel Dda UHB, 2008-2012 Produced by Public Health Wales Observatory, using Welsh Health Survey (WG) 95% confidence interval 16-24 46 25-44 51 45-64 48 65+ 32 16-24 42 25-44 41 45-64 37 65+ 14 The highest rates reported for drinking above guidelines was greatest in males between the ages of 25-44 years and females aged 16-24 years. Page 69 of 74

4.2.5 Excess winter deaths in residents aged 65 and over Figure 64: Excess Winter Deaths (EWD) index, Wales health boards, residents aged 65 and over, 2007-10. Hywel Dda UHB scored 22.7, which was slightly greater than the Welsh average of 21 for Excess Winter Deaths amongst residents aged 65 and over. Page 70 of 74

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CHAPTER 5: LINKS TO LOCAL SINGLE INTEGRATED PLANS The Single Integrated Plans commit all partners within the Local Service Board to a new way of working, which replaces previous plans and strategies. The websites with each Local Authority (listed below) provide full details about how each locality plan to address the wider determinants agenda, acknowledging the challenges of inequalities and deprivation. 5.1 Carmarthenshire The Integrated Community Strategy for Carmarthenshire 2011-2016 focuses on five strategic outcomes which all contribute to the overarching vision for the County: People in Carmarthenshire are healthier People in Carmarthenshire fulfil their learning potential People who love, work and visit Carmarthenshire are safe and feel safer. Carmarthenshire s communities and environment are sustainable Carmarthenshire has a stronger and more prosperous economy For further details please refer to: http://www.wales.nhs.uk/sitesplus/documents/862/ics%20integrated%20community %20Strategy%202011-2016.pdf Page 72 of 74

5.2 Ceredigion Ceredigion for All Ceredigion Local Service Board s Single Integrated Plan 2013-2017. This Plan has selected 3 outcomes to concentrate on in the coming years: Supporting families Economy and place Independent living For further details please refer to: http://www.ceredigion2020.org.uk/utilities/action/act_download.cfm?mediaid=45442& langtoken=eng Page 73 of 74

5.3 Pembrokeshire Pembrokeshire Single Integrated Plan 2013-2018. Six outcomes have been agreed in Pembrokeshire: Children, young people and families have the opportunity to fulfil their learning potential and to live healthy and happy lives Pembrokeshire has a competitive, productive and sustainable economy People in Pembrokeshire enjoy an attractive, sustainable and diverse environment People in Pembrokeshire are healthier Children and adults are safeguarded Communities in Pembrokeshire feel safe For further details please refer to: http://www.pembrokeshire.gov.uk/content.asp?nav=101,126,2182&parent_directory_ id=646&textonly=true Page 74 of 74