Elsevier

Public Health

Volume 126, Issue 6, June 2012, Pages 459-470
Public Health

Original Research
Why the Scots die younger: Synthesizing the evidence

https://doi.org/10.1016/j.puhe.2012.03.007Get rights and content

Summary

Objective

To identify explanations for the higher mortality in Scotland relative to other European countries, and to synthesize those best supported by evidence into an overall explanatory framework.

Study design

Review and dialectical synthesis.

Methods

Candidate hypotheses were identified based on a literature review and a series of research dissemination events. Each hypothesis was described and critically evaluated in relation to the Bradford-Hill criteria for causation in observational epidemiology. A synthesis of the more convincing hypotheses was then attempted using a broadly ‘dialectical’ approach.

Results

Seventeen hypotheses were identified including: artefactual explanations (deprivation, migration); ‘downstream explanations’ (genetics, health behaviours, individual values); ‘midstream’ explanations (substance misuse; culture of boundlessness and alienation; family, gender relations and parenting differences; lower social capital; sectarianism; culture of limited social mobility; health service supply or demand; deprivation concentration); and ‘upstream’ explanations (climate, inequalities, de-industrialization, political attack). There is little evidence available to determine why mortality rates diverged between Scotland and other European countries between 1950 and 1980, but the most plausible explanations at present link to particular industrial, employment, housing and cultural patterns. From 1980 onwards, the higher mortality has been driven by unfavourable health behaviours, and it seems quite likely that these are linked to an intensifying climate of conflict, injustice and disempowerment. This is best explained by developing a synthesis beginning from the political attack hypothesis, which suggests that the neoliberal policies implemented from 1979 onwards across the UK disproportionately affected the Scottish population.

Conclusions

The reasons for the high Scottish mortality between 1950 and 1980 are unclear, but may be linked to particular industrial, employment, housing and cultural patterns. From 1980 onwards, the higher mortality is most likely to be accounted for by a synthesis which begins from the changed political context of the 1980s, and the consequent hopelessness and community disruption experienced. This may have relevance to faltering health improvement in other countries, such as the USA.

Introduction

Life expectancy in Scotland (75.8 years for men and 80.4 years for women in 2008–2010), particularly the West of Scotland and Glasgow (71.6 years for men and 78.0 years for women in 2008–2010),1, 2 is markedly lower than that in other European nations and the rest of the UK (Fig. 1).3 However, mortality has not always been worse in Scotland; it was only from around 1950 onwards that Scottish life expectancy diverged.3, 4 From the mid-point of last century, higher mortality rates were largely attributable to chronic disease: cardiovascular disease, stroke and cancer. Alcohol-related deaths, together with those ascribed to ‘external’ causes including suicide, were all lower in Scotland from 1950 to 1980 than in other Western European countries.3 The Scottish mortality differential intensified during the 1980s, and its composition changed.5, 6, 7 Mortality rates increased for alcohol- and drug-related deaths, ‘external causes’ (principally violent deaths and road traffic accidents) and suicide. This added to continuing high rates for cardiovascular disease,8 cancer and stroke.7, 9, 10, 11 Furthermore, the ability of the Carstairs Index (a measure of area deprivation derived from census data) to explain the excess mortality in Scotland12, 13 compared with England and Wales declined from around two-thirds in 1981 to under half in 1991 and 2001.14 Over the same time period, the excess in mortality increased. The reason(s) for this is (are) not clear, and this has led to the labelling of this modern phenomenon as the ‘Scottish effect’.5, 15

To the authors' knowledge, this is the first report to collate the various hypotheses proposed to explain the higher mortality during these two distinct periods of divergence, and evaluate how well each can be seen to explain the trends by reviewing the current evidence base in light of the Bradford-Hill criteria for causality based on observational data.16 This was done in order to develop a more integrated understanding of the contributory causes of the mortality phenomena. Investigating the pattern of Scotland's mortality divergence may also help to inform efforts to explain faltering health improvement in other countries during the 1980s, such as the USA.17

Section snippets

Methods

A five-pronged approach was used to search for evidence: (1) Embase (1980–April 2010) and Medline (1950–April 2010) electronic databases were searched using the strategy outlined in Webtable 1; (2) key authors' websites were searched for other publications; (3) reference sections of key papers were scrutinized; (4) publications citing these papers were traced (forward citation); and (5) an internet (Google) search was undertaken based on the terms ‘Scottish effect’, ‘Glasgow effect’, ‘excess

Results

The electronic database search yielded 309 potentially relevant papers. From these, 76 were selected for detailed examination on the basis of the relevance of the title and abstract. The notes from the discussions at various fora for the dissemination of previous research5, 9, 10, 12, 13 identified further hypotheses which were not reflected in the academic literature.

In total, 17 hypotheses were identified which addressed either: the higher mortality in Scotland, the higher mortality in

Discussion

Clearly, further work is required on the higher mortality in Scotland between 1950 and 1980. The most plausible causal explanation on the basis of current thinking and available evidence is that higher poverty, deprivation and inequality were associated with particular industrial employment patterns, housing and urban environments, particular community and family dynamics, and negative health behaviour cultures. From 1980 onwards, the higher mortality is driven by negative health behaviours,

Conclusion

For over half a century, Scotland has suffered from higher mortality than comparably wealthy countries, and for the last 30 years has suffered from a new and troubling mortality pattern. It is unlikely that any single cause is entirely responsible, and there is uncertainty around why Scotland started to diverge from elsewhere in Europe around 1950. It is clearer that the health and social patterns that emerged from the 1980s are more closely linked to negative health behaviours (e.g. alcohol

Acknowledgements

Ethical approval

None sought.

Funding

None declared.

Competing interests

GM is a member of the Scottish Socialist Party. DW, GDB and CC have no competing interests.

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