Original ResearchWhy the Scots die younger: Synthesizing the evidence
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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