A “Scottish effect” for health? Frank Popham, University of St Andrews f.popham@st-andrews.ac.uk

Source: Human mortality database

Source: Author calculations from Human mortality database life tables

Defining the Scottish effect Carstairs and Morris (1989) Scotland more deprived than England and Wales (Carstairs score, an area based score of % unemployed, low social class, no car ownership and overcrowding) Accounting for deprivation in 1981, rather than social class, largely negated the mortality difference SMR 103 (for all ages and under 65s) after adjustment for deprivation Carstairs V, Morris R. (1989) Deprivation: Explaining differences in mortality between Scotland and England and Wales. BMJ 299: 886-889

Defining the Scottish effect cont. Hanlon et al. (2001, 2005) Found compared to 1981 in 1991 and 2001 that Carstairs score was explaining less of the mortality excess (from 60% to below 50%) This residual excess located mainly in those of working age The inability of deprivation to fully explain differences was named the Scottish effect What could this be? Suggest a psychosocial explanation. Scotland facing a ‘crisis of confidence’? Hanlon P, et al. (2005) Why is mortality higher in Scotland than in England and Wales? Decreasing influence of socioeconomic deprivation between 1981 and 2001 supports the existence of a ‘Scottish effect'. J Public Health 27(2): 199-204.

Support for the Scottish effect Mitchell et al. (2005) using comparable health survey data from 1998 found that Scotland’s higher prevalence of self reported heart disease (ages 45 to 74) could not be explained by differences in Social class, employment status Health behaviours Physical measurements (blood pressure etc.) Self reported mental health Odds ratio reduced from age adjusted 1.64 to 1.50 Mitchell R, et al. (2005) High rates of ischaemic heart disease in Scotland are not explained by conventional risk factors. Journal of Epidemiology and Community Health 59(7): 565-567.

Questioning the Scottish effect Apart from Mitchell et al. most studies have used aggregated measures of deprivation I used 2001 individual level census data Country of birth approach (ages 25 to 64) Individual employment status, tenure, car access and housing quality For general health odds ratio reduced from 1.31 to 1.04 (for born Scotland live Scotland compared to born England live England) No Scottish effect? probably is difference in socio-economic circumstances (particularly employment)? However, not mortality! Popham F. (2006) Is there a “Scottish effect" for self reports of health? Individual level analysis of the 2001 UK census. BMC Public Health 6(1): 191.

De-industrialisation? Walsh et al. (in press) Like others identified a recent rise in mortality for 15-44 year olds in (west central) Scotland (especially amongst males) not seen in other European de-industrialised areas Aggregate measures of wealth / employment do not explain regional differences (Scotland is relatively wealthy) De-industrialisation and deprivation not the whole story despite de-industrialisation being particularly severe in Scotland However, an aggregate level picture Is variation within Scotland larger / grown more than in other locations and is this the cause of the Scottish effect? Walsh D et al. (in press) The aftershock of deindustrialization--trends in mortality in Scotland and other parts of post-industrial Europe. European Journal of Public Health .

Widening inequalities in Scotland Leyland et al. 2008 Under 65 mortality rates decreased 1991 to 2001 by more in least deprived areas and actually increased in the most deprived for men (so little change from 1981). In all areas heart disease and cancer mortality rates have fallen (although less fast in more deprived) but in more deprived areas replaced by suicide, alcohol related and drug deaths A clue to the Scottish effect? Leyland A, et al. (2007) Cause-specific inequalities in mortality in Scotland: Two decades of change. A population-based study. BMC Public Health 7(1): 172.

New analysis Human mortality database Scotland added in 2008 Life tables allow measures of disparity to be calculated and decomposed Move beyond life expectancy Demographers using “e-dagger” = average life expectancy lost per death. Lower value means people more likely to die at same age http://paa2009.princeton.edu/download.aspx?submissionId=90499

Source: Human mortality database

Source: Human mortality database

Is it drugs? Bloor et al. (2008) found that a third of the excess deaths in Scotland for 15 to 54 year olds could be explained by illicit drug use (using estimates derived from the DORIS study) However, this was the age and sex adjusted excess rather than the deprivation adjusted excess So not clear if this is a part of the mechanism through which deprivation causes mortality or a distinct explanation of the Scottish effect Bloor M, et al. (2008) Contribution of problem drug users' deaths to excess mortality in Scotland: Secondary analysis of cohort study. BMJ 337: a478.

Conclusions The most likely explanation for Scotland’s higher mortality remains the negative socio-economic position of a larger proportion of its population Whether there is a distinct additional Scottish effect for mortality is not proven Joint analysis of the Scottish Longitudinal Study / ONS Longitudinal Study will allow an individual level test of the existence of the Scottish effect

Acknowledgements Thanks to the Chief Scientist Office and the Scottish Collaboration for Public Health Policy and Research who have / are funding some of my research in this area These are my opinions only, however