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Walsh D, McCartney G, Collins C, Taulbut M, Batty GD. History, politics and vulnerability: explaining excess mortality in Scotland and Glasgow. Public Health 2017; 151:1-12. [PMID: 28697372 DOI: 10.1016/j.puhe.2017.05.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 05/24/2017] [Accepted: 05/30/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES High levels of excess mortality (i.e. that not explained by deprivation) have been observed for Scotland compared with England & Wales, and especially for Glasgow in comparison with similar post-industrial cities such as Liverpool and Manchester. Many potential explanations have been suggested. Based on an assessment of these, the aim was to develop an understanding of the most likely underlying causes. Note that this paper distils a larger research report, with the aim of reaching wider audiences beyond Scotland, as the important lessons learnt are relevant to other populations. STUDY DESIGN Review and dialectical synthesis of evidence. METHODS Forty hypotheses were examined, including those identified from a systematic review. The relevance of each was assessed by means of Bradford Hill's criteria for causality alongside-for hypotheses deemed causally linked to mortality-comparisons of exposures between Glasgow and Liverpool/Manchester, and between Scotland and the rest of Great Britain. Where gaps in the evidence base were identified, new research was undertaken. Causal chains of relevant hypotheses were created, each tested in terms of its ability to explain the many different aspects of excess mortality. The models were further tested with key informants from public health and other disciplines. RESULTS In Glasgow's case, the city was made more vulnerable to important socioeconomic (deprivation, deindustrialisation) and political (detrimental economic and social policies) exposures, resulting in worse outcomes. This vulnerability was generated by a series of historical factors, processes and decisions: the lagged effects of historical overcrowding; post-war regional policy including the socially selective relocation of population to outside the city; more detrimental processes of urban change which impacted on living conditions; and differences in local government responses to UK government policy in the 1980s which both impacted in negative terms in Glasgow and also conferred protective effects on comparator cities. Further resulting protective factors were identified (e.g. greater 'social capital' in Liverpool) which placed Glasgow at a further relative disadvantage. Other contributory factors were highlighted, including the inadequate measurement of deprivation. A similar 'explanatory model' resulted for Scotland as a whole. This included: the components of the Glasgow model, given their impact on nationally measured outcomes; inadequate measurement of deprivation; the lagged effects of deprivation (in particular higher levels of overcrowding historically); and additional key vulnerabilities. CONCLUSIONS The work has helped to further understanding of the underlying causes of Glasgow's and Scotland's high levels of excess mortality. The implications for policy include the need to address three issues simultaneously: to protect against key exposures (e.g. poverty) which impact detrimentally across all parts of the UK; to address the existing consequences of Glasgow's and Scotland's vulnerability; and to mitigate against the effects of future vulnerabilities which are likely to emerge from policy responses to contemporary problems which fail sufficiently to consider and to prevent long-term, unintended social consequences.
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Affiliation(s)
- D Walsh
- Glasgow Centre for Population Health, Olympia Building, 2-16 Orr Street, Bridgeton Cross, Glasgow G40 2QH, Scotland, UK.
| | | | - C Collins
- University of the West of Scotland, Paisley Campus, Scotland, UK
| | - M Taulbut
- NHS Health Scotland, Glasgow, Scotland, UK
| | - G D Batty
- University College London, London, UK
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McCartney G, Hearty W, Taulbut M, Mitchell R, Dryden R, Collins C. Regeneration and health: a structured, rapid literature review. Public Health 2017; 148:69-87. [DOI: 10.1016/j.puhe.2017.02.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/20/2017] [Accepted: 02/27/2017] [Indexed: 10/19/2022]
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Walsh D, McCartney G, Collins C, Taulbut M, Batty GD. History, politics and vulnerability: explaining excess mortality in a post-industrial Scottish city. Eur J Public Health 2016. [DOI: 10.1093/eurpub/ckw166.061] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Walsh D, McCartney G, Collins C, Taulbut M, Batty GD. P85 History, politics and vulnerability: explaining excess mortality in Glasgow. Br J Soc Med 2016. [DOI: 10.1136/jech-2016-208064.184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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McCartney G, Bouttell J, Craig N, Craig P, Graham L, Lakha F, Lewsey J, McAdams R, MacPherson M, Minton J, Parkinson J, Robinson M, Shipton D, Taulbut M, Walsh D, Beeston C. Explaining trends in alcohol-related harms in Scotland 1991-2011 (II): policy, social norms, the alcohol market, clinical changes and a synthesis. Public Health 2016; 132:24-32. [PMID: 26921977 DOI: 10.1016/j.puhe.2015.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/21/2015] [Accepted: 12/25/2015] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To provide a basis for evaluating post-2007 alcohol policy in Scotland, this paper tests the extent to which pre-2007 policy, the alcohol market, culture or clinical changes might explain differences in the magnitude and trends in alcohol-related mortality outcomes in Scotland compared to England & Wales (E&W). STUDY DESIGN Rapid literature reviews, descriptive analysis of routine data and narrative synthesis. METHODS We assessed the impact of pre-2007 Scottish policy and policy in the comparison areas in relation to the literature on effective alcohol policy. Rapid literature reviews were conducted to assess cultural changes and the potential role of substitution effects between alcohol and illicit drugs. The availability of alcohol was assessed by examining the trends in the number of alcohol outlets over time. The impact of clinical changes was assessed in consultation with key informants. The impact of all the identified factors were then summarised and synthesised narratively. RESULTS The companion paper showed that part of the rise and fall in alcohol-related mortality in Scotland, and part of the differing trend to E&W, were predicted by a model linking income trends and alcohol-related mortality. Lagged effects from historical deindustrialisation and socio-economic changes exposures also remain plausible from the available data. This paper shows that policy differences or changes prior to 2007 are unlikely to have been important in explaining the trends. There is some evidence that aspects of alcohol culture in Scotland may be different (more concentrated and home drinking) but it seems unlikely that this has been an important driver of the trends or the differences with E&W other than through interaction with changing incomes and lagged socio-economic effects. Substitution effects with illicit drugs and clinical changes are unlikely to have substantially changed alcohol-related harms: however, the increase in alcohol availability across the UK is likely to partly explain the rise in alcohol-related mortality during the 1990s. CONCLUSIONS Future policy should ensure that alcohol affordability and availability, as well as socio-economic inequality, are reduced, in order to maintain downward trends in alcohol-related mortality in Scotland.
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Affiliation(s)
- G McCartney
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom.
| | - J Bouttell
- Health Economics and Health Technology Assessment, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, United Kingdom.
| | - N Craig
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom.
| | - P Craig
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Top Floor, 200 Renfield Street, Glasgow, G2 3QB, United Kingdom.
| | - L Graham
- Public Health and Intelligence, NHS National Services Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh, EH12 9EB, United Kingdom.
| | - F Lakha
- NHS Lothian, Waverley Gate, 2-4 Waterloo Place, Edinburgh EH1 3EG, United Kingdom.
| | - J Lewsey
- Health Economics and Health Technology Assessment, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, United Kingdom.
| | - R McAdams
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom.
| | - M MacPherson
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom.
| | - J Minton
- Urban Studies, School of Social and Political Sciences, University of Glasgow, 25 Bute Gardens, Glasgow, United Kingdom.
| | - J Parkinson
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom.
| | - M Robinson
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom.
| | - D Shipton
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom.
| | - M Taulbut
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom.
| | - D Walsh
- Glasgow Centre for Population Health, Olympia Building, Bridgeton Cross, Glasgow, G40 2QH, United Kingdom.
| | - C Beeston
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, United Kingdom.
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McCartney G, Bouttell J, Craig N, Craig P, Graham L, Lakha F, Lewsey J, McAdams R, MacPherson M, Minton J, Parkinson J, Robinson M, Shipton D, Taulbut M, Walsh D, Beeston C. Explaining trends in alcohol-related harms in Scotland, 1991-2011 (I): the role of incomes, effects of socio-economic and political adversity and demographic change. Public Health 2016; 132:13-23. [PMID: 26917268 DOI: 10.1016/j.puhe.2015.12.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/21/2015] [Accepted: 12/25/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This paper tests the extent to which differing trends in income, demographic change and the consequences of an earlier period of social, economic and political change might explain differences in the magnitude and trends in alcohol-related mortality between 1991 and 2011 in Scotland compared to England & Wales (E&W). STUDY DESIGN Comparative time trend analyses and arithmetic modelling. METHODS Three approaches were utilised to compare Scotland with E&W: 1. We modelled the impact of changes in income on alcohol-related deaths between 1991-2001 and 2001-2011 by applying plausible assumptions of the effect size through an arithmetic model. 2. We used contour plots, graphical exploration of age-period-cohort interactions and calculation of Intrinsic Estimator coefficients to investigate the effect of earlier exposure to social, economic and political adversity on alcohol-related mortality. 3. We recalculated the trends in alcohol-related deaths using the white population only to make a crude approximation of the maximal impact of changes in ethnic diversity. RESULTS Real incomes increased during the 1990s but declined from around 2004 in the poorest 30% of the population of Great Britain. The decline in incomes for the poorest decile, the proportion of the population in the most deprived decile, and the inequality in alcohol-related deaths, were all greater in Scotland than in E&W. The model predicted less of the observed rise in Scotland (18% of the rise in men and 29% of the rise in women) than that in E&W (where 60% and 68% of the rise in men and women respectively was explained). One-third of the decline observed in alcohol-related mortality in Scottish men between 2001 and 2011 was predicted by the model, and the model was broadly consistent with the observed trends in E&W and amongst women in Scotland. An age-period interaction in alcohol-related mortality was evident for men and women during the 1990s and 2000s who were aged 40-70 years and who experienced rapidly increasing alcohol-related mortality rates. Ethnicity is unlikely to be important in explaining the trends or differences between Scotland and E&W. CONCLUSIONS The decline in alcohol-related mortality in Scotland since the early 2000s and the differing trend to E&W were partly described by a model predicting the impact of declining incomes. Lagged effects from historical social, economic and political change remain plausible from the available data.
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Affiliation(s)
- G McCartney
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, UK.
| | - J Bouttell
- Health Economics and Health Technology Assessment, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK.
| | - N Craig
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, UK.
| | - P Craig
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Top Floor, 200 Renfield Street, Glasgow, G2 3QB, UK.
| | - L Graham
- Public Health and Intelligence, NHS National Services Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh, EH12 9EB, UK.
| | - F Lakha
- NHS Lothian, Waverley Gate, 2-4 Waterloo Place, Edinburgh EH1 3EG, UK.
| | - J Lewsey
- Health Economics and Health Technology Assessment, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK.
| | - R McAdams
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, UK.
| | - M MacPherson
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, UK.
| | - J Minton
- Urban Studies, School of Social and Political Sciences, University of Glasgow, 25 Bute Gardens, University of Glasgow, Glasgow, UK.
| | - J Parkinson
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, UK.
| | - M Robinson
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, UK.
| | - D Shipton
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, UK.
| | - M Taulbut
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, UK.
| | - D Walsh
- Glasgow Centre for Population Health, Olympia Building, Bridgeton Cross, Glasgow, G40 2QH, UK.
| | - C Beeston
- NHS Health Scotland, Meridian Court, 5 Cadogan Street, Glasgow, G2 6QE, UK.
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Taulbut M, Walsh D, Parcell S, Hartmann A, Poirier G, Strniskova D, Daniels G, Hanlon P. What can ecological data tell us about reasons for divergence in health status between West Central Scotland and other regions of post-industrial Europe? Public Health 2013; 127:153-63. [DOI: 10.1016/j.puhe.2012.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Revised: 08/29/2012] [Accepted: 11/10/2012] [Indexed: 11/28/2022]
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