Excess mortality: developing a coherent understanding and response
Gerry McCartneyNHS Health Scotland and ScotPHO
Outline
• Discuss the previous synthesis of the causes of the excess mortality
• Discuss the limitations of the previous synthesis
• Summarise subsequent relevant research
• Propose a framework for updating the synthesis and a prompt for discussion
[Note – I will be presenting lots of others’ work and the credit goes to them and blame for misrepresentation to me]
Previous synthesis
• Search for hypotheses • Application of Bradford‐Hill criteria for causality (Strength of
association, Consistency, Specificity, Temporality, Biological gradient, Plausibility, Coherence, Experiment, Analogy)
• Priority and emphasis given to most likely candidate hypotheses
• Periodisation of excess mortality • Creation of loose diagrams
Identified hypotheses – artefact and ‘downstream’
1. Poverty and material deprivation*
2. Migration
3. Genetic vulnerability
4. Health behaviours
* Only artefactual in relation to the excess mortality
Identified hypotheses – ‘midstream’
5. Different culture of substance misuse6. Different individual values (time, aspiration)7. Family, gender or parenting differences8. Health service supply or demand9. Greater inequalities10. Greater concentration of deprivation11. Deindustrialisation12. Sectarianism13. Different culture (boundlessness, alienation)14. Lower social capital
Identified hypotheses – ‘upstream’
15. Culture of limited social mobility
16. Political attack
17. Climate (sunlight, cold weather)
Number of Bradford-Hill criteria met by each hypothesis for the divergence of Scottish mortality in the mid-20th Century
0 1 2 3 4 5 6 7 8 9
Health service supply and demandCulture of limited social mobility
Different culture (boundlessness, alienation)Different culture of substance misuse
Climatic differencesGenetic differences
Deprivation and povertyFamily and gender differences
MigrationSectarianism
Political attackLower social capital
Different individual values (time, aspiration)
Deprivation concentrationDeindustrialisation
Greater inequalitiesHealth behaviours
Hyp
othe
sis
in r
elat
ion
to t
he d
iver
genc
e of
Sco
ttis
h
mor
tali
ty p
atte
rn f
rom
els
ewhe
re i
n Eu
rope
Number of Bradford-Hill criteria
Meets criteria
Does not meet criteria
0 1 2 3 4 5 6 7 8 9
Health service supply and demand
Culture of limited social mobility
Climatic differences
Different culture (boundlessness, alienation)
Different culture of substance misuse
Genetic differences
Family and gender differences
Migration
Sectarianism
Different individual values (time, aspiration)
Deprivation concentration
Deindustrialisation
Lower social capital
Artefact
Greater inequalities
Health behaviours
Political attack
Hyp
othe
sis
in r
elat
ion
to t
he e
mer
genc
e of
a
Scot
tish
Eff
ect
or G
lasg
ow E
ffec
t
Number of Bradford-Hill criteria
Meets criteria
Does not meet criteria
Number of Bradford-Hill criteria met by each hypothesis for the emergence of the Scottish Effect or Glasgow Effect
Substance misuse
Rise in inequality and poverty
Instability of industrial employment
Increased stress
Gender disharmony
Possible mechanisms and key factors Outcomes
Poverty and inequality
Migration patterns
Industrial dependence
Sectarian divide
Cardiovascular disease
Respiratory disease
Stroke
Cancer
Insecurity of employment
Overcrowded city centre housing
Development of new peripheral housing
estates
Scottish culture
Synthesis for the divergence of Scottish mortality from mid-20th
Century
Substance misuse
Rise in inequality and poverty
Instability of industrial employment
Increased stress
Gender disharmony
Possible mechanisms and key factors Outcomes
Poverty and inequality
Migration patterns
Industrial dependence
Sectarian divide
Cardiovascular disease
Respiratory disease
Stroke
Cancer
Insecurity of employment
Overcrowded city centre housing
Development of new peripheral housing
estates
Scottish culture
Synthesis for the divergence of Scottish mortality from mid-20th
Century
Reduced community cohesion
Breakdown in confidence of working class communities
Decreased well-being
Substance misuse
Suicide
Vulnerability
Rise in inequality and
poverty
Increased violence
Disempowerment and hopelessness
1976 financial crisis and subsequent
'political attack' by Thatcher government on numerous elements
of the organised working class
Increased stress
Individuation and competition
Reduced self-esteem & self-efficacy
Trigger Mechanisms Outcomes
Scottish culture
Greater poverty and inequality
Industrial dependence
Sectarian divide
Scottish climate
Genetic factors
Road-traffic accidents
Alcohol-related
Drugs-related
Cardiovascular disease
Respiratory disease
Stroke
Cancer
Family breakdown
Deindustrialisation
Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’
Reduced community cohesion
Breakdown in confidence of working class communities
Decreased well-being
Substance misuse
Suicide
Vulnerability
Rise in inequality and
poverty
Increased violence
Disempowerment and hopelessness
1976 financial crisis and subsequent
'political attack' by Thatcher government on numerous elements
of the organised working class
Increased stress
Individuation and competition
Reduced self-esteem & self-efficacy
Trigger Mechanisms Outcomes
Scottish culture
Greater poverty and inequality
Industrial dependence
Sectarian divide
Scottish climate
Genetic factors
Road-traffic accidents
Alcohol-related
Drugs-related
Cardiovascular disease
Respiratory disease
Stroke
Cancer
Family breakdown
Deindustrialisation
Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’
Reduced community cohesion
Breakdown in confidence of working class communities
Decreased well-being
Substance misuse
Suicide
Vulnerability
Rise in inequality and
poverty
Increased violence
Disempowerment and hopelessness
1976 financial crisis and subsequent
'political attack' by Thatcher government on numerous elements
of the organised working class
Increased stress
Individuation and competition
Reduced self-esteem & self-efficacy
Trigger Mechanisms Outcomes
Scottish culture
Greater poverty and inequality
Industrial dependence
Sectarian divide
Scottish climate
Genetic factors
Road-traffic accidents
Alcohol-related
Drugs-related
Cardiovascular disease
Respiratory disease
Stroke
Cancer
Family breakdown
Deindustrialisation
Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’
Political attack by the Thatcher government
post 1979
Reduced community cohesion
Breakdown in confidence of working class communities
Decreased well-being
Substance misuse
Suicide
Vulnerability
Rise in inequality and
poverty
Increased violence
Disempowerment and hopelessness
1976 financial crisis and subsequent
'political attack' by Thatcher government on numerous elements
of the organised working class
Increased stress
Individuation and competition
Reduced self-esteem & self-efficacy
Trigger Mechanisms Outcomes
Scottish culture
Greater poverty and inequality
Industrial dependence
Sectarian divide
Scottish climate
Genetic factors
Road-traffic accidents
Alcohol-related
Drugs-related
Cardiovascular disease
Respiratory disease
Stroke
Cancer
Family breakdown
Deindustrialisation
Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’
Political attack by the Thatcher government
post 1979
Limitations of existing synthesis1. Lots of new research has been published
Limitations of existing synthesis1. Lots of new research has been publisheda. Taulbut M, Walsh D. Poverty, parenting and poor health: comparing early years’ experiences in Scotland, England and three city
regions. Glasgow, Glasgow Centre for Population Health, 2013. b. Rush L, McCartney G, Walsh D, MacKay D. Vitamin D and subsequent all‐age and premature mortality: a systematic review. BMC Public
Health 2013, 13: 679.c. Walsh D, McCartney G. Trends in terminations of pregnancy in Glasgow, Liverpool and Manchester. Public Health 2013; 127: 143‐152.d. Graham P, Walsh D, McCartney G. Shipyards and sectarianism: how do mortality and deprivation compare in Glasgow and Belfast?
Public Health 2012; 126(5): 378–385.e. McCartney G, Shipley M, Hart C, Smith GD, Kivimaki M, Walsh D, Watt GC, Batty GD. Why Do Males in Scotland Die Younger Than Those
in England? Evidence From Three Prospective Cohort Studies. PLoS One 2012; 7(7). f. Stanners G., Walsh D., McCartney G. Is ‘excess’ mortality in Glasgow an artefact of measurement? Submitted, 2014. g. Walsh D, McCartney G, McCullough S, et al. Exploring potential reasons for Glasgow’s ‘excess’ mortality: results of a three city survey of
Glasgow, Liverpool and Manchester. Glasgow, Glasgow Centre for Population Health, 2013. h. Shipton D, Whyte B, Walsh D. Alcohol‐related mortality in deprived UK cities: worrying trends in young women challenge recent
national downward trends. al. J Epi Community Health 2013; 0:1–8. doi:10.1136/jech‐2013‐202574. i. Livingston M, Walsh D, Whyte B, Bailey N. The spatial distribution of deprivation. Glasgow, Glasgow Centre for Population Health, 2013. j. Tunstall H, Mitchell R, Gibbs J, Platt S, Dorling D. Socio‐demographic diversity and unexplained variation in death rates among the most
deprived parliamentary constituencies in Britain. Journal of Public Health 2011; 34(2): 296–304. k. Ji C, Kandala NB, Cappuccio FP. Spatial variation of salt intake in Britain and association with socioeconomic status. BMJ Open 2013; 3:
e002246.doi:10.1136/bmjopen‐2012‐002246. l. Desai M, Nolte E, Karanikolos M, Khoshaba B, McKee M. Measuring NHS performance 1990–2009 using amenable mortality: interpret
with care. J R Soc Med 2011: 104: 370–379.m. Connolly S, Rosato M, Kinnear H, O’Reilly D. Variation in mortality by country of birth in Northern Ireland: A record linkage study.
Health &Place 2011: doi:10.1016/j.healthplace.2011.03.001n. Brown D, O’Reilly D, Gayle V, Macintyre S, Benzeval M, Leyland AH. Socio‐demographic and health characteristics of individuals left
behind. Health &Place 2012; 18: 440–444.
And more are currently underway…
Limitations of existing synthesis1. Lots of new research has been published2. Non‐systematic searches of the literature 3. Reductionist to consider individual hypotheses for causality
rather than groups or pathways4. Synthesis does not clearly explain all observed phenomena 5. Limited description of lagged or historical effects
Summary of subsequent & planned research (1)
1. Early years and parenting
Percentage of children living in poverty, Glasgow, Liverpool and Manchester: 2009Source: HMRC
34.3 34.4
39.8
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
Glasgow Liverpool Manchester
Perc
enta
ge
Percentage of mothers reporting father plays a big role, equal to mother, age 7 and 11, Glasgow & the Clyde Valley, Merseyside and Greater Manchester: 1965 and 1969
Source: NCDS 1958
61.5
73.272.7
59.760.865.9
0.0
20.0
40.0
60.0
80.0
100.0
Glasgow & theClyde Valley
Merseyside GreaterManchester
Glasgow & theClyde Valley
Merseyside GreaterManchester
Age 7 Age 11(*)
Per
cent
age
Percentage of parents with a CAGE score of >=2, child age 3: 2004Source: Millenium Cohort Survey
7.5
4.2
18.1
16.0
0
5
10
15
20
25
G. Manchester Glasgow & the Clyde Valley G. Manchester Glasgow & the Clyde Valley
Mother (*) Father
Perc
enta
ge
Percentage of mothers with medium-high psychological distress (Kessler score), Glasgow & the Clyde Valley and Greater Manchester: 2004, 2006 and 2008
Sources: Millenium Cohort Study
31.9
36.9
29.532.5 30.1
32.9
0.0
10.0
20.0
30.0
40.0
50.0
Glasgow & theClyde Valley
GreaterManchester
Glasgow & theClyde Valley
GreaterManchester
Glasgow & theClyde Valley
GreaterManchester
Age 3 Age 5 Age 7
Per
cent
age
Parents reading to child at age 7: 1965Source: National Child Development Study 1958
14.2
19.5
13.6
23.5
29.2 28.1
0.0
10.0
20.0
30.0
40.0
Glasgow & theClyde Valley
Merseyside GreaterManchester
Glasgow & theClyde Valley
Merseyside GreaterManchester
Mother hardly ever reads to child (*) Father hardly ever reads to child
Perc
enta
ge
Percentage of BCS70 cohort with low warmth score (<7) at age 10: 1980Source: British Cohort Survey 1970
9.29.4
6.3
0
5
10
15
Glasgow & the Clyde Valley Merseyside Greater Manchester
Per
cent
age
Summary of subsequent & planned research (1)
1. Early years and parenting 2. 3 cities survey – social capital, sense of coherence,
psychological outlook
Social capital ‐ reciprocity
Reciprocity: % exchanging favours with people who live nearby
46.6%
63.6%
41.8%
0%
20%
40%
60%
80%
Glasgow Liverpool Manchester
How many people exchange favours with? (mean)
2.1
2.9
2.3
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
Glasgow Liverpool Manchester
Social capital ‐ trust
Trust: % saying most people in neighbourhood can be trusted
17.1%
27.0%
22.7%
0%
5%
10%
15%
20%
25%
30%
35%
Glasgow Liverpool Manchester
Trust: % saying most people in neighbourhood can be trusted
31.5%
21.2%
39.1%
31.6%
23.8%
17.9%
22.7%
28.8%
19.8%
14.0%
18.9%
13.9%
10.7%
24.2%
11.8%
0%
10%
20%
30%
40%
50%
Glas Liv Man Glas Liv Man Glas Liv Man Glas Liv Man Glas Liv Man
1 (Most) 2 3 4 5 (least)
And same overall pattern by age and sex as well
Unpaid help: at least one example of unpaid help in previous 12 months
7.1%
17.3%
15.3%
0%
5%
10%
15%
20%
25%
Glasgow Liverpool Manchester
Unpaid help: at least one example of unpaid help in previous 12 months
4.2%
16.7%
15.6%
9.8%
17.7%
14.9%
0%
5%
10%
15%
20%
25%
Glasgow Liverpool Manchester Glasgow Liverpool Manchester
Male Female
Unpaid help: at least one example of unpaid help in previous 12 months
5.8%
16.4% 17.1%
6.1%
18.1%
14.6%
10.6%
17.4%
14.6%
4.6%
17.8%
12.0%
0%
5%
10%
15%
20%
25%
Glasgow Liverpool Man Glasgow Liverpool Man Glasgow Liverpool Man Glasgow Liverpool Man
16 ‐ 29 30 ‐ 44 45 ‐ 64 65+
Age Group
Unpaid help: at least one example in previous 12 months
10.5%
32.6%31.7%
10.9%
20.0%
26.9%
5.4%
11.5%9.4%
4.5%
14.8%
9.0%
4.7%
14.3%
4.2%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Glas Liv Man Glas Liv Man Glas Liv Man Glas Liv Man Glas Liv Man
A & B (higher andintermed
managerial/admin/prof)
C1 (supervisory, clerical,junior managerial/
admin/ prof)
C2 (skilled manual) D (semi‐skilled/ unskilledmanual)
E (on state benefit/unemployed/ lowest
grade workers)
Social Grade
Social capital ‐ summary
• Views of local area, civic participation, social networks/support all similar (or better)
• But lower reciprocity, trust and social participation (e.g. volunteering)
• Some of clearest differences in comparison of those of high SES…
Sense of Coherence
Mean Sense of Coherence (soc‐13) score (13‐91)
67.6
63.1
59.3
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
Glasgow Liverpool Manchester
Mean Sense of Coherence (soc‐13) score (13‐91)
63.364.6
69.7
65.167.8
72.2
69.2
58.7
65.963.2 61.9
54.1 53.8
63.8
58.3
0
10
20
30
40
50
60
70
80
Glas Liv Man Glas Liv Man Glas Liv Man Glas Liv Man Glas Liv Man
A & B (higher and intermedmanagerial/admin/prof)
C1 (supervisory, clerical, juniormanagerial/ admin/ prof)
C2 (skilled manual) D (semi‐skilled/ unskilled manual) E (on state benefit/ unemployed/lowest grade workers)
Psychological outlook
Life Orientation Test (revised) (LOT‐R): mean overall optimism score (0‐24)
13.9
14.714.7
0.0
5.0
10.0
15.0
20.0
Glasgow Liverpool Manchester
Life Orientation Test (revised) (LOT‐R) mean score (possible score range: 0‐24)
14.815.715.1
15.816.316.1
15.214.0 14.5 14.2
13.011.7 12.3
14.9
13.3
0.0
5.0
10.0
15.0
20.0
Glas Liv Man Glas Liv Man Glas Liv Man Glas Liv Man Glas Liv Man
A & B (higher andintermed
managerial/admin/prof)
C1 (supervisory, clerical,junior managerial/ admin/
prof)
C2 (skilled manual) D (semi‐skilled/ unskilledmanual)
E (on state benefit/unemployed/ lowest grade
workers)
Life Orientation Test (revised) (LOT‐R) mean score (possible score range: 0‐24)
14.314.115.114.8
13.414.3
15.4 15.314.3 14.4 14.3
13.5
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
Glasgow Liverpool Man Glasgow Liverpool Man Glasgow Liverpool Man Glasgow Liverpool Man
16 ‐ 29 30 ‐ 44 45 ‐ 64 65+
Age Group
Summary of subsequent & planned research (1)
1. Early years and parenting 2. 3 cities survey ‐ social capital, sense of coherence,
psychological outlook 3. Vitamin D
SMR of Glasgow relative to Belfast(indirectly standardised to two‐city deprivation deciles, age and gender)
Summary of subsequent & planned research (1)
1. Early years and parenting 2. 3 cities survey ‐ social capital, sense of coherence,
psychological outlook 3. Vitamin D 4. Health behaviours
Model Deaths NEngland Scotland
HR HRAge‐ & sex‐adjusted
(basic model)21,345 193,873 1
1.40(1.34 to 1.47)
+ Occupational social class 20,410 183,043 11.39
(1.33 to 1.46)
+ Educational attainment 21,318 193,733 11.39
(1.32 to 1.45)
+ Smoking status 21,309 193,068 11.31
(1.25 to 1.37)+ Frequency of alcohol
consumption21,311 191,531 1
1.39(1.33 to 1.45)
+ Self‐assessed general health 21,339 193,835 11.39
(1.33 to 1.46)
+ Longstanding illness 21,341 193,829 11.41
(1.35 to 1.48)
Multiply adjusted 20,330 181,560 11.29
(1.23 to 1.36)
Hazard ratios for all‐cause mortality: Scotland relative to England
Source: McCartney G, Russ TC, Walsh D, Lewsey J, Smith M, Davey Smith G, Stamatakis E, Batty GD. Explaining the excess mortality in Scotland compared with England: pooling of 18 cohort studies [forthcoming].
Summary of subsequent & planned research (1)
1. Early years and parenting 2. 3 cities survey ‐ social capital, sense of coherence,
psychological outlook 3. Vitamin D 4. Health behaviours 5. Spatial patterning of deprivation
Spatial patterning of deprivation
Summary of subsequent & planned research (1)
1. Early years and parenting 2. 3 cities survey ‐ social capital, sense of coherence,
psychological outlook 3. Vitamin D 4. Health behaviours 5. Spatial patterning of deprivation 6. Historical, political and economic influences on mortality
across deindustrialised areas in Europe
Source: Taulbut M, Walsh D, McCartney G, et al. Spatial inequalities in life expectancy within postindustrial regions of Europe: a cross-sectional observational study. BMJ Open 2014; 4: e004711.
Source: Taulbut M, Walsh D, McCartney G, et al. Spatial inequalities in life expectancy within postindustrial regions of Europe: a cross-sectional observational study. BMJ Open 2014; 4: e004711.
Box plots of spatial variation in female life expectancy (showing maximum, minimum, upper and lower quartile data within each region)
Source: Taulbut M, Walsh D, McCartney G, et al. Spatial inequalities in life expectancy within postindustrial regions of Europe: a cross-sectional observational study. BMJ Open 2014; 4: e004711.
Box plots of spatial variation in male life expectancy (showing maximum, minimum, upper and lower quartile data within each region)
Underlying influences across deindustrialised areas in Europe• Transition from an industrial region and diversification was
more problematic in West Central Scotland (WCS)• Other areas emphasised social protection and social cohesion
whilst WCS focussed on economic growth • The deprivation and inequality in WCS have resulted from the
social and economic policy pursued• Other deindustrialising areas have made a successful social,
economic and health transition
Source: Daniels G. Underlying influences on health and mortality trends in post‐industrial regions of Europe. PhD thesis. University of Glasgow, 2013 (submitted).
Summary of subsequent & planned research (1)
1. Early years and parenting 2. 3 cities survey ‐ social capital, sense of coherence,
psychological outlook 3. Vitamin D 4. Health behaviours 5. Spatial patterning of deprivation 6. Historical, political and economic influences on mortality
across deindustrialised areas in Europe 7. Qualitative work comparing Glasgow‐Liverpool‐Manchester
Summary of subsequent & planned research (2)
1. Was the scale of urban change experienced historically in the cities different?
2. Was there a differences in ‘vulnerability’ of the cities to national and local political decisions?
3. Were there differences in housing quality and provision?4. Were there differences in diet?5. Were there differences in the nature of employment?6. Systematic review of hypotheses7. …then update the synthesis
Trends in overcrowding% population living in overcrowded households, 1981‐2001
Source: Census
0
5
10
15
20
25
30
1981 1991 2001
% of total pop
ulation
Glasgow
Manchester
Liverpool
Distribution of overcrowding (households > 1 person per room) across city‐specific deciles, 1971
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
1 (highest) 2 3 4 5 6 7 8 9 10(lowest)
City‐specific decile
% of households
Glasgow
Liverpool
Manchester
Proposed method for synthesis
1. Review and update hypotheses and evidence for these2. Create causal models using the more plausible hypotheses3. Test and iterate causal models against ability to explain all
observed phenomena 4. Identify assumptions and remaining research questions
Early thoughts on updated synthesis
European comparisons
Poverty, deprivation & deindustrialisation
e.g. Silesia Nor-pas-de-Calais
Merseyside West Central Scotland
Worse health within countries
Poverty, deprivation & deindustrialisation
e.g. Silesia Nor-pas-de-Calais
Merseyside West Central Scotland
Worse health within countries
Neoliberal economic policy from 1980s
UK areas improve more slowly and
inequalities are wider
European comparisons
Poverty, deprivation & deindustrialisation
Excess mortality in Glasgow
UK comparisons
Poverty, deprivation & deindustrialisation
Excess mortality in Glasgow
? greater scale of urban change
? greater vulnerability to neoliberalism
UK comparisons
? political influences
Summary• Poverty, deprivation and deindustrialisation are all important causes of
high mortality and health inequalities
• The combination of this with a neoliberal economic policy from the 1980s is likely to be part of the explanation for the worse health emerging in the UK
• There is some emerging evidence that Glasgow may have been more vulnerable to the changing political context (e.g. disinvestment in council housing) and experienced greater urban change
• There is some emerging evidence that urban change in Glasgow both greater in scale than other cities and that the nature of this change may have more detrimental to population health (e.g. Liverpool encourages growth of suburbs within city, migrants to New Towns less skewedtowards the more affluent population)
• Work is ongoing to understand the political influences on the different outcomes across Glasgow, Liverpool and Manchester
Discussion and task: 1. Have any important factors/plausible explanations not been
mentioned in the presentations/discussion?
2. Do you agree with the proposed method for synthesising the evidence? Or are there other ways of looking at this?
3. In the light of evidence amassed to date, can your table construct plausible causal pathways to explain the excess mortality seen among different populations in Glasgow and Scotland?