Excess mortality: developing a coherent understanding and ... · PDF fileExcess mortality: developing a coherent understanding and response Gerry McCartney NHS Health Scotland and

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


Sectarian divide


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


Sectarian divide

Scottish climate

Genetic factors

Road-traffic accidents

Alcohol-related

Drugs-related


Respiratory disease

Stroke

Cancer

Family breakdown

Deindustrialisation

Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’




Substance misuse

Suicide

Vulnerability


poverty

Increased violence





Increased stress




Scottish culture



Sectarian divide

Scottish climate

Genetic factors


Alcohol-related

Drugs-related


Respiratory disease

Stroke

Cancer

Family breakdown

Deindustrialisation





Substance misuse

Suicide

Vulnerability


poverty

Increased violence





Increased stress




Scottish culture



Sectarian divide

Scottish climate

Genetic factors


Alcohol-related

Drugs-related


Respiratory disease

Stroke

Cancer

Family breakdown

Deindustrialisation


Political attack by the Thatcher government

post 1979




Substance misuse

Suicide

Vulnerability


poverty

Increased violence





Increased stress




Scottish culture



Sectarian divide

Scottish climate

Genetic factors


Alcohol-related

Drugs-related


Respiratory disease

Stroke

Cancer

Family breakdown

Deindustrialisation


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



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


GreaterManchester


GreaterManchester


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





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


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%


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


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%


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%



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


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%


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


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


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


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


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


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)



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].



psychological outlook 3. Vitamin D 4. Health behaviours 5. Spatial patterning of deprivation

Spatial patterning of deprivation



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.


Box plots of spatial variation in female life expectancy (showing maximum, minimum, upper and lower quartile data within each region)


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).



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


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


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


Excess mortality in Glasgow

UK comparisons


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?

Thank you for listening/heckling**delete as appropriate

Contact: [email protected]

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Excess mortality: developing a coherent understanding and ... · PDF fileExcess mortality: developing a coherent understanding and response Gerry McCartney NHS Health Scotland and