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'

OBJECTIVES: To determine the degree to which changing patterns of deprivation in Scotland and the rest of Great Britain between 1981 and 2001 explain Scotland's higher mortality rates over that period. DESIGN: Cross-sectional analyses using population and mortality data from around the 1981, 1991 and 2001 censuses. SETTING: Great Britain (GB). PARTICIPANTS: Populations of Great Britain enumerated in the 1981, 1991 and 2001 censuses. MAIN OUTCOME MEASURES: Carstairs deprivation scores derived for wards (England and Wales) and postcode sectors (Scotland). Mortality rates adjusted for age, sex and deprivation decile. RESULTS: Between 1981 and 2001 Scotland became less deprived relative to the rest of Great Britain. Age and sex standardized all-cause mortality rates decreased by approximately 25% across Great Britain, including Scotland but mortality rates were on average 12% higher in Scotland in 1981 rising to 15% higher in 2001. While over 60% of the excess mortality in 1981 could be explained by differences in deprivation profile, less than half the excess could be explained in 1991 and 2001. After adjusting for age, sex and deprivation, excess mortality in Scotland rose from 4.7% (95% CI: 3.9% to 5.4%) in 1981 to 7.9% (95% CI: 7.2% to 8.7%) in 1991 and 8.2% (95% CI: 7.4% to 9.0%) in 2001. All deprivation deciles showed excess indicating that populations in Scotland living in areas of comparable deprivation to populations in the rest of Great Britain always had higher mortality rates. By 2001 the largest excesses were found in the most deprived areas in Scotland with a 17% higher mortality rate in the most deprived decile compared to similarly deprived areas in England and Wales. Excess mortality in Scotland has increased most among males aged <65 years. CONCLUSIONS: Scotland's relative mortality disadvantage compared to the rest of Great Britain, after allowing for deprivation, is worsening. By 1991 measures of deprivation no longer explained most of the excess mortality in Scotland and the unexplained excess has persisted during the 1990s. More research is required to understand what is causing this 'Scottish effect'.     

Urban/rural inequalities in suicide in Scotland, 1981-1999

Although suicide accounts for a small percentage of deaths in Scotland (1.4% in 1999), it has been steadily increasing over the last two decades. In the US, Australia, England and Wales the greatest rises in suicide for this time period, occurred in rural areas. This study describes the pattern and magnitude of urban/rural variation in suicide in Scotland, examines methods of suicide within differing geographies and looks at trends in suicides over time. Scotland is split into four rurality types. Suicide data for all areas of Scotland (apart from Grampian which underwent changes in postcode sector boundaries in 1996) are investigated using Standardised Mortality Ratios (SMRs) and multilevel Poisson modelling, adjusting for age, sex and deprivation. SMRs for 1981-85, 1989-93 and 1995-99 are created across the four geographies, using the populations of Scotland in 1983, 1991 and 1997 as the standard populations (SMR=100). The highest rates in 1995-99 are seen in "remote rural" areas, SMR=125 (95% confidence interval 107-146). Models adjusted for age and deprivation show significantly greater risk of male suicide in remote rural areas relative to urban areas and significantly lower risk of female suicide in accessible rural areas. The method of suicide varies across ruralities for both males and females. The study considers how the relationship between suicides and rurality varies over time and how methods of suicide vary across different ruralities. The steepest rises in suicide amongst men, adjusting for age and deprivation, were seen to occur in accessible rural areas, however highest rates remain in remote rural areas.     

Urban/rural inequalities in suicide in Scotland, 1981–1999

Although suicide accounts for a small percentage of deaths in Scotland (1.4% in 1999), it has been steadily increasing over the last two decades. In the US, Australia, England and Wales the greatest rises in suicide for this time period, occurred in rural areas. This study describes the pattern and magnitude of urban/rural variation in suicide in Scotland, examines methods of suicide within differing geographies and looks at trends in suicides over time.Scotland is split into four rurality types. Suicide data for all areas of Scotland (apart from Grampian which underwent changes in postcode sector boundaries in 1996) are investigated using Standardised Mortality Ratios (SMRs) and multilevel Poisson modelling, adjusting for age, sex and deprivation. SMRs for 1981–85, 1989–93 and 1995–99 are created across the four geographies, using the populations of Scotland in 1983, 1991 and 1997 as the standard populations (SMR=100). The highest rates in 1995–99 are seen in “remote rural” areas, SMR=125 (95% confidence interval 107–146). Models adjusted for age and deprivation show significantly greater risk of male suicide in remote rural areas relative to urban areas and significantly lower risk of female suicide in accessible rural areas. The method of suicide varies across ruralities for both males and females. The study considers how the relationship between suicides and rurality varies over time and how methods of suicide vary across different ruralities. The steepest rises in suicide amongst men, adjusting for age and deprivation, were seen to occur in accessible rural areas, however highest rates remain in remote rural areas.     

Life and death of the people of London: a historical GIS of Charles Booth's inquiry

Social reformer Charles Booth undertook a massive survey into the social and economic conditions of the people of London at the end of the 19th century. An important innovation of his Inquiry was the construction of large, detailed maps displaying social class of inner London on a street-by-street basis. These provide a detailed and vivid picture of the geography of poverty and affluence at this time. These maps have been digitised, georeferenced and linked to contemporary ward boundaries allowing Booth's measurement of social class to be matched to the measurement of social class in the 1991 census of population and standardised mortality ratios derived for all causes of death in the survey area between 1991 and 1995. The social class data were used to derive an index of relative poverty for both time periods and a comparison of the geographies of relative poverty and their relationship with contemporary mortality was made. Although the overall standard of living had increased, the geography of poverty at the end of the 19th century was very similar to that at the end of the 20th century. Moreover, the geography of all causes of death for people over the age of 65 was more strongly related to the geography of poverty in the late 19th century than contemporary patterns of poverty. This relationship was also true for mortality for specific diseases that are related to deprivation in early life. The paper concludes that the spatial patterns of poverty in inner London are extremely robust and a century of change has failed to disrupt it.     

Towards a geography of fitness: an ethnographic case study of the gym in British bodybuilding culture

During recent years, research in health geography has engaged with peoples' health as well as diseases, an interest reflected by therapeutic geographies and geographies of public health. At the same time, studies have focused on micro-contexts such as the body, reflected in geographies of diseased and disadvantaged bodies. However, little research has combined elements of the two approaches and engaged in research on active healthy bodies and fitness. Equally the sub-discipline of sports geography provides little insight into fitness activities because this research has tended to focus on elite sports, their fans and facilities. Given these contexts, a detailed case study is presented to demonstrate the potential for geographical research on fitness. Through an observational study of a specialist gym facility, the study investigates how bodybuilding culture and place are co-produced. Indeed, the gym provides a narrative resource and a crucial setting for individual body projects and collective body culture which involve social conflicts, cohesions and hierarchies, illegal and potentially health harming activities, as well as personal comfort and therapeutic attachments. It is argued that beyond this case study, many activities crosscut health maintenance, or conversely risks to health, and the enjoyment of sports and fitness. A greater emphasis therefore at the sub-disciplinary interface of sports and health geography on hybrid 'fitness geographies' may help researchers towards a more comprehensive understanding, and coverage, of health issues in society.     

Geographical inequalities in health in New Zealand, 1980-200: the gap widens

OBJECTIVE: To monitor geographical inequalities in health in New Zealand during the period 1980 to 2001, a time of rapid social and economic change in society. METHODS: Age-standardised mortality rates were calculated using mortality records aggregated to a consistent set of geographical areas (the 2001 District Health Boards) for the periods 1980-82, 1985-87, 1990-92, 1995-97 and 1999-2001. In addition, the Relative Index of Inequality (RII) was calculated for each period to provide a robust measure of mortality rates over time. RESULTS: Although overall mortality rates have declined through the period 1980 to 2001, the reduction has not been consistent for all areas of New Zealand. Indeed for a small number of DHBs, mortality rates have increased slightly. There has been an increase in the geographical inequalities in health as measured by the RII between each time period except for between 1986 and 1991, where there was a small reduction. CONCLUSIONS: At the start of the 21st century, geographical inequalities in health in New Zealand have reached very high levels and continue to increase. The excess mortality for the worst areas in New Zealand increased from 15% in 1981 to 25% in 2000. If policy makers are committed to reducing health inequalities then more redistributive economic policies are required.     

Socioeconomic differentials in mortality among men within Great Britain: time trends and contributory causes

STUDY OBJECTIVE: To assess the size of mortality differentials in men by social class in Scotland as compared with England and Wales, and to analyse the time trends in these differentials. SUBJECTS: Men from England and Wales and Scotland around each census from 1951 to 1981. METHODS: Poisson regression analysis was used to calculate relative indices of inequality for disease specific and all cause mortality as a measure of mortality differentials between social classes. This measure is not dependent on the size of the social class groups, so it can be used to compare the magnitude of differentials over time periods during which the relative sizes of social class groups change. MAIN RESULTS: While overall death rates were higher in Scotland than in England and Wales around the 1951, 1961, and 1971 censuses the relative indices of inequality indicated smaller mortality differences between social classes in Scotland. Inequality, as indexed by the relative index of inequality, increased over time in both Scotland and England and Wales, but to a greater degree in Scotland, resulting in greater social class mortality differentials for Scotland in 1981 (the relative index of inequality increased from 1.40 to 2.43 for England and Wales, and from 1.22 to 2.57 for Scotland between 1951 and 1981). This greater increase in the magnitude of inequalities in all cause mortality in Scotland seemed to result from increasing social class differentials in cardiovascular disease, accidents and external causes, and "all other causes of death". Examining the trends in overall death rates, it seems that the greater increase in social class differences in Scotland occurred because of the greater decrease in death rates among the privileged social groups, in combination with a smaller decrease (or a greater increase) in the death rates in the lower social class groups. CONCLUSIONS: This study has shown that trends in mortality and in inequalities in mortality differ within Great Britain. Although death rates were higher in Scotland than in England and Wales, smaller mortality differentials by social class were found in Scotland over the period 1951 to 1971. By 1981, however, social class mortality differentials were greater in Scotland than in England and Wales. The greater increase in the social class differentials over time in Scotland, may have contributed to the worsening overall mortality profile in Scotland as compared with England and Wales that occurred between 1971 and 1981.       

The utility and validity for public health of ethnicity categorization in the 1991, 2001 and 2011 British Censuses

Objectives

To evaluate the utility and validity of the ethnicity categorizations across the 1991, 2001 and 2011 British Censuses for public health purposes.

Study design

Narrative review.

Methods

A review of journal literature and census and other policy reports was undertaken to assess specified criteria for the utility and validity of the 1991, 2001 and 2011 Censuses for public health.

Results

The census ethnicity categorization satisfactorily captures the ethnic diversity of the population, and adheres to the principle of self-identification in the labels used and underlying conceptual base. The stability of some of the categories (especially ‘Black’ groups and ‘Mixed’) continues to be problematic for public health. Concealed heterogeneity has been partially addressed in the ‘White’ group but remains in the ‘Black African’ group. Colour categories (‘White’ and ‘Black’) have been retained in the 2011 Census, with only limited objection amongst the communities they describe.

Conclusions

The complexity of the classifications and range of data on the dimensions of ethnicity have increased over the three decades. The breakdown of the ‘Black African’ group, the shortcomings of ‘Mixed’ categorization, and the way in which the ‘White’ category is subdivided require further investigation.     

A comparison of health inequalities in urban and rural Scotland

Previous research suggests that there are significant differences in health between urban and rural areas. Health inequalities between the deprived and affluent in Scotland have been rising over time. The aim of this study was to examine health inequalities between deprived and affluent areas of Scotland for differing ruralities and look at how these have changed over time. Postcode sectors in Scotland were ranked by deprivation and the 20% most affluent and 20% most deprived areas were found using the Carstairs indicator and male unemployment. Scotland was then split into 4 rurality types. Ratios of health status between the most deprived and most affluent areas were investigated using all cause mortality for the Scottish population, 1979-2001. These were calculated over time for 1979-1983, 1989-1993, 1998-2001. Multilevel Poisson modelling was carried out for all of Scotland excluding Grampian to assess inequalities in the population. There was an increase in inequalities between 1981 and 2001, which was greatest in remote rural Scotland for both males and females; however, male health inequalities remained higher in urban areas throughout this period. In 2001 female health inequalities were higher in remote rural areas than urban areas. Health inequalities amongst the elderly (age 65+) in 2001 were greater in remote rural Scotland than urban areas for both males and females.     

Selective internal migration. Does it explain Glasgow's worsening mortality record?

The mortality difference between Glasgow and the rest of Scotland has been increasing and mortality rates are higher than Glasgow's excess deprivation would suggest. One plausible explanation for this excess is selective migration. A sample of 137,073 individuals aged 15 to 64 in 1991 from the Scottish Longitudinal Study was used to test this explanation. Three geographic areas were compared: Glasgow; Aberdeen, Dundee and Edinburgh cities combined and the rest of Scotland. The impact of selective migration was assessed by calculating age and sex standardised mortality rates for 2001/03 by residence in 2001 and by residence in 1991. Glasgow experienced the greatest loss of population (−7.1%) between 1991 and 2001 but this was not strongly related to deprivation. It had the highest mortality at baseline and the difference between it and the other areas increased over the ten years. This pattern was not significantly affected by calculating death rates according to area of residence at 1991 or in 2001. Our results suggest that the increasing difference in mortality rates between Glasgow and the rest of Scotland over this period was probably not caused by selective migration.     

The changing face of infection: a comparative review of admissions to a regional infection unit over three decades

BACKGROUND AND AIMS: Our group previously published retrospective analyses of 12 months of admissions to the Grampian Regional Infectious Diseases Unit from 1980-81 and from 1991. This study aimed to collect data in 2001 and to compare annual admission numbers, diagnoses, duration of stay and outcome in 1980-81, 1991 and 2001. METHODS: Data on all admissions was collected prospectively throughout 2001. This was compared with the previously published data. RESULTS: Total admissions rose from 605 in 1980-81 to 900 in 1991 and to 1152 in 2001. Sixty one percent of admissions in 1980-81 were confirmed as having infection compared to 72% in 1991 and to 83% in 2001. The most common reason for admission in 2001 was skin and soft tissue infection, but this was only the ninth commonest reason in 1981. Mean length of stay fell from 9.6 days in 1980-81 to 7.4 days in 1991 and to 5.5 days in 2001. The mortality rate fell from 3.1% in 1981 and 1991 to 1.0% in 2001. CONCLUSIONS: This study demonstrates significant changes in type, number and outcome of admissions to a regional infection unit. We discuss possible reasons for these changes.     

Public policy and private provisions: changes in residential care from 1991 to 2001

This research examined changes in the number of care homes and their residents in the UK between the 1991 and 2001 Censuses. Local-authority-owned provision universally declined in this period, but changes in private residential and nursing homes were far more varied. Some parts of Britain experienced a growth in this market, in particular Scotland. Regions which were traditionally linked with greater numbers of retired people in their populations declined in their private residential home markets (e.g. the South West and South East). Wales experienced a regional decline that was greater than most English regions. Using additional Department of Health data, it was possible to estimate which local authority areas in England were exporting state-funded supported residents to homes out of their area. Most of these authorities were in urban areas and the highest rates of exporting were from Inner London boroughs. Political control and average property prices were explored as possible independent variables influencing the percentage rate of decline in homes in a local authority area. It appeared that Conservative authorities experienced a more rapid decline in government-owned homes than those run by Labour, but the results were not statistically significant, suggesting that local politics was a not a key influence on the trend. Average property prices did not affect all areas of the country, but were found to have a negative and significant association with percentage rates of decline in care homes in both Wales and London.     

沈阳市大东区中小学生身高体重长期变化趋势

目的描述沈阳市大东区7~18岁儿童青少年生长发育的长期趋势,为开展儿童青少年生长发育的有关研究提供参考。方法对沈阳市大东区1981,1991,2001和2008年4次学生健康体检的身高、体重数据进行比较。结果 1981-2008年学生身高、体重呈现逐渐增加的趋势。7~16岁男生1991-2001年、2001-2008年的身高增幅都小于1981-1991年,增长趋势出现减缓;身高快速增长年龄提前,女生提前趋势明显,2008年较1981年提前2岁。男、女生身高体重2次交叉的后交叉年龄逐渐提前。结论大东区男女生身高、体重呈现明显增加的长期趋势,青春发动的时间也显著提前。     

Marital status and bed occupancy in health and social care facilities in the United Kingdom

The purpose of the study was to test the hypothesis that marriage and physical health are positively related.A secondary analysis was performed of census data on all individuals aged 15 y and over occupying beds in general health and social care facilities (excluding mental health) in England and Wales, Scotland, and Northern Ireland in 1971, 1981 and 1991.Using bed occupancy in health and social care facilities as a proxy for ill health, this paper investigates the relationship between marital status and physical health in the United Kingdom. The findings, expressed as the proportion of individuals (excluding staff and visitors) aged 15 y and over within these facilities, suggest that: a) Whether considered separately or together, married men and women are healthier than non-married men and women, as reflected in their much lower use of health and social care beds; b) This positive relationship between marriage and health has increased steadily since the 1970s; c) Within the non-married population, whereas the single are most at risk among men, the widowed are most at risk among women; d) In contrast to the married and widowed, there are some consistent age-specific gender differences among the divorced and single, with men of working age at much higher risk than women of working age.This study confirms research findings elsewhere that marriage and physical health are positively related. Throughout the United Kingdom, not only are married people healthier than non-married people, as reflected in their much lower use of health and social care beds, but this relationship holds irrespective of gender.     

Predicting smoking behaviour in census output areas across Scotland

Spatially disaggregated surveys of smoking behaviour are rare and hence estimating the geography of the incidence of smoking is difficult. The main aim of this study is to develop a technique for estimating smoking probability for different age/sex groups in small areas across the whole of Scotland using information on smoking behaviour from the Scottish Household Survey. This is useful not only in its own right, but as an aid to studies of geographical variations in diseases such as lung cancer that, as a first step, need to control for smoking behaviour. The method developed uses individual-level characteristics from the Scottish Household Survey combined with a set of output area and pseudo-postcode sector measures from the 1991 census to model the probability of smoking. The parameters from this model are then used to make smoking predictions by age and sex for output areas across Scotland. This is the first time that such geographically detailed estimates of smoking have been made available.     

Themes in British health geography at the end of the century: a review of published research 1998-2000

This paper provides a succinct overview of some recent trends in geography of health in Britain since 1998. We consider how the research we have reviewed illuminates the relationships between geographies of health and three fundamental processes which are widely recognized as being important for contemporary human geography as a whole: globalization, urbanization and polarization. We also consider the contribution of health geography to agendas in cultural geography agenda which we refer to here as 'geographies of imagination'. These perspectives all relate to dynamic and diverse processes operating in Britain and throughout the world. We explore how health geography is responding to change, and what the agenda for future research will be. By considering these themes, we also seek to show how the geography of health is contributing to a wider discourse, shared to some extent in human geography as a whole, and we discuss the themes which are likely to feature in the future health geography research agenda.     

Urban-rural differences in self-reported limiting long-term illness in Scotland

BACKGROUND: Previous research suggests that there are significant differences in health between urban and rural areas. The aim of this study is to describe the pattern and magnitude of urban-rural variation in health in Scotland and to examine the factors associated with health inequalities in urban and rural areas. METHODS: The data used in this study were limiting long-term illness (LLTI) and socio-economic data collected by the 1991 Census. A rurality indicator was created using Scottish Household Survey rurality classifications. Multilevel Poisson regression modelling was carried out with LLTI as a health indicator for each type of rurality within Scotland. A variety of socio-economic factors were investigated for each rurality. RESULTS: Areas with the highest Standardized Illness Ratios (SIRs) (>125) are predominantly urban whereas the lowest SIRs (<75) are found in both urban and rural areas. Rural communities are more heterogeneous than urban areas in terms of their social make-up with relation to health; however, when these areas are split according to minor road length and different socio-economic factors are added, the model fit for each new model is improved and the reduction in total variation is comparable with that of the urban models. CONCLUSION: These findings suggest that rural areas should not be treated as a homogeneous group but should be subdivided into rural types.     

Low birthweight, preterm, and small for gestational age babies in Scotland, 1981-1984.

STUDY OBJECTIVE--The aim was to examine the effect of maternal age, gravidity, marital status, previous perinatal deaths, and parental social class on babies born low birthweight, preterm, and small for gestational age. DESIGN--The study used data on discharge summaries from all maternity hospitals in Scotland. SETTING--The study was based on all singleton deliveries in Scotland. PARTICIPANTS--The analysis involved information on 259,462 singleton babies born during the four years 1981-84 in Scotland. MEASUREMENTS AND MAIN RESULTS--Previous perinatal death was found to be the strongest predictor for both preterm and low birthweight. Single mothers were at particularly high risk of having a small for gestational age baby and those who were previously married of having a preterm baby. Women aged less than 20 years old, those over 34 years old, nulligravidae, and those of parity 3 or more were also at increased risk of adverse pregnancy outcome. Mothers and fathers in manual social classes and those who could not be assigned a social class on the basis of their occupation were at increased risk for all three adverse outcomes studied. The babies of parents who were in manual occupations were twice as likely as those of parents in non-manual occupations to be small for gestational age and almost twice as likely to be low birthweight. CONCLUSIONS--Mother's social class is a risk factor for adverse pregnancy outcome independent of maternal age, parity, and adverse reproductive history, and also independent of father's social class. Information on both parents' occupations should be collected in maternity discharge systems.     

Voluntarism, health and place: Bringing an emerging field into focus

Featuring a review of health geography contributions to the recent 'voluntary turn' in the health and social sciences, this paper introduces a theme section comprising five other papers that explore the links among voluntarism, health and place. The introductory paper elucidates the emergence of health voluntarism as a field of study within geography and highlights the crucial difference 'place' makes to understanding voluntary activity in the context of health, care and wellbeing. Questions are raised about theoretical, methodological and policy contributions and potential avenues for fulfilling a more inclusive 'health geographies of voluntarism' are discussed.