Explaining the excess mortality in Scotland compared with England: pooling of 18 cohort studies
- Gerry McCartney1,
- Tom C Russ2,3,4,
- David Walsh5,
- Jim Lewsey6,
- Michael Smith7,
- George Davey Smith8,
- Emmanuel Stamatakis9,10,
- G David Batty4,9
- 1NHS Health Scotland, Glasgow, UK
- 2Alzheimer Scotland Dementia Research Centre, University of Edinburgh, Edinburgh, UK
- 3Scottish Dementia Clinical Research Network, NHS Scotland, Murray Royal Hospital, Perth, UK
- 4Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
- 5Glasgow Centre for Population Health, Glasgow, UK
- 6Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
- 7NHS Greater Glasgow and Clyde, Glasgow, UK
- 8MRC Centre for Causal Analyses in Translational Epidemiology, School of Social and Community Medicine, University of Bristol, Bristol, UK
- 9Department of Epidemiology and Public Health, University College London, London, UK
- 10Charles Perkins Centre, University of Sydney, Sydney, Australia
- Correspondence to Dr Gerry McCartney, NHS Health Scotland, Glasgow G2 2AF, UK;
- Received 23 March 2014
- Revised 15 August 2014
- Accepted 20 August 2014
- Published Online First 12 September 2014
Background Mortality in Scotland is higher than in the rest of west and central Europe and is improving more slowly. Relative to England and Wales, the excess is only partially explained by area deprivation. We tested the extent to which sociodemographic, behavioural, anthropometric and biological factors explain the higher mortality in Scotland compared with England.
Methods Pooled data from 18 nationally representative cohort studies comprising the Health Surveys for England (HSE) and the Scottish Health Survey (SHS). Cox regression analysis was used to quantify the excess mortality risk in Scotland relative to England with adjustment for baseline characteristics.
Results A total of 193 873 participants with a mean of 9.6 years follow-up gave rise to 21 345 deaths. The age-adjusted and sex-adjusted all-cause mortality HR for Scottish respondents compared with English respondents was 1.40 (95% CI 1.34 to 1.47), which attenuated to 1.29 (95% CI 1.23 to 1.36) with the addition of the baseline socioeconomic and behavioural characteristics. Cause-specific mortality HRs attenuated only marginally to 1.43 (95% 1.28 to 1.60) for ischaemic heart disease, 1.37 (95% CI 1.15 to 1.63) for stroke, 1.41 (95% CI 1.30 to 1.53) for all cancers, 3.43 (95% CI 1.85 to 6.36) for illicit drug-related poisoning and 4.64 (95% CI 3.55 to 6.05) for alcohol-related mortality. The excess was greatest among young adults (16–44 years) and was observed across all occupational social classes with the greatest excess in the unskilled group.
Conclusions Only a quarter of the excess mortality among Scottish respondents could be explained by the available baseline risk factors. Greater understanding is required on the lived experience of poverty, the role of social support, and the historical, environmental, cultural and political influences on health in Scotland.
This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/