Comparing Antonovsky's sense of coherence scale across three UK post-industrial cities

Objectives: High levels of ‘excess’ mortality (ie, that seemingly not explained by deprivation) have been shown for Scotland compared to England and Wales and, especially, for its largest city, Glasgow, compared to the similarly deprived English cities of Liverpool and Manchester. It has been suggested that this excess may be related to differences in ‘Sense of Coherence’ (SoC) between the populations. The aim of this study was to ascertain whether levels of SoC differed between these cities and whether, therefore, this could be a plausible explanation for the ‘excess’. Setting: Three post-industrial UK cities: Glasgow, Liverpool and Manchester. Participants: A representative sample of more than 3700 adults (over 1200 in each city). Primary and secondary outcome measures: SoC was measured using Antonovsky's 13-item scale (SOC-13). Multivariate linear regression was used to compare SoC between the cities while controlling for characteristics (age, gender, SES etc) of the samples. Additional modelling explored whether differences in SoC moderated city differences in levels of self-assessed health (SAH). Results: SoC was higher, not lower, among the Glasgow sample. Fully adjusted mean SoC scores for residents of Liverpool and Manchester were, respectively, 5.1 (−5.1 (95% CI −6.0 to −4.1)) and 8.1 (−8.1 (−9.1 to −7.2)) lower than those in Glasgow. The additional modelling confirmed the relationship between SoC and SAH: a 1 unit increase in SoC predicted approximately 3% lower likelihood of reporting bad/very bad health (OR=0.97 (95% CI 0.96 to 0.98)): given the slightly worse SAH in Glasgow, this resulted in slightly lower odds of reporting bad/very bad health for the Liverpool and Manchester samples compared to Glasgow. Conclusions: The reasons for the high levels of ‘excess’ mortality seen in Scotland and particularly Glasgow remain unclear. However, on the basis of these analyses, it appears unlikely that a low SoC provides any explanation

Has Scotland always been the ‘sick man’ of Europe? An observational study from 1855 to 2006

Background: Scotland has been dubbed ‘the sick man of Europe’ on account of its higher mortality rates compared with other western European countries. It is not clear the length of time for which Scotland has had higher mortality rates. The root causes of the higher mortality in Scotland remain elusive. Methods: Life expectancy data from the Human Mortality Database were tabulated and graphed for a selection of wealthy, mainly European countries from around 1850 onwards. Results: Scotland had a life expectancy in the mid-range of countries included in the Human Mortality Database from the mid-19th century until around 1950. After 1950, Scottish life expectancy improved at a slower rate than in comparably wealthy nations before further faltering during the last 30 years. Scottish life expectancy now lies between that of western European and eastern European nations. The USA also displays a marked faltering in its life expectancy trend after 1981. There is an inverse association between life expectancy and the Index of Economic Freedom such that greater neoliberalism is associated with a smaller increase, or a decrease, in life expectancy. Conclusion: Life expectancy in Scotland has only been relatively low since around 1950. From 1980, life expectancy in Scotland, the USA and, to a greater extent, the former USSR displays a further relative faltering. It has been suggested that Scotland suffered disproportionately from the adoption of neoliberalism across the nations of the UK, and the evidence here both supports this suggestion and highlights other countries which may have suffered similarly

Do patients who die from an alcohol-related condition ‘drift’ into areas of greater deprivation? Alcohol-related mortality and health selection theory in Scotland

Background: Health selection has been proposed to explain the patterning of alcohol-related mortality by area deprivation. This study investigated whether persons who die from alcohol-related conditions are more likely to experience social drift than those who die from other causes. Methods: Deaths recorded in Scotland (2013, >21 years) were coded as ‘alcohol-related’ or ‘other’ and by deprivation decile of residence at death. Acute hospital admissions data from 1996 to 2012 were used to provide premortality deprivation data. χ² tests estimated the difference between observed and expected alcohol-related deaths by first Scottish Index of Multiple Deprivation (SIMD) decile and type of death. Logistic regression models were fitted using type of death as the outcome of interest and change in SIMD decile as the exposure of interest. Results: Of 47 012 deaths, 1458 were alcohol-related. Upward and downward mobility was observed for both types of death. An estimated 31 more deaths than expected were classified ‘alcohol-related’ among cases whose deprivation score decreased, while 204 more deaths than expected were classified ‘alcohol-related’ among cases whose initial deprivation ranking was in the four most deprived deciles. Becoming more deprived and first deprivation category were both associated with increased odds of type of death being alcohol-related after adjusting for confounders. Conclusion: This study suggests that health selection appears to contribute less to the deprivation gradient in alcohol-related mortality in Scotland than an individual’s initial area deprivation category

Regional alcohol consumption and alcohol-related mortality in Great Britain: novel insights using retail sales data

Background: Regional differences in population levels of alcohol-related harm exist across Great Britain, but these are not entirely consistent with differences in population levels of alcohol consumption. This incongruence may be due to the use of self-report surveys to estimate consumption. Survey data are subject to various biases and typically produce consumption estimates much lower than those based on objective alcohol sales data. However, sales data have never been used to estimate regional consumption within Great Britain (GB). This ecological study uses alcohol retail sales data to provide novel insights into regional alcohol consumption in GB, and to explore the relationship between alcohol consumption and alcohol-related mortality. Methods: Alcohol sales estimates derived from electronic sales, delivery records and retail outlet sampling were obtained. The volume of pure alcohol sold was used to estimate per adult consumption, by market sector and drink type, across eleven GB regions in 2010–11. Alcohol-related mortality rates were calculated for the same regions and a cross-sectional correlation analysis between consumption and mortality was performed. Results: Per adult consumption in northern England was above the GB average and characterised by high beer sales. A high level of consumption in South West England was driven by on-trade sales of cider and spirits and off-trade wine sales. Scottish regions had substantially higher spirits sales than elsewhere in GB, particularly through the off-trade. London had the lowest per adult consumption, attributable to lower off-trade sales across most drink types. Alcohol-related mortality was generally higher in regions with higher per adult consumption. The relationship was weakened by the South West and Central Scotland regions, which had the highest consumption levels, but discordantly low and very high alcohol-related mortality rates, respectively. Conclusions: This study provides support for the ecological relationship between alcohol-related mortality and alcohol consumption. The synthesis of knowledge from a combination of sales, survey and mortality data, as well as primary research studies, is key to ensuring that regional alcohol consumption, and its relationship with alcohol-related harms, is better understood

Drug-related deaths in Scotland 1979-2013: evidence of a vulnerable cohort of young men living in deprived areas

Background: Even after accounting for deprivation, mortality rates are higher in Scotland relative to the rest of Western Europe. Higher mortality from alcohol- and drug-related deaths (DRDs), violence and suicide (particularly in young adults) contribute to this ‘excess’ mortality. Age-period and cohort effects help explain the trends in alcohol-related deaths and suicide, respectively. This study investigated whether age, period or cohort effects might explain recent trends in DRDs in Scotland and relate to exposure to the changing political context from the 1980s. Methods: We analysed data on DRDs from 1979 to 2013 by sex and deprivation using shaded contour plots and intrinsic estimator regression modelling to identify and quantify relative age, period and cohort effects. Results: The peak age for DRDs fell around 1990, especially for males as rates increased for those aged 18 to 45 years. There was evidence of a cohort effect, especially among males living in the most deprived areas; those born between 1960 and 1980 had an increased risk of DRD, highest for those born 1970 to 1975. The cohort effect started around a decade earlier in the most deprived areas compared to the rest of the population. Conclusion: Age-standardised rates for DRDs among young adults rose during the 1990s in Scotland due to an increased risk of DRD for the cohort born between 1960 and 1980, especially for males living in the most deprived areas. This cohort effect is consistent with the hypothesis that exposure to the changing social, economic and political contexts of the 1980s created a delayed negative health impact

How do trends in mortality inequalities by deprivation and education in Scotland and England & Wales compare? A repeat cross-sectional study

Objective: To compare the trends in mortality inequalities by educational attainment with trends using area deprivation. Setting: Scotland and England & Wales (E&W). Participants: All people resident in Scotland and E&W between 1981 and 2011 aged 35–79 years. Primary outcome measures: Absolute inequalities (measured using the Slope Index of Inequality (SII)) and relative inequalities (measured using the Relative Index of Inequality (RII)) in all-cause mortality. Results: Relative inequalities in mortality by area deprivation have consistently increased for men and women in Scotland and E&W between 1981–1983 and 2010–2012. Absolute inequalities increased for men and women in Scotland, and for women in E&W, between 1981–1983 and 2000–2002 before subsequently falling. For men in E&W, absolute inequalities were more stable until 2000–2002 before a subsequent decline. Both absolute and relative inequalities were consistently higher in men and in Scotland. These trends contrast markedly with the reported declines in mortality inequalities by educational attainment and apparent improvement of Scotland’s inequalities with those in E&W. Conclusions: Trends in health inequalities differ when assessed using different measures of socioeconomic status, reflecting either genuinely variable trends in relation to different aspects of social stratification or varying error or bias. There are particular issues with the educational attainment data in Great Britain prior to 2001 that make these education-based estimates less certain

Spatial inequalities in life expectancy within postindustrial regions of Europe: a cross-sectional observational study

Objectives To compare spatial inequalities in life expectancy (LE) in West Central Scotland (WCS) with nine other postindustrial European regions.<p></p> Design A cross-sectional observational study.<p></p> Setting WCS and nine other postindustrial regions across Europe.<p></p> Participants Data for WCS and nine other comparably deindustrialised European regions were analysed. Male and female LEs at birth were obtained or calculated for the mid-2000s for 160 districts within selected regions. Districts were stratified into two groups: small (populations of between 141 000 and 185 000 people) and large (populations between 224 000 and 352 000). The range and IQR in LE were used to describe within-region disparities.<p></p> Results In small districts, the male LE range was widest in WCS and Merseyside, while the IQR was widest in WCS and Northern Ireland. For women, the LE range was widest in WCS, though the IQR was widest in Northern Ireland and Merseyside. In large districts, the range and IQR in LE was widest in WCS and Wallonia for both sexes.<p></p> Conclusions Subregional spatial inequalities in LE in WCS are wide compared with other postindustrial mainland European regions, especially for men. Future research could explore the contribution of economic, social and political factors in reducing these inequalities.<p></p&gt

Evaluating the impact of the Alcohol Act on off-trade alcohol sales: a natural experiment in Scotland

<b>Background and aims</b> A ban on multi-buy discounts of off-trade alcohol was introduced as part of the Alcohol Act in Scotland in October 2011. The aim of this study was to assess the impact of this legislation on alcohol sales, which provide the best indicator of population consumption.<p></p> <b>Design Setting and Participants</b> Interrupted time-series regression was used to assess the impact of the Alcohol Act on alcohol sales among off-trade retailers in Scotland. Models accounted for underlying seasonal and secular trends and were adjusted for disposable income, alcohol prices and substitution effects. Data for off-trade retailers in England and Wales combined (EW) provided a control group.<p></p> <b>Measurements</b> Weekly data on the volume of pure alcohol sold by off-trade retailers in Scotland and EW between January 2009 and September 2012.<p></p> <b>Findings</b> The introduction of the legislation was associated with a 2.6% (95% CI -5.3 to 0.2%, P = 0.07) decrease in off-trade alcohol sales in Scotland, but not in EW (-0.5%, -4.6 to 3.9%, P = 0.83). A statistically significant reduction was observed in Scotland when EW sales were adjusted for in the analysis (-1.7%, -3.1 to -0.3%, P = 0.02). The decline in Scotland was driven by reduced off-trade sales of wine (-4.0%, -5.4 to -2.6%, P < 0.001) and pre-mixed beverages (-8.5%, -12.7 to -4.1%, P < 0.001). There were no associated changes in other drink types in Scotland, or in sales of any drink type in EW.<p></p> <b>Conclusions</b> The introduction of the Alcohol Act in Scotland in 2011 was associated with a decrease in total off-trade alcohol sales in Scotland, largely driven by reduced off-trade wine sales

Challenges in evaluating Welfare to Work policy interventions: would an RCT design have been the answer to all our problems?

<p>Background: UK policy direction for recipients of unemployment and sickness benefits is to support these people into employment by increasing 'into work' interventions. Although the main aim of associated interventions is to increase levels of employment, improved health is stated as a benefit, and a driver of these interventions. This is therefore a potentially important policy intervention with respect to health and health inequalities, and needs to be validated through rigorous impact evaluation.</p> <p>We attempted to evaluate the Pathways Advisory Service intervention which aims to provide employment support for Incapacity Benefit recipients, but encountered a number of challenges and barriers to evaluation. This paper explores the issues that arose in designing a suitable evaluation of the Pathways Advisory Service.</p> <p>Discussion: The main issues that arose were that characteristics of the intervention lead to difficulties in defining a suitable comparison group; and governance restrictions such as uncertainty regarding ethical consent processes and data sharing between agencies for research. Some of these challenges threatened fundamentally to limit the validity of any experimental or quasi-experimental evaluation we could design - restricting recruitment, data collection and identification of an appropriate comparison group. Although a cluster randomised controlled trial design was ethically justified to evaluate the Pathways Advisory Service, this was not possible because the intervention was already being widely implemented. However, this would not have solved other barriers to evaluation. There is no obvious method to perform a controlled evaluation for interventions where only a small proportion of those eligible are exposed. Improved communication between policymakers and researchers, clarification of data sharing protocols and improved guidelines for ethics committees are tangible ways which may reduce the current obstacles to this and other similar evaluations of policy interventions which tackle key determinants of health.</p> <p>Summary: The evaluation of social interventions is hampered by more than their suitability to randomisation. Data sharing, participant identification and recruitment problems are common to randomised and non-randomised evaluation designs. These issues require further attention if we are to learn from current social policy.</p&gt