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2.  The effect of area of residence over the life course on subsequent mortality 
Life course epidemiology concentrates on the contribution that social or physical exposures have across the life course on adult health. It is known that the area of residence can affect health, but little is known about the effect of the area of residence across the life course. We examine the contribution that area of residence in 1960, 1970, 1980 and 1990 made on subsequent mortality for 49736 male inhabitants of Oslo in 1990. We compare the performance of multiple-membership and cross-classified multilevel models on these data with a correlated cross-classified model that was developed for this.
PMCID: PMC3001114  PMID: 21197131
Cross-classified models; Life course epidemiology; Multilevel models; Multiple-membership models
3.  Disparities in cataract surgery between Aboriginal and non-Aboriginal people in New South Wales, Australia 
To investigate variation in rates of cataract surgery in New South Wales, Australia by area of residence for Aboriginal and non-Aboriginal adults.
Observational data linkage study of hospital admissions.
Two hundred eighty-nine thousand six hundred forty-six New South Wales residents aged 30 years and over admitted to New South Wales hospitals for 444 551 cataract surgery procedures between 2001 and 2008.
Analysis of linked routinely collected hospital data using direct standardization and multilevel negative binomial regression models accounting for clustering of individuals within Statistical Local Areas.
Main Outcome Measures
Age-standardized cataract surgery rates and adjusted rate ratios.
Aboriginal people had lower rates of cataract procedures than non-Aboriginal people of the same age and sex, living in the same Statistical Local Area (adjusted rate ratio 0.71, 95% confidence interval 0.68–0.75). There was significant variation in cataract surgery rates across Statistical Local Areas for both Aboriginal and non-Aboriginal people, with the disparity greater in major cities and less disadvantaged areas. Rates of surgery were lower for Aboriginal than non-Aboriginal people in most Statistical Local Areas, but in a few, the rates were similar or higher for Aboriginal people.
Aboriginal people in New South Wales received less cataract surgery than non-Aboriginal people, despite evidence of higher cataract rates. This disparity was greatest in urban and wealthier areas. Higher rates of surgery for Aboriginal people observed in some specific locations are likely to reflect the availability of public ophthalmology services, targeted services for Aboriginal people and higher demand for surgery in these populations.
PMCID: PMC4233999  PMID: 24299196
Aboriginal health; cataract surgery; data linkage; disadvantage
4.  Evaluation of Health in Pregnancy grants in Scotland: a protocol for a natural experiment 
BMJ Open  2014;4(10):e006547.
A substantial proportion of low birth weight is attributable to the mother's cultural and socioeconomic circumstances. Early childhood programmes have been widely developed to improve child outcomes. In the UK, the Health in Pregnancy (HiP) grant, a universal conditional cash transfer of £190, was introduced for women reaching the 25th week of pregnancy with a due date on/or after 6 April 2009 and subsequently withdrawn for women reaching the 25th week of pregnancy on/or after 1 January 2011. The current study focuses on the evaluation of the effectiveness and cost-effectiveness of the HiP grant.
Methods and analysis
The population under study will be all singleton births in Scotland over the periods of January 2004 to March 2009 (preintervention), April 2009 to April 2011 (intervention) and May 2011 to December 2013 (postintervention). Data will be extracted from the Scottish maternity and neonatal database. The analysis period 2004–2013 should yield over 585 000 births. The primary outcome will be birth weight among singleton births. Other secondary outcomes will include gestation at booking, booking before 25 weeks; measures of size and stage; gestational age at delivery; weight-for-dates, term at birth; birth outcomes and maternal smoking. The main statistical method we will use is interrupted time series. Outcomes will be measured on individual births nested within mothers, with mothers themselves clustered within data zones. Multilevel regression models will be used to determine whether the outcomes changed during the period in which the HiP grants was in effect. Subgroup analyses will be conducted for those groups most likely to benefit from the payments.
Ethics and dissemination
Approval for data collection, storage and release for research purpose has been given (6 May 2014, PAC38A/13) by the Privacy Advisory Committee. The results of this study will be disseminated through peer-reviewed publications in journals, national and international conferences.
PMCID: PMC4202003  PMID: 25324327
5.  Assessing the Representativeness of Population-Sampled Health Surveys Through Linkage to Administrative Data on Alcohol-Related Outcomes 
American Journal of Epidemiology  2014;180(9):941-948.
Health surveys are an important resource for monitoring population health, but selective nonresponse may impede valid inference. This study aimed to assess nonresponse bias in a population-sampled health survey in Scotland, with a focus on alcohol-related outcomes. Nonresponse bias was assessed by examining whether rates of alcohol-related harm (i.e., hospitalization or death) and all-cause mortality among respondents to the Scottish Health Surveys (from 1995 to 2010) were equivalent to those in the general population, and whether the extent of any bias varied according to sociodemographic attributes or over time. Data from consenting respondents (aged 20–64 years) to 6 Scottish Health Surveys were confidentially linked to death and hospitalization records and compared with general population counterparts. Directly age-standardized incidence rates of alcohol-related harm and all-cause mortality were lower among Scottish Health Survey respondents compared with the general population. For all years combined, the survey-to-population rate ratios were 0.69 (95% confidence interval: 0.61, 0.76) for the incidence of alcohol-related harm and 0.89 (95% confidence interval: 0.83, 0.96) for all-cause mortality. Bias was more pronounced among persons residing in more deprived areas; limited evidence was found for regional or temporal variation. This suggests that corresponding underestimation of population rates of alcohol consumption is likely to be socially patterned.
PMCID: PMC4207717  PMID: 25227767
alcohol-related harm; bias; health surveys; nonresponse; record linkage; Scotland
6.  A comparison of the Scottish Index of Multiple Deprivation (SIMD) 2004 with the 2009 + 1 SIMD: does choice of measure affect the interpretation of inequality in mortality? 
There is a growing international literature assessing inequalities in health and mortality by area based measures. However, there are few works comparing measures available to inform research design. The analysis here seeks to begin to address this issue by assessing whether there are important differences in the relationship between deprivation and inequalities in mortality when measures that have been constructed at different time points are compared.
We contrast whether the interpretation of inequalities in all-cause mortality between the years 2008-10 changes in Scotland if we apply the earliest (2004) and the 2009 + 1 releases of the Scottish Index of Multiple Deprivation (SIMD) to make this comparison. The 2004 release is based on data from 2001/2 and the 2009 + 1 release is based on data from 2008/9. The slope index of inequality (SII) and 1:10 ratio are used to summarise inequalities standardised by age/sex using population and mortality records.
The 1:10 ratio suggests some differences in the magnitude of inequalities measured using SIMD at different time points. However, the SII shows much closer correspondence.
Overall the findings show that substantive conclusions in relation to inequalities in all-cause mortality are little changed by the updated measure. This information is beneficial to researchers as the most recent measures are not always available. This adds to the body of literature showing stability in inequalities in health and mortality by geographical deprivation over time.
PMCID: PMC4105786  PMID: 25001866
Deprivation; Inequality; Mortality; Measurement; Scottish Index of Multiple Deprivation (SIMD)
7.  Early-Life School, Neighborhood, and Family Influences on Adult Health: A Multilevel Cross-Classified Analysis of the Aberdeen Children of the 1950s Study 
American Journal of Epidemiology  2014;180(2):197-207.
Lifetime exposures to adverse social environments influence adult health, as do exposures in early life. It is usual to examine the influences of school on teenage health and of adult area of residence on adult health. We examined the combined long-term association of the school attended, as well as the area of residence in childhood, with adult health. A total of 6,285 children from Aberdeen, Scotland, who were aged 5–12 years in 1962, were followed up at a mean age of 47 years in 2001. Cross-classified multilevel logistic regression was used to estimate the associations of family, school, and area of residence with self-reported adult health and mental health, adjusting for childhood family-, school-, and neighborhood-level factors, as well as current adult occupational position. Low early-life social position (as determined by the father's occupational level) was associated with poor adult self-rated health but not poor mental health. There were small contextual associations between childhood school environment (median odds ratio = 1.08) and neighborhood environment (median odds ratio = 1.05) and adult self-rated health. The share of the total variance in health at the family level was 10.1% compared with 89.6% at the individual level. Both socioeconomic context and composition in early life appear to have an influence on adult health, even after adjustment for current occupational position.
PMCID: PMC4082339  PMID: 24925065
family; median odds ratio; neighborhood; schools
8.  How effective is the Forestry Commission Scotland's woodland improvement programme—‘Woods In and Around Towns’ (WIAT)—at improving psychological well-being in deprived urban communities? A quasi-experimental study 
BMJ Open  2013;3(8):e003648.
There is a growing body of evidence that suggests that green spaces may positively influence psychological well-being. This project is designed to take advantage of a natural experiment where planned physical and social interventions to enhance access to natural environments in deprived communities provide an opportunity to prospectively assess impacts on perceived stress and mental well-being.
Study design and methods
A controlled, prospective study comprising a repeat cross-sectional survey of residents living within 1.5 km of intervention and comparison sites. Three waves of data will be collected: prephysical environment intervention (2013); postphysical environment intervention (2014) and postwoodland promotion social intervention (2015). The primary outcome will be a measure of perceived stress (Perceived Stress Scale) preintervention and postintervention. Secondary, self-report outcomes include: mental well-being (Short Warwick-Edinburgh Mental Well-being Scale), changes in physical activity (IPAQ-short form), health (EuroQoL EQ-5D), perception and use of the woodlands, connectedness to nature (Inclusion of Nature in Self Scale), social cohesion and social capital. An environmental audit will complement the study by evaluating the physical changes in the environment over time and recording any other contextual changes over time. A process evaluation will assess the implementation of the programme. A health economics analysis will assess the cost consequences of each stage of the intervention in relation to the primary and secondary outcomes of the study.
Ethics and dissemination
Ethical approval has been given by the University of Edinburgh, Edinburgh College of Art Research, Ethics and Knowledge Exchange Committee (ref. 19/06/2012). Findings will be disseminated through peer-reviewed publications, national and international conferences and, at the final stage of the project, through a workshop for those interested in implementing environmental interventions.
PMCID: PMC3758971  PMID: 23996826
9.  Socioeconomic Position and Adolescent Trajectories in Smoking, Drinking, and Psychiatric Distress 
The Journal of Adolescent Health  2013;53(2):202-208.e2.
Smoking, drinking, and psychiatric distress are inter-related and may also be associated with socioeconomic position (SEP). This paper investigates the role of SEP in adolescent development across all three of these outcomes.
Data were self-reported by adolescents in the Twenty-07 Study (N = 1,515) at ages 15, 17, and 18 years. Latent class analysis was used to identify homogeneous subgroups of adolescents with distinct developmental patterns. Associations between developmental patterns and a range of socioeconomic indicators were then tested.
Five classes were identified. A Low Risk class had low levels for all outcomes. A High Distress class had persistently high levels of distress, but was otherwise similar to the Low Risk group. A High Drinking class drank alcohol earlier and more heavily but also had higher levels of distress than the Low Risk group. Smokers were grouped in two classes, Early Smokers and Late Smokers, and both also had raised levels of drinking and distress. Early Smokers tended to begin earlier and smoke more heavily than Late Smokers. Relative to the Low Risk class, adolescents in a disadvantaged SEP were more likely to be Early Smokers and somewhat less likely to be in the High Drinking class. SEP was not consistently associated with membership in the High Distress or Late Smokers classes.
Associations with SEP are evident in opposing directions or absent depending on the combination and timing of outcomes, suggesting that a disadvantaged SEP is not a simple common cause for all three outcomes.
PMCID: PMC3721032  PMID: 23643540
Smoking; Alcohol; Psychiatric distress; Socioeconomic position; Adolescence; Development; Latent class analysis; Longitudinal
10.  Use of record-linkage to handle non-response and improve alcohol consumption estimates in health survey data: a study protocol 
BMJ Open  2013;3(3):e002647.
Reliable estimates of health-related behaviours, such as levels of alcohol consumption in the population, are required to formulate and evaluate policies. National surveys provide such data; validity depends on generalisability, but this is threatened by declining response levels. Attempts to address bias arising from non-response are typically limited to survey weights based on sociodemographic characteristics, which do not capture differential health and related behaviours within categories. This project aims to explore and address non-response bias in health surveys with a focus on alcohol consumption.
Methods and analysis
The Scottish Health Surveys (SHeS) aim to provide estimates representative of the Scottish population living in private households. Survey data of consenting participants (92% of the achieved sample) have been record-linked to routine hospital admission (Scottish Morbidity Records (SMR)) and mortality (from National Records of Scotland (NRS)) data for surveys conducted in 1995, 1998, 2003, 2008, 2009 and 2010 (total adult sample size around 40 000), with maximum follow-up of 16 years. Also available are census information and SMR/NRS data for the general population. Comparisons of alcohol-related mortality and hospital admission rates in the linked SHeS-SMR/NRS with those in the general population will be made. Survey data will be augmented by quantification of differences to refine alcohol consumption estimates through the application of multiple imputation or inverse probability weighting. The resulting corrected estimates of population alcohol consumption will enable superior policy evaluation. An advanced weighting procedure will be developed for wider use.
Ethics and dissemination
Ethics approval for SHeS has been given by the National Health Service (NHS) Multi-Centre Research Ethics Committee and use of linked data has been approved by the Privacy Advisory Committee to the Board of NHS National Services Scotland and Registrar General. Funding has been granted by the MRC. The outputs will include four or five public health and statistical methodological international journal and conference papers.
Primary subject heading
Public health.
Secondary subject heading
Addiction: health policy; mental health.
PMCID: PMC3612815  PMID: 23457333
Mental Health; Public Health; Statistics & Research Methods
11.  Proof firm downsizing and diagnosis-specific disability pensioning in Norway 
BMC Public Health  2013;13:27.
We wanted to investigate if firm downsizing is related to an increased rate of disability pensions among the former employed, especially for those with musculoskeletal and psychiatric diagnoses, and for those having to leave the firm.
Statistics Norway provided a linked file with demographic information and all social security grants from the National Insurance Administration for 1992–2004 for all inhabitants in Norway. Our sample was aged 30–55 years in 1995, being alive, employed and not having a disability pension at the end of 2000. Downsizing was defined as percent change in number of employed per firm from 1995 to end 2000. Employment data were missing for 25.6% of the sample.
Disability pension rates in the next four years were 25% higher for those experiencing a 30-59% downsizing than for those not experiencing a reduction of the workforce. 1-29% and 60-100% downsizing did not have this effect. Stayers following down-sizing had higher disability pension rates than leavers. What we have called complex musculoskeletal and psychiatric diagnoses were relatively most common.
Moderate downsizing is followed by a significant increase in disability pension rates in the following four years, often with complex musculoskeletal and psychiatric diagnoses.
PMCID: PMC3655911  PMID: 23311568
Disability pension; Labour market; Firm downsizing
12.  Socioeconomic differences in mortality amenable to health care among Finnish adults 1992-2003: 12 year follow up using individual level linked population register data 
Finland decentralised its universal healthcare system and introduced market reforms in the 1990s. Despite a commitment to equity, previous studies have identified persistent socio-economic inequities in healthcare, with patterns of service use that are more pro-rich than in most other European countries. To examine whether similar socio-economic patterning existed for mortality amenable to intervention in primary or specialist care, we investigated trends in amenable mortality by income group from 1992-2003.
We analysed trends in all cause, total disease and mortality amenable to health care using individual level data from the National Causes of Death Register for those aged 25 to 74 years in 1992-2003. These data were linked to sociodemographic data for 1990-2002 from population registers using unique personal identifiers. We examined trends in causes of death amenable to intervention in primary or specialist healthcare by income quintiles.
Between 1992 and 2003, amenable mortality fell from 93 to 64 per 100,000 in men and 74 to 54 per 100,000 in women, an average annual decrease in amenable mortality of 3.6% and 3.1% respectively. Over this period, all cause mortality declined less, by 2.8% in men and 2.5% in women. By 2002-2003, amenable mortality among men in the highest income group had halved, but the socioeconomic gradient had increased as amenable mortality reduced at a significantly slower rate for men and women in the lowest income quintile. Compared to men and women in the highest income quintile, the risk ratio for mortality amenable to primary care had increased to 14.0 and 20.5 respectively, and to 8.8 and 9.36 for mortality amenable to specialist care.
Our findings demonstrate an increasing socioeconomic gradient in mortality amenable to intervention in primary and specialist care. This is consistent with the existing evidence of inequity in healthcare use in Finland and provides supporting evidence of changes in the socioeconomic gradient in health service use and in important outcomes. The potential adverse effect of healthcare reform on timely access to effective care for people on low incomes provides a plausible explanation that deserves further attention.
PMCID: PMC3602718  PMID: 23286878
Socioeconomic factors; Avoidable deaths; Equity in health care; Registers; Record linkage; Finland
13.  Assessing Preventable Hospitalisation InDicators (APHID): protocol for a data-linkage study using cohort study and administrative data 
BMJ Open  2012;2(6):e002344.
Potentially preventable hospitalisation (PPH) has been adopted widely by international health systems as an indicator of the accessibility and overall effectiveness of primary care. The Assessing Preventable Hospitalisation InDicators (APHID) study will validate PPH as a measure of health system performance in Australia and Scotland. APHID will be the first large-scale study internationally to explore longitudinal relationships between primary care and PPH using detailed person-level information about health risk factors, health status and health service use.
Methods and analysis
APHID will create a new longitudinal data resource by linking together data from a large-scale cohort study (the 45 and Up Study) and prospective administrative data relating to use of general practitioner (GP) services, dispensing of pharmaceuticals, emergency department presentations, hospital admissions and deaths. We will use these linked person-level data to explore relationships between frequency, volume, nature and costs of primary care services, hospital admissions for PPH diagnoses, and health outcomes, and factors that confound and mediate these relationships. Using multilevel modelling techniques, we will quantify the contributions of person-level, geographic-level and service-level factors to variation in PPH rates, including socioeconomic status, country of birth, geographic remoteness, physical and mental health status, availability of GP and other services, and hospital characteristics.
Ethics and dissemination
Participants have consented to use of their questionnaire data and to data linkage. Ethical approval has been obtained for the study. Dissemination mechanisms include engagement of policy stakeholders through a reference group and policy forum, and production of summary reports for policy audiences in parallel with the scientific papers from the study.
PMCID: PMC3533070  PMID: 23242247
Epidemiology; Health Services Administration & Management; Primary Care; Public Health; Statistics & Research Methods
14.  A comparison of trends in caesarean section rates in former communist (transition) countries and other European countries 
Caesarean section rates are rising across Europe, and concerns exist that increases are not clinically indicated. Societal, cultural and health system factors have been identified as influential. Former communist (transition) countries have experienced radical changes in these potential determinants, and we, therefore, hypothesized they may exhibit differing trends to non-transition countries. By analysing data from the WHO Europe Health for All Database, we find transition countries had a relatively low caesarean section rate in 2000 but have since experienced more rapid increases than other countries (average annual percentage change 7.9 vs. 2.4).
PMCID: PMC3662018  PMID: 23204216
15.  Neighbourhood food and physical activity environments in England, UK: does ethnic density matter? 
In England, obesity is more common in some ethnic minority groups than in Whites. This study examines the relationship between ethnic concentration and access to fast food outlets, supermarkets and physical activity facilities.
Data on ethnic concentration, fast food outlets, supermarkets and physical activity facilities were obtained at the lower super output area (LSOA) (population average of 1500). Poisson multilevel modelling was used to examine the association between own ethnic concentration and facilities, adjusted for area deprivation, urbanicity, population size and clustering of LSOAs within local authority areas.
There was a higher proportion of ethnic minorities residing in areas classified as most deprived. Fast food outlets and supermarkets were more common and outdoor physical activity facilities were less common in most than least deprived areas. A gradient was not observed for the relationship between indoor physical activity facilities and area deprivation quintiles. In contrast to White British, increasing ethnic minority concentration was associated with increasing rates of fast food outlets. Rate ratios comparing rates of fast food outlets in high with those in low level of ethnic concentration ranged between 1.28, 95% confidence interval 1.06-1.55 (Bangladeshi) and 2.62, 1.46-4.70 (Chinese). Similar to White British, however, increasing ethnic minority concentration was associated with increasing rate of supermarkets and indoor physical activity facilities. Outdoor physical activity facilities were less likely to be in high than low ethnic concentration areas for some minority groups.
Overall, ethnic minority concentration was associated with a mixture of both advantages and disadvantages in the provision of food outlets and physical activity facilities. These issues might contribute to ethnic differences in food choices and engagement in physical activity.
PMCID: PMC3409029  PMID: 22709527
Obesity; Ethnicity; Neighbourhoods; Deprivation; Fast food outlets; Supermarkets; Physical activity facilities; Built environments
16.  Mortality after admission for acute myocardial infarction in Aboriginal and non-Aboriginal people in New South Wales, Australia: a multilevel data linkage study 
BMC Public Health  2012;12:281.
Heart disease is a leading cause of the gap in burden of disease between Aboriginal and non-Aboriginal Australians. Our study investigated short- and long-term mortality after admission for Aboriginal and non-Aboriginal people admitted with acute myocardial infarction (AMI) to public hospitals in New South Wales, Australia, and examined the impact of the hospital of admission on outcomes.
Admission records were linked to mortality records for 60047 patients aged 25–84 years admitted with a diagnosis of AMI between July 2001 and December 2008. Multilevel logistic regression was used to estimate adjusted odds ratios (AOR) for 30- and 365-day all-cause mortality.
Aboriginal patients admitted with an AMI were younger than non-Aboriginal patients, and more likely to be admitted to lower volume, remote hospitals without on-site angiography. Adjusting for age, sex, year and hospital, Aboriginal patients had a similar 30-day mortality risk to non-Aboriginal patients (AOR: 1.07; 95% CI 0.83-1.37) but a higher risk of dying within 365 days (AOR: 1.34; 95% CI 1.10-1.63). The latter difference did not persist after adjustment for comorbid conditions (AOR: 1.12; 95% CI 0.91-1.38). Patients admitted to more remote hospitals, those with lower patient volume and those without on-site angiography had increased risk of short and long-term mortality regardless of Aboriginal status.
Improving access to larger hospitals and those with specialist cardiac facilities could improve outcomes following AMI for all patients. However, major efforts to boost primary and secondary prevention of AMI are required to reduce the mortality gap between Aboriginal and non-Aboriginal people.
PMCID: PMC3481361  PMID: 22490109
Hospital performance; Acute myocardial infarction; Ischaemic heart disease; Aboriginal health; Health outcomes; Multilevel modelling; Data linkage
17.  Do social inequalities in health widen or converge with age? Longitudinal evidence from three cohorts in the West of Scotland 
BMC Public Health  2011;11:947.
Existing studies are divided as to whether social inequalities in health widen or converge as people age. In part this is due to reliance on cross-sectional data, but also among longitudinal studies to differences in the measurement of both socioeconomic status (SES) and health and in the treatment of survival effects. The aim of this paper is to examine social inequalities in health as people age using longitudinal data from the West of Scotland Twenty-07 Study to investigate the effect of selective mortality, the timing of the SES measure and cohort on the inequality patterns.
The Twenty-07 Study has followed three cohorts, born around 1932, 1952 and 1972, from 1987/8 to 2007/8; 4,510 respondents were interviewed at baseline and, at the most recent follow-up, 2,604 were interviewed and 674 had died. Hierarchical repeated-measures models were estimated for self-assessed health status, with and without mortality, with baseline or time-varying social class, sex and cohort.
Social inequalities in health emerge around the age of 30 after which they widen until the early 60s and then begin to narrow, converging around the age of 75. This pattern is a result of those in manual classes reporting poor health at younger ages, with the gap narrowing as the health of those in non-manual classes declines at older ages. However, employing a more proximal measure of SES reduces inequalities in middle age so that convergence of inequalities is not apparent in old age. Including death in the health outcome steepens the health trajectories at older ages, especially for manual classes, eliminating the convergence in health inequalities, suggesting that healthy survival effects are important. Cohort effects do not appear to affect the pattern of inequalities in health as people age in this study.
There is a general belief that social inequalities in health appear to narrow at older ages; however, taking account of selective mortality and employing more proximal measures of SES removes this convergence, suggesting inequalities in health continue into old age.
PMCID: PMC3265552  PMID: 22192620
18.  Trends in adult cardiovascular disease risk factors and their socio-economic patterning in the Scottish population 1995–2008: cross-sectional surveys 
BMJ Open  2011;1(1):e000176.
To examine secular and socio-economic changes in cardiovascular disease risk factor prevalences in the Scottish population. This could contribute to a better understanding of why the decline in coronary heart disease mortality in Scotland has recently stalled along with a widening of socio-economic inequalities.
Four Scottish Health Surveys 1995, 1998, 2003 and 2008 (6190, 6656, 5497 and 4202 respondents, respectively, aged 25–64 years) were used to examine gender-stratified, age-standardised prevalences of smoking, alcohol consumption, physical activity, fruit and vegetable consumption, discretionary salt use and self-reported diabetes or hypertension. Prevalences were determined according to education and social class. Inequalities were assessed using the slope index of inequality, and time trends were determined using linear regression.
There were moderate secular declines in the prevalence of smoking, excess alcohol consumption and physical inactivity. Smoking prevalence declined between 1995 and 2008 from 33.4% (95% CI 31.8% to 35.0%) to 29.9% (27.9% to 31.8%) for men and from 36.1% (34.5% to 37.8%) to 27.4% (25.5% to 29.3%) for women. Adverse trends in prevalence were noted for self-reported diabetes and hypertension. Over the four surveys, the diabetes prevalence increased from 1.9% (1.4% to 2.4%) to 3.6% (2.8% to 4.4%) for men and from 1.7% (1.2% to 2.1%) to 3.0% (2.3% to 3.7%) for women. Socio-economic inequalities were evident for almost all risk factors, irrespective of the measure used. These social gradients appeared to be maintained over the four surveys. An exception was self-reported diabetes where, although inequalities were small, the gradient increased over time. Alcohol consumption was unique in consistently showing an inverse gradient, especially for women.
There has been only a moderate decline in behavioural cardiovascular risk factor prevalences since 1995, with increases in self-reported diabetes and hypertension. Adverse socio-economic gradients have remained unchanged. These findings could help explain the recent stagnation in coronary heart disease mortalities and persistence of related inequalities.
Article summary
Article focus
In Scotland, as in other developed countries, coronary heart disease mortality has declined substantially over time.
This decline may now be slowing among younger groups, and there are still large inequalities in mortality between socio-economic groups.
This study examined secular and socio-economic changes in cardiovascular disease risk factor prevalences in the Scottish population.
Key messages
In Scotland, over a 13-year period since 1995 there have been at best only moderate declines in the prevalence of behavioural risk factors and no change in their socio-economic patterning, notably for smoking and poor diet.
There has, however, been an increase in self-reported conditions predisposing to cardiovascular disease.
This threatens to maintain inequalities in coronary heart disease mortalities and stifle further declines in mortality.
Strengths and limitations of this study
This study utilised data from nationally representative surveys conducted over a 13-year period.
The declining response levels to these surveys are of concern, possibly introducing bias. However, differential non-response by the socio-economically disadvantaged may lead to an underestimation of the magnitude of inequalities.
PMCID: PMC3191578  PMID: 22021783
Cardiovascular diseases; risk factors; socio-economic factors; cross-sectional studies; Scotland; epidemiology; public health; social medicine; coronary heart disease; multilevel modelling; inequalities; modelling; prevention; health services research; mortality; routine data; statistics
19.  The influence of both individual and area based socioeconomic status on temporal trends in Caesarean sections in Scotland 1980-2000 
BMC Public Health  2011;11:330.
Caesarean section rates have risen over the last 20 years. Elective Caesarean section rates have been shown to be linked to area deprivation in England, women in the most deprived areas were less likely to have an elective section than those in the most affluent areas. We examine whether individual social class, area deprivation or both are related to Caesarean sections in Scotland and investigate changes over time.
Routine maternity discharge data from live singleton births in Scottish hospitals from three time periods were used; 1980-81 (n = 133,555), 1990-91 (n = 128,933) and 1999-2000 (n = 102,285). Multilevel logistic regression, with 3 levels (births, postcode sector and Health Board) was used to analyse emergency and elective Caesareans separately; analysis was further stratified by previous Caesarean section. The relative index of inequality (RII) was used to assess socioeconomic inequalities.
Between 1980-81 and 1999-2000 the emergency section rate increased from 6.3% to 11.9% and the elective rate from 3.6% to 5.5%. In 1980-81 and 1990-91 emergency Caesareans were more likely among women at the bottom of the social class hierarchy compared to those at the top (RII = 1.14, 95%CI 1.00-1.25 and RII = 1.13, 1.03-1.23 respectively) and also among women in the most deprived areas compared to those in the most affluent (RII = 1.18, 1.05-1.32 and RII = 1.13, 1.02-1.26 respectively). In 1999-2000 the odds of an elective section were lower for women at the bottom of the social class hierarchy than those at the top (RII = 0.87, 0.76-1.00) and also lower in women in the most deprived areas compared to those in the most affluent (RII = 0.85, 0.73-0.99).
Both individual social class and area deprivation are independently associated with Caesarean sections in Scotland. The tendency for disadvantaged women to be more likely to receive emergency sections disappeared at the same time as the likelihood of advantaged groups receiving elective sections increased.
PMCID: PMC3114726  PMID: 21592328
Caesarean section; social class; area deprivation
20.  Contribution of smoking-related and alcohol-related deaths to the gender gap in mortality: evidence from 30 European countries 
Tobacco Control  2011;20(2):166-168.
Women now outlive men throughout the globe, a mortality advantage that is very established in developed European countries. Debate continues about the causes of the gender gap, although smoking is known to have been a major contributor to the difference in the past.
To compare the magnitude of the gender gap in all-cause mortality in 30 European countries and assess the contribution of smoking-related and alcohol-related deaths.
Data on all-cause mortality, smoking-related mortality and alcohol-related mortality for 30 European countries were extracted from the World Health Organization Health for All database for the year closest to 2005. Rates were standardised by the direct method using the European population standard and were for all age groups. The proportion of the gender gap in all-cause mortality attributable to smoking-related and alcohol-related deaths was then calculated.
There was considerable variation in the magnitude of the male ‘excess’ of all-cause mortality across Europe, ranging from 188 per 100 000 per year in Iceland to 942 per 100 000 per year in Ukraine. Smoking-related deaths accounted for around 40% to 60% of the gender gap, while alcohol-related mortality typically accounted for 20% to 30% of the gender gap in Eastern Europe and 10% to 20% elsewhere in Europe.
Smoking continues to be the most important cause of gender differences in mortality across Europe, but its importance as an explanation for this difference is often overshadowed by presumptions about other explanations. Changes in smoking patterns by gender suggest that the gender gap in mortality will diminish in the coming decades.
PMCID: PMC3045524  PMID: 21228431
Smoking-related mortality; alcohol-related mortality; gender difference; smoking caused disease
21.  International differences in self-reported health measures in 33 major metropolitan areas in Europe 
Background: The increasing concentration of populations into large conurbations in recent decades has not been matched by international health assessments, which remain largely focused at the country level. We aimed to demonstrate the use of routine survey data to compare the health of large metropolitan centres across Europe and determine the extent to which differences are due to socio-economic factors. Methods: Multilevel modelling of health survey data on 126 853 individuals from 33 metropolitan areas in the UK, Republic of Ireland, Sweden, Norway, Finland, Spain, Belgium and Germany compared general health, longstanding illness, acute sickness, psychological distress and obesity with the average for all areas, accounting for education and social class. Results: We found some areas (Greater Glasgow; Greater Manchester, Cheshire and Merseyside; Northumberland, Tyne and Wear and South Yorkshire) had significantly higher levels of poor health. Other areas (West Flanders and Antwerp) had better than average health. Differences in individual socio-economic circumstances did not explain findings. With a few exceptions, acute sickness levels did not vary. Conclusion: Health tended to be worse in metropolitan areas in the north and west of the UK and the central belt and south east of Germany, and more favourable in Sweden and north west Belgium, even accounting for socio-economic composition of local populations. This study demonstrated that combining national health survey data covering different areas is viable but not without technical difficulties. Future comparisons between European regions should be made using standardized sampling, recruitment and data collection protocols, allowing proper monitoring of health inequalities.
PMCID: PMC3265749  PMID: 21148178
22.  Trends and inequalities in short-term acute myocardial infarction case fatality in Scotland, 1988-2004 
There have been substantial declines in ischemic heart disease in Scotland, partly due to decreases in acute myocardial infarction (AMI) incidence and case fatality (CF). Despite this, Scotland's IHD mortality rates are among the worst in Europe. We examine trends in socioeconomic inequalities in short-term CF after a first AMI event and their associations with age, sex, and geography.
We used linked hospital discharge and death records covering the Scottish population (5.1 million). Between 1988 and 2004, 178,781 of 372,349 patients with a first AMI died on the day of the event (Day0 CF) and 34,198 died within 28 days after surviving the day of their AMI (Day1-27 CF).
Age-standardized Day0 CF at 30+ years decreased from 51% in 1988-90 to 41% in 2003-04. Day1-27 CF decreased from 29% to 18% over that period. Socioeconomic inequalities in Day0 CF existed for both sexes and persisted over time. The odds of case fatality for men aged 30-59 living in the most deprived areas in 2000-04 were 1.7 (95%CI: 1.3-2.2) times as high as in the least deprived areas and 1.9 (1.1-3.2) times as high for women. There was little evidence of socioeconomic inequality in Day1-27 CF in men or women. After adjustment for socioeconomic deprivation, significant geographic variation still remained for both CF definitions.
A high proportion of AMI incidents in Scotland result in death on the day of the first event; many of these are sudden cardiac deaths. Short-term CF has improved, perhaps reflecting treatment advances and reductions in first AMI severity. However, persistent socioeconomic and geographic inequalities suggest these improvements are not uniform across all population groups, emphasizing the need for population-wide primary prevention.
PMCID: PMC3014876  PMID: 21134255
23.  Scottish mortality rates 2000–2002 by deprivation and small area population mobility☆ 
Social Science & Medicine (1982)  2010;71(11-3):1951-1957.
Despite recent increases in life expectancy, inequalities in mortality in Scotland have been widening. Previous research has suggested that one of the potential drivers of geographical inequalities in health is the process of selective migration. Although support for the effect of selective migration on widening geographic inequalities in health has been mixed, several studies have shown that people in good health move away from deprived areas while people in poor health move towards more deprived areas. In this paper, we examine mortality rates in Scotland by area deprivation and population mobility. Previous research in Scotland has shown that the relationship between population mobility and migration disappears once deprivation is accounted for. However, the authors measure population mobility over a longer time period than we do here and at a different geographical level. We consider small area population mobility on the basis of moves made in the year prior to the 2001 Scottish census. Areas were classified as one of four types: decreasing, increasing or stable (with high or low turnover). Mortality rates, calculated for the period 2000–2002, were found to be highest in deprived areas that had declined in population over the previous year. In the most deprived quintile, the causes of death contributing disproportionately to the excess mortality in decreasing areas were causes linked to alcohol and drug use, suicides and assault. Focussing on those individuals in the most deprived areas who live in areas that are declining in population could help to reduce widening inequalities for these causes of death. This work shows the extent to which population migration can influence small areas over a relatively short time period and gives some insight into potential factors, not measured by traditional indices of area level deprivation, which may lead to differences in the health status of areas.
Research highlights
► Scottish mortality rates were highest in deprived areas that declined in population in the year before the 2001 census. ► Excess mortality was due to causes linked to alcohol and drug use, suicides and assault. ► Focussing on individuals living in these areas could help to reduce widening inequalities for these causes of death.
PMCID: PMC3070801  PMID: 20950907
Migration; All-cause mortality; Cause-specific mortality; Health inequalities; Area level deprivation; Scotland; UK
24.  Do differences in the administrative structure of populations confound comparisons of geographic health inequalities? 
Geographical health inequalities are naturally described by the variation in health outcomes between areas (e.g. mortality rates). However, comparisons made between countries are hampered by our lack of understanding of the effect of the size of administrative units, and in particular the modifiable areal unit problem. Our objective was to assess how differences in geographic and administrative units used for disseminating data affect the description of health inequalities.
Retrospective study of standard populations and deaths aggregated by administrative regions within 20 European countries, 1990-1991. Estimated populations and deaths in males aged 0-64 were in 5 year age bands. Poisson multilevel modelling was conducted of deaths as standardised mortality ratios. The variation between regions within countries was tested for relationships with the mean region population size and the unequal distribution of populations within each country measured using Gini coefficients.
There is evidence that countries whose regions vary more in population size show greater variation and hence greater apparent inequalities in mortality counts. The Gini coefficient, measuring inequalities in population size, ranged from 0.1 to 0.5 between countries; an increase of 0.1 was accompanied by a 12-14% increase in the standard deviation of the mortality rates between regions within a country.
Apparently differing health inequalities between two countries may be due to differences in geographical structure per se, rather than having any underlying epidemiological cause. Inequalities may be inherently greater in countries whose regions are more unequally populated.
PMCID: PMC2933682  PMID: 20718968

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