1. MEASURING EQUITABLE HEALTH IMPROVEMENT:
HOW IS SCOTLAND DOING?
(A snapshot of health disparities in Scotland,
and a new approach to tackling them)
John Frank Director, Scottish Collaboration for Public Health
Research and Policy:
Professor and Chair, Public Health Research
and Policy, University of Edinburgh
c/o MRC Human Genetics Unit, Western General Hospital, Crewe Road, Edinburgh EH4 2XU
email john.frank@hgu.mrc.ac.uk

2. How are we monitoring health status and
inequalities over time?
• In report after report, across almost all developed
nations, the great majority of health outcomes
monitored at the population level are based on:
• Mortality statistics, often summarized across all ages as
life expectancy and sometimes combined with quality-of-
life/morbidity data, as “health expectancy” – our most
holistic routine measure
• Routinely collected birth outcomes, especially birth-weight,
gestational age, and combinations thereof
• Hospitalization rates, usually by cause (often affected by
small-area-variation due to health care factors,
independent of disease burden)
• Cancer – and, rarely, other – disease incidence
• Self-reported survey data –e.g. self-assessed health
status, smoking, height & weight, activity levels, food
intake, etc. (“warts and all” – some cultural framing
occurs; e.g. self-assessed health status)

3. Overarching Questions:
1) Are Scottish health inequalities, as measured by these
international standard indicators, moving in the right
direction?
2) If not, why not?
3) Could it be partly because these are in fact rather
insensitive indicators, inherently difficult to budge in less
than a human generation?
4) What sort of indicators might be more amenable to
demonstrating progress “within a decade” (assuming that
serious investments are made, in the interim, in reducing
Scottish health inequalities.)

4. Scottish HI Indicators in Current Use
• Recent Scottish analyses of Health
Inequalities trends and patterns, over
the last decade or more, are among the
most statistically sophisticated in the
world
• Despite this, they are liable to the
criticism universally applicable to most
routinely collected health outcomes in
developed countries:

5. Criticism: major causes of mortality – and
many other routinely collected health
outcomes -- are no longer very sensitive
to societal changes, in the short run
• Conventional wisdom among epidemiologists: “Improved
medical care – and indeed most deliberate health policies and
programs – at least in developed countries, now only reduce
broad categories of mortality rather slowly, and all-cause
mortality very slowly.”
• Life expectancy, and even all-cause mortality rates, seem subject
to “epidemiological momentum / inertia:” they are hard to shift
quickly, especially when deaths occur mostly among the elderly,
where chronic disease and competing risks matter!
• Exceptions: 1) universally accessible, revolutionary treatment
advances in epidemic-level disease, e.g. HIV since the 1990s in
Brazil; 2) rapidly worsening exposures with rather short latency to
death, e.g. liver disease mortality, and alcohol-related deaths, in
Scotland since the 1980s
• Many other routinely collected outcomes, such as low birth-weight
rates and hospitalization rates, suffer from other serious flaws.

6. 1) Absolute SES range over time -- Low
birth weight babies Scotland 1998-2005
Source: Scottish Government Health Analytical Services (2008) Long-term monitoring of health inequalities

7. 2a) Absolute range: Healthy life
expectancy, Males – Scotland 1999- 2006
(Data not available 2003/04)
Source: Scottish Government Health Analytical Services (2008) Long-term monitoring of health inequalities

8. 2b) Absolute range: Healthy life
expectancy, Females Scotland 1999-2006
(Data not available 2003/04)
Source: Scottish Government Health Analytical Services (2008) Long-term monitoring of health inequalities

9. 3a) Absolute range: Alcohol-related mortality
45-74y – Scotland 1998-2006
(European Age-Standardised Rates per 100,000)
Source: Scottish Government Health Analytical Services (2008) Long-term monitoring of health inequalities

10. 3b) Alcohol-related mortality amongst those aged 45-74y by Income-
Employment Index: Scotland 2006
(European Age-Standardised Rates per 100,000)
Source: Scottish Government Health Analytical Services (2008) Long-term monitoring of health inequalities

11. What major causes of death are clearly
declining?
• Coronary heart disease (CHD) age 45-74, showing a clear 45 %
decline from 1997 to 2006, after a similar decline in the previous
decade (some recent levelling-off below age 55 – obesity??) Stroke
mortality has also declined, by almost as much, in most developed
countries, BUT starting many decades earlier – role of improved
diet/reduced salt consumption?
• Most studies attempting to parse out the contributions of improved
prevention, versus treatment, to the CHD mortality decline, show
about half of the decline is due to each, but it is not possible to clearly
distinguish which aspects of risk factor (e.g. blood pressure, serum
cholesterol, smoking) reduction, before CHD symptoms, are due to
each of: 1) inherent cultural trends; 2) public health programs to
change lifestyle; 3) prevention in primary care [For example what has
driven smoking declines!? – many factors!]
• OK, but how is the SES gradient in CHD doing, in Scotland?

12. 4a) Absolute range: CHD mortality, 45-74 years, Scotland
1997-2006
(European Age-Standardised Rates per 100,000)

13. 4b) Absolute range: First-ever hospital admissions for heart
attack<75y – Scotland 1997-2006 – i.e. those “arriving alive”
(European Age-Standardised Rates per 100,000)

14. QUESTION:
Why has the SES gradient in CHD
mortality recently remained so much
bigger than that for heart-attack “arrive
alive” hospital admissions?

15. Answer:
• Example: ratio of bottom-SES decile’s rate to
top-decile’s rate in 2006:
CHD mortality ratio: 340/100 =3.4
AMI hospital’n ratio: 75/65 =1.15
• Suggests that many of the low-SES deaths
occur prior to hospital arrival, which could be
due to any/all of:
• More sudden death presentation of CHD, due in turn to
“worse disease” at presentation/more primary and
secondary tobacco exposure/worse fats in diets?
• Delayed presentation – e.g. due to lack of
awareness/denial of chest pain at home?
• Worse ambulance response times and care? (Police
escorts requested for ambulances entering some
housing estates, but response can be slow?)
• Systematically more “public” settings where sudden
collapse occurs, among the privileged, allowing better
chance of resuscitation/ early ambulance arrival?

16. Incident CHD in Scotland, 2000-4
Sudden Deaths and AMI admissions
47% 53%
Of 93,701 incident AMI events, 50,075 (53%) resulted in death, of
which 42,189 (84%) died within the first day – ergo, surely
prevention is at least as important as care?
Should there be a focused research effort on sudden death here?

17. 5) Absolute range: Cancer incidence (all sites) <75y – Scotland
1996-2005
(European Age-Standardised Rates per 100,000)
Source: Scottish Government Health Analytical Services (2008) Long-term monitoring of health inequalities

18. Which Causes of Death Currently Contribute Most to Recent
Scottish Changes in Overall Mortality, and to Changing
Inequalities? – A New Analysis by Age and SES
Alastair H Leyland, Ruth Dundas, Philip McLoone, F Andrew Boddy.
Inequalities in Mortality in Scotland, 1981-2001.
MRC Social and Public Health Sciences Unit
Occasional Paper Series no. 16
Series Editors: Mark Petticrew, Kate Hunt
February 2007
ISBN: 1-901519-06-6
Published by:
MRC Social and Public Health Sciences Unit
4 Lilybank Gardens
Glasgow G12 8RZ

20. age (5 year age bands)

22. age (5 year age bands)

23. Comments on foregoing four slides:
• These graphs elegantly confirm our earlier
impressions: that the death rates among
Scottish young adults have steadily worsened
over recent decades, due to “external” causes
– first in males (1980s) and then spreading to
females (1990s)
• Beware of thinking, however, that the size of
the y-axis-values, across various age-groups,
are directly comparable; they are not, because
they are proportionate mortality changes over
time, as a multiple of the baseline death rate
in that age-group, which varies exponentially
with age among adults.

26. Comments on two previous “mountain” graphs:
• These are now famous for their novel depiction of a complex SES
death pattern – note the very creative use of colour!
• They confirm that the main causes of the SES disparities in Scottish
death rates are precisely the same “external” causes of death that are
driving the increased overall mortality in young adults;
• But mortality inequalities in late life are driven by the usual causes of
death in older adults, chronic diseases, which are becoming less
common overall, but are still very unequally distributed in Scotland.
• “It is as if Scotland had two cemeteries, one for the old and one for
the young, and the latter is filling up so fast, especially with poor
youth, that space must be lent from the old people’s cemetery to
meet the need, due to (mostly richer) old persons who now live
longer.” (John Frank, April 2007).
END OF “CORE” CONTENT FOR THIS LECTURE – REMAINING SLIDES
ARE REALLY JUST FOR INTEREST, TO GIVE A SENSE OF PROF.
FRANK’S CURRENT WORK!

27. Comments on two previous “mountain” graphs:
• These are now famous for their novel depiction of a complex SES
death pattern – note the very creative use of colour!
• They confirm that the main causes of the SES disparities in Scottish
death rates are precisely the same “external” causes of death that are
driving the increased overall mortality in young adults;
• But mortality inequalities in late life are driven by the usual causes of
death in older adults, chronic diseases, which are becoming less
common overall, but are still very unequally distributed in Scotland.
• “It is as if Scotland had two cemeteries, one for the old and one for
the young, and the latter is filling up so fast, especially with poor
youth, that space must be lent from the old people’s cemetery to
meet the need, due to (mostly richer) old persons who now live
longer.” (John Frank, April 2007).

28. WHAT MIGHT BE MORE SENSITIVE
INDICATORS OF SOCIAL INEQUALITIES
IN HEALTH AND FUNCTION?
Given the “prompt sensitivity to feasible change”
of early childhood cognitive and educational
outcomes, and their strong predictive power for
lifelong function and health, what might a
ROUTINE surveillance system for such “upstream”
indicators look like, for Scotland?

29. A Useful Example from Canada: HELP (Human Early
Learning Partnership) at the University of British Columbia,
Vancouver
“The Early Child Development (ECD)
Mapping Project involves implementation
of the Early Development Instrument
(EDI) in British Columbia (Canada) school
districts, to assess the aggregate state of
human development, at the Kindergarten
level, in each sequential birth cohort.
Kindergarten teachers in B.C. began to
collect EDI data in 1999/2000, using one
day annually of paid time. As of March
2004, all 59 school districts in B.C. had
collected EDI data, which is fed back to all
communities each year.”

30. “What the EDI Measures”
The EDI gathers data, from K1 teachers,
on five subscales of children’s “readiness
to learn” aspects of development, age 5-6:
• Physical health and well-being
• Social competence.
• Emotional maturity.
• Language and cognitive development.
• Communication skills and general
knowledge.

31. 36

33. The Public Health Challenge in Scotland
• The public health problems in Scotland have been well
described.
• The real public health challenge now, is to develop
novel interventions, policies and programmes that make
a real difference to the lives of people in Scotland and
reduce health inequalities, both within the short- to
medium- and longer-term.
• How can we best use the extraordinary Scottish public
health talent to achieve this?

34. Scottish Collaboration for Public Health
Research & Policy (SCPHRP)
• To identify key areas of opportunity for developing
novel public health interventions that address major
health problems in Scotland.
• To foster collaboration between government,
researchers and the public health community to develop
a national programme of intervention development,
implementation and large-scale evaluation.
• Build capacity within the public health community for
collaborative research of the highest quality.

35. SCPHRP Principles
SCPHRP-sponsored research should:
• Address determinants of health that are both important
and potentially reversible.
• Develop and test interventions that are feasible, socially
acceptable, affordable, scalable and sustainable -- and
that will result in measurable, equitable health
improvement within a reasonable time-frame.
• Constitute a legitimate Scottish niche, both within the
UK and the wider international research landscapes.
• Lie within the current -- or future -- capability (skills
and person-power) of the Scottish public health
community (researchers and decision-makers).

36. The Process
• SCPHRP will convene a series of consensus workshops to prioritise
potential interventions for development, and to establish a series
of Working Groups organised around key preventive stages in the
life course:
• Early years
• Teenage and early adulthood
• Early to mid-working life
• Later life
• Each Working Group will develop a three-year work programme
designed to support the development and piloting of promising
and novel interventions, at the program and policy level.
• SCPHRP will facilitate the work of the Working Groups and provide
limited pump-prime funding.
• Depending on the outcome of these preliminary studies, the final
outputs from the Working Groups should be large-scale
intervention-grant submissions to U.K. and Int’l agencies.

37. Priority Intervention Categories Selected by
SCPHRP Workshop, Edinburgh, January 2009
• Early Life: interventions to improve parenting,
especially for high-risk families, with special attention to
maternal-infant mental health outcomes
• Teenage and Early Adult Life: interventions,
including high-risk targeting, to facilitate social, cultural
and family connectedness, and mentoring, so that
young people make sound decisions about health-
related behaviours, and manage life transitions
successfully
• Early to Mid-Working Life: Interventions to tackle
our obesogenic environment: socio-cultural and physical
• Later Life: Interventions to maintain function and
independence as long as possible, so as to reduce
unnecessary or premature disability and dependency

38. How to Reach Us
John Frank
john.frank@hgu.mrc.ac.uk
Sally Haw
sally.haw@hgu.mrc.ac.uk
Caroline Rees
caroline.rees@hgu.mrc.ac.uk
Human Genetics Unit
Western General Hospital, Crewe Rd., Edinburgh EH4 2XU
Tel 0131-332-2471, ext. 2119