Why the Scots die younger: synthesizing the evidence

Area of Science:

• Public Health and Epidemiology
• Sociology and Social Policy
• Health Economics

Background:

• Scotland exhibits higher mortality rates compared to other European nations.
• Understanding the drivers of this disparity is crucial for public health interventions.
• Historical and socio-economic factors are suspected contributors.

Purpose of the Study:

• To identify and evaluate hypotheses explaining Scotland's elevated mortality rates.
• To synthesize evidence-based explanations into a cohesive framework.
• To analyze the divergence in mortality rates between Scotland and Europe.

Main Methods:

• A comprehensive literature review identified seventeen candidate hypotheses.
• Hypotheses were critically assessed using the Bradford-Hill criteria for causation.
• A dialectical synthesis approach was employed to integrate the most plausible explanations.

Main Results:

• Explanations range from artefactual and downstream (genetics, behaviors) to midstream (substance misuse, social capital) and upstream (inequalities, de-industrialization, political attack).
• For 1950-1980, industrial, employment, housing, and cultural patterns are plausible drivers.
• Post-1980, unfavorable health behaviors, linked to conflict, injustice, and disempowerment stemming from neoliberal policies, are key.

Conclusions:

• Mortality divergence pre-1980 remains unclear, potentially linked to socio-economic and cultural factors.
• Post-1980, a synthesis starting with the political context of neoliberal policies explains higher mortality through hopelessness and community disruption.
• Findings may offer insights into faltering health improvement in other nations, such as the USA.