How have trends in lifespan variation changed since 1950? A comparative study of 17 Western European countries

Differences in ill health and in socioeconomic inequalities in health by ethnic groups: a cross-sectional study using 2011 Scottish census

Objectives: We compare rates of ill health and socioeconomic inequalities in health by ethnic groups in Scotland by age. We focus on ethnic differences in socioeconomic inequalities in health. There is little evidence of how socioeconomic inequalities in health vary by ethnicity, especially in Scotland, where health inequalities are high compared to other European countries.Design: A cross-sectional study using the 2011 Scottish Census (population 5.3 million) was conducted. Directly standardized rates were calculated for two self-rated health outcomes (poor general health and limiting long-term illness) separately by ethnicity, age and small-area deprivation. Slope and relative indices of inequality were calculated to measure socioeconomic inequalities in health.Results: The results show that the White Scottish population tend to have worse health and higher socioeconomic inequalities in health than many other ethnic groups, while White Polish and Chinese people tend to have better health and low socioeconomic inequalities in health. These results are more salient for ages 30-44. The Pakistani population has high rates of poor health similar to the White Scottish for ages 15-44, but at ages 45 and above Pakistani people have the highest rates of poor self-rated health. Compared to other ethnicities, Pakistani people are also more likely to experience poor health in the least deprived areas, particularly at ages 45 and above.Conclusions: There are statistically significant and substantial differences in poor self-rated health and in socioeconomic inequalities in health between ethnicities. Rates of ill health vary between ethnic groups at any age. The better health of the younger minority population should not be taken as evidence of better health outcomes in later life. Since socioeconomic gradients in health vary by ethnicity, policy interventions for health improvement in Scotland that focus only on deprived areas may inadvertently exclude minority populations.

Diversification in causes of death in low-mortality countries: emerging patterns and implications

INTRODUCTION

An important role of public health organisations is to monitor indicators of variation, so as to disclose underlying inequality in health improvement. In industrialised societies, more individuals than ever are reaching older ages and have become more homogeneous in their age at death. This has led to a decrease in lifespan variation, with substantial implications for the reduction of health inequalities. We focus on a new form of variation to shed further light on our understanding of population health and ageing: variation in causes of death.

METHODS

Data from the WHO Mortality Database and the Human Mortality Database are used to estimate cause-of-death distributions and life tables in 15 low-mortality countries. Cause-of-death variation, using 19 groups of causes, is quantified using entropy measures and analysed from 1994 to 2017.

RESULTS

The last two decades have seen increasing diversity in causes of death in low-mortality countries. There have been important reductions in the share of deaths from diseases of the circulatory system, while the share of a range of other causes, such as diseases of the genitourinary system, mental and behavioural disorders, and diseases of the nervous system, has been increasing, leading to a more complex cause-of-death distribution.

CONCLUSIONS

The diversification in causes of death witnessed in recent decades is most likely a result of the increase in life expectancy, together with better diagnoses and awareness of certain diseases. Such emerging patterns bring additional challenges to healthcare systems, such as the need to research, monitor and treat a wider range of diseases. It also raises new questions concerning the distribution of health resources.

All-cause and cause-specific mortality in Scotland 1981-2011 by age, sex and deprivation: a population-based study

Background

Average life expectancy has stopped increasing for many countries. This has been attributed to causes such as influenza, austerity policies and deaths of despair (drugs, alcohol and suicide). Less is known on the inequality of life expectancy over time using reliable, whole population, data. This work examines all-cause and cause-specific mortality rates in Scotland to assess the patterning of relative and absolute inequalities across three decades.

Methods

Using routinely collected Scottish mortality and population records we calculate directly age-standardized mortality rates by age group, sex and deprivation fifths for all-cause and cause-specific deaths around each census 1981–2011.

Results

All-cause mortality rates in the most deprived areas in 2011 (472 per 100 000 population) remained higher than in the least deprived in 1981 (422 per 100 000 population). For those aged 0–64, deaths from circulatory causes more than halved between 1981 and 2011 and cancer mortality decreased by a third (with greater relative declines in the least deprived areas). Over the same period, alcohol- and drug-related causes and male suicide increased (with greater absolute and relative increases in more deprived areas). There was also a significant increase in deaths from dementia and Alzheimer’s disease for those aged 75+.

Conclusions

Despite reductions in mortality, relative (but not absolute) inequalities widened between 1981 and 2011 for all-cause mortality and for several causes of death. Reducing relative inequalities in Scotland requires faster mortality declines in deprived areas while countering increases in mortality from causes such as drug- and alcohol-related harm and male suicide.

Is austerity responsible for the recent change in mortality trends across high-income nations? A protocol for an observational study

INTRODUCTION

Mortality rates in many high-income countries have changed from their long-term trends since around 2011. This paper sets out a protocol for testing the extent to which economic austerity can explain the variance in recent mortality trends across high-income countries.

METHODS AND ANALYSIS

This is an ecological natural experiment study, which will use regression adjustment to account for differences in exposure, outcomes and confounding. All high-income countries with available data will be included in the sample. The timing of any changes in the trends for four measures of austerity (the Alesina-Ardagna Fiscal Index, real per capita government expenditure, public social spending and the cyclically adjusted primary balance) will be identified and the cumulative difference in exposure to these measures thereafter will be calculated. These will be regressed against the difference in the mean annual change in life expectancy, mortality rates and lifespan variation compared with the previous trends, with an initial lag of 2 years after the identified change point in the exposure measure. The role of underemployment and individual incomes as outcomes in their own right and as mediating any relationship between austerity and mortality will also be considered. Sensitivity analyses varying the lag period to 0 and 5 years, and adjusting for recession, will be undertaken.

ETHICS AND DISSEMINATION

All of the data used for this study are publicly available, aggregated datasets with no individuals identifiable. There is, therefore, no requirement for ethical committee approval for the study. The study will be lodged within the National Health Service research governance system. All results of the study will be published following sharing with partner agencies. No new datasets will be created as part of this work for deposition or curation.

The increasing lifespan variation gradient by area-level deprivation: A decomposition analysis of Scotland 1981-2011

Life expectancy inequalities are an established indicator of health inequalities. More recent attention has been given to lifespan variation, which measures the amount of heterogeneity in age at death across all individuals in a population. International studies have documented diverging socioeconomic trends in lifespan variation using individual level measures of income, education and occupation. Despite using different socioeconomic indicators and different indices of lifespan variation, studies reached the same conclusion: the most deprived experience the lowest life expectancy and highest lifespan variation, a double burden of mortality inequality. A finding of even greater concern is that relative differences in lifespan variation between socioeconomic group were growing at a faster rate than life expectancy differences. The magnitude of lifespan variation inequalities by area-level deprivation has received limited attention. Area-level measures of deprivation are actively used by governments for allocating resources to tackle health inequalities. Establishing if the same lifespan variation inequalities emerge for area-level deprivation will help to better inform governments about which dimension of mortality inequality should be targeted. We measure lifespan variation trends (1981-2011) stratified by an area-level measure of socioeconomic deprivation that is applicable to the entire population of Scotland, the country with the highest level of variation and one of the longest, sustained stagnating trends in Western Europe. We measure the gradient in variation using the slope and relative indices of inequality. The deprivation, age and cause specific components driving the increasing gradient are identified by decomposing the change in the slope index between 1981 and 2011. Our results support the finding that the most advantaged are dying within an ever narrower age range while the most deprived are facing greater and increasing uncertainty. The least deprived group show an increasing advantage, over the national average, in terms of deaths from circulatory disease and external causes.

Changing contribution of area-level deprivation to total variance in age at death: a population-based decomposition analysis

OBJECTIVES

Two processes generate total variance in age at death: heterogeneity (between-group variance) and individual stochasticity (within-group variance). Limited research has evaluated how these two components have changed over time. We quantify the degree to which area-level deprivation contributed to total variance in age at death in Scotland between 1981 and 2011.

DESIGN

Full population and mortality data for Scotland were obtained and matched with the Carstairs score, a standardised z-score calculated for each part-postcode sector that measures relative area-level deprivation. A z-score above zero indicates that the part-postcode sector experienced higher deprivation than the national average. A z-score below zero indicates lower deprivation. From the aggregated data we constructed 40 lifetables, one for each deprivation quintile in 1981, 1991, 2001 and 2011 stratified by sex.

PRIMARY OUTCOME MEASURES

Total variance in age at death and the proportion explained by area-level deprivation heterogeneity (between-group variance).

RESULTS

The most deprived areas experienced stagnating or slightly increasing variance in age at death. The least deprived areas experienced decreasing variance. For males, the most deprived quintile life expectancy was between 7% and 11% lower and the SD is between 6% and 25% higher than the least deprived. This suggests that the effect of deprivation on the SD of longevity is comparable to its effect on life expectancy. Decomposition analysis revealed that contributions from between-group variance doubled between 1981 and 2011 but at most only explained 4% of total variance.

CONCLUSIONS

This study adds to the emerging body of literature demonstrating that socio-economic groups have experienced diverging trends in variance in age at death. The contribution from area-level deprivation to total variance in age at death, which we were able to capture, has doubled since 1981. Area-level deprivation may play an increasingly important role in mortality inequalities.

Pilot study protocol to inform a future longitudinal study of ageing using linked administrative data: Healthy AGeing in Scotland (HAGIS)

INTRODUCTION

Population ageing is a welcome testament to improvements in the social, economic and health circumstances over the life course. However, these successes necessitate that we understand more about the pathways of ageing to plan and cost our health and social care services, to support our ageing population to live healthier for longer and to make adequate provisions for retirement. Longitudinal studies of ageing facilitate such understanding in many countries around the world. Scotland presently does not have a longitudinal study of ageing, despite dramatic increases to its ageing population and its poor health record. Healthy AGeing in Scotland (HAGIS) constitutes the launch of Scotland's first comprehensive longitudinal study of ageing.

METHODS

A sample of 1000 people aged 50+ years will be invited to take part in a household social survey. The innovative sampling procedure used administrative data to identify eligible households. Anonymised survey responses will be linked to administrative data.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the host institution for the study design and from the Public Benefits and Privacy Panel for administrative data linkage. Anonymised survey data will be deposited with the UK Data Service. A subset of survey data, harmonised with other global ageing studies, will be available via the Gateway to Global Aging platform. These data will enable powerful cross-country comparisons across the social, economic and health domains that will be relevant for national and international research.Research publications from the HAGIS team will be disseminated through journal articles and national and international conferences. The findings will support current and future research and policy debate on ageing populations.

Increasing inequality in age of death at shared levels of life expectancy: A comparative study of Scotland and England and Wales

There is a strong negative correlation between increasing life expectancy and decreasing lifespan variation, a measure of inequality. Previous research suggests that countries achieving a high level of life expectancy later in time generally do so with lower lifespan variation than forerunner countries. This may be because they are able to capitalise on lessons already learnt. However, a few countries achieve a high level of life expectancy later in time with higher inequality. Scotland appears to be such a country and presents an interesting case study because it previously experienced lower inequality when reaching the same level of life expectancy as its closest comparator England and Wales. We calculated life expectancy and lifespan variation for Scotland and England and Wales for the years 1950 to 2012, comparing Scotland to England and Wales when it reached the same level of life expectancy later on in time, and assessed the difference in the level of lifespan variation. The lifespan variation difference between the two countries was then decomposed into age-specific components. Analysis was carried out for males and females separately. Since the 1950s Scotland has achieved the same level of life expectancy at least ten years later in time than England and Wales. Initially it did so with lower lifespan variation. Following the 1980s Scotland has been achieving the same level of life expectancy later in time than England and Wales and with higher inequality, particularly for males. Decomposition revealed that higher inequality is partly explained by lower older age mortality rates but primarily by higher premature adult age mortality rates when life expectancy is the same. Existing studies suggest that premature adult mortality rates are strongly associated with the social determinants of health and may be amenable to social and economic policies. So addressing these policy areas may have benefits for both inequality and population health in Scotland.