Why the Scots die younger: synthesizing the evidence.

OBJECTIVE: To identify explanations for the higher mortality in Scotland relative to other European countries, and to synthesize those best supported by evidence into an overall explanatory framework. STUDY
DESIGN: Review and dialectical synthesis.
METHODS: Candidate hypotheses were identified based on a literature review and a series of research dissemination events. Each hypothesis was described and critically evaluated in relation to the Bradford-Hill criteria for causation in observational epidemiology. A synthesis of the more convincing hypotheses was then attempted using a broadly 'dialectical' approach.
RESULTS: Seventeen hypotheses were identified including: artefactual explanations (deprivation, migration); 'downstream explanations' (genetics, health behaviours, individual values); 'midstream' explanations (substance misuse; culture of boundlessness and alienation; family, gender relations and parenting differences; lower social capital; sectarianism; culture of limited social mobility; health service supply or demand; deprivation concentration); and 'upstream' explanations (climate, inequalities, de-industrialization, political attack). There is little evidence available to determine why mortality rates diverged between Scotland and other European countries between 1950 and 1980, but the most plausible explanations at present link to particular industrial, employment, housing and cultural patterns. From 1980 onwards, the higher mortality has been driven by unfavourable health behaviours, and it seems quite likely that these are linked to an intensifying climate of conflict, injustice and disempowerment. This is best explained by developing a synthesis beginning from the political attack hypothesis, which suggests that the neoliberal policies implemented from 1979 onwards across the UK disproportionately affected the Scottish population.
CONCLUSIONS: The reasons for the high Scottish mortality between 1950 and 1980 are unclear, but may be linked to particular industrial, employment, housing and cultural patterns. From 1980 onwards, the higher mortality is most likely to be accounted for by a synthesis which begins from the changed political context of the 1980s, and the consequent hopelessness and community disruption experienced. This may have relevance to faltering health improvement in other countries, such as the USA.