Trends in psychological distress in Great Britain, 1991-2019: evidence from three representative surveys.

BACKGROUND: Previously improving UK mortality trends stalled around 2012, with evidence implicating economic policy as the cause. This paper examines whether trends in psychological distress across three population surveys show similar trends. METHODS: We report the percentages reporting psychological distress (4+ in the 12-item General Health Questionnaire) from Understanding Society (Great Britain, 1991-2019), Scottish Health Survey (SHeS, 1995-2019) and Health Survey for England (HSE, 2003-2018) for the population overall, and stratified by sex, age and area deprivation. Summary inequality indices were calculated and segmented regressions fitted to identify breakpoints after 2010. RESULTS: Psychological distress was higher in Understanding Society than in SHeS or HSE. There was slight improvement between 1992 and 2015 in Understanding Society (with prevalence declining from 20.6% to 18.6%) with some fluctuations. After 2015 there is some evidence of a worsening in psychological distress across surveys. Prevalence worsened notably among those aged 16-34 years after 2010 (all three surveys), and aged 35-64 years in Understanding Society and SHeS after 2015. In contrast, the prevalence declined in those aged 65+ years in Understanding Society after around 2008, with less clear trends in the other surveys. The prevalence was around twice as high in the most deprived compared with the least deprived areas, and higher in women, with trends by deprivation and sex similar to the populations overall. CONCLUSION: Psychological distress worsened among working-age adults after around 2015 across British population surveys, mirroring the mortality trends. This indicates a widespread mental health crisis that predates the COVID-19 pandemic.

The increasing significance of disease severity in a burden of disease framework.

Recent estimates have reiterated that non-fatal causes of disease, such as low back pain, headaches and depressive disorders, are amongst the leading causes of disability-adjusted life years (DALYs). For these causes, the contribution of years lived with disability (YLD) - put simply, ill-health - is what drives DALYs, not mortality. Being able to monitor trends in YLD closely is particularly relevant for countries that sit high on the socio-demographic spectrum of development, as it contributes more than half of all DALYs. There is a paucity of data on how the population-level occurrence of disease is distributed according to severity, and as such, the majority of global and national efforts in monitoring YLD lack the ability to differentiate changes in severity across time and location. This raises uncertainties in interpreting these findings without triangulation with other relevant data sources. Our commentary aims to bring this issue to the forefront for users of burden of disease estimates, as its impact is often easily overlooked as part of the fundamental process of generating DALY estimates. Moreover, the wider health harms of the COVID-19 pandemic have underlined the likelihood of latent and delayed demand in accessing vital health and care services that will ultimately lead to exacerbated disease severity and health outcomes. This places increased importance on attempts to be able to differentiate by both the occurrence and severity of disease.

Is austerity a cause of slower improvements in mortality in high-income countries? A panel analysis.

BACKGROUND: The rate of improvement in mortality slowed across many high-income countries after 2010. Following the 2007-08 financial crisis, macroeconomic policy was dominated by austerity as countries attempted to address perceived problems of growing state debt and government budget deficits. This study estimates the impact of austerity on mortality trends for 37 high-income countries between 2000 and 2019. METHODS: We fitted a suite of fixed-effects panel regression models to mortality data (period life expectancy, age-standardised mortality rates (ASMRs), age-stratified mortality rates and lifespan variation). Austerity was measured using the Alesina-Ardagna Fiscal Index (AAFI), Cyclically-Adjusted Primary Balance (CAPB), real indexed Government Expenditure, and Public Social Spending as a % of GDP. Sensitivity analyses varied the lag times, and confined the panel to economic downturns and to non-oil-dominated economies. RESULTS: Slower improvements, or deteriorations, in life expectancy and mortality trends were seen in the majority of countries, with the worst trends in England & Wales, Estonia, Iceland, Scotland, Slovenia, and the USA, with generally worse trends for females than males. Austerity was implemented across all countries for at least some time when measured by AAFI and CAPB, and for many countries across all four measures (and particularly after 2010). Austerity adversely impacted life expectancy, ASMR, age-specific mortality and lifespan variation trends when measured with Government Expenditure, Public Social Spending and CAPB, but not with AAFI. However, when the dataset was restricted to periods of economic downturn and in economies not dominated hydrocarbon production, all measures of austerity were found to reduce the rate of mortality improvement. INTERPRETATION: Stalled mortality trends and austerity are widespread phenomena across high-income countries. Austerity is likely to be a cause of stalled mortality trends. Governments should consider alternative economic policy approaches if these harmful population health impacts are to be avoided.

Widening of inequalities in COVID-19 years of life lost from 2020 to 2021: a Scottish Burden of Disease Study.

BACKGROUND: Previous studies have highlighted the large extent of inequality in adverse COVID-19 health outcomes. Our aim was to monitor changes in overall, and inequalities in, COVID-19 years of life lost to premature mortality (YLL) in Scotland from 2020 and 2021. METHODS: Cause-specific COVID-19 mortality counts were derived at age group and area deprivation level using Scottish death registrations for 2020 and 2021. YLL was estimated by multiplying mortality counts by age-conditional life expectancy from the Global Burden of Disease 2019 reference life table. Various measures of absolute and relative inequality were estimated for triangulation purposes. RESULTS: There were marked inequalities in COVID-19 YLL by area deprivation in 2020, which were further exacerbated in 2021; confirmed across all measures of absolute and relative inequality. Half (51%) of COVID-19 YLL was attributable to inequalities in area deprivation in 2021, an increase from 41% in 2020. CONCLUSION: Despite a highly impactful vaccination programme in preventing mortality, COVID-19 continues to represent a substantial area of fatal population health loss for which inequalities have widened. Tackling systemic inequalities with effective interventions is required to mitigate further unjust health loss in the Scottish population from COVID-19 and other causes of ill-health and mortality.

What is the potential for plural ownership to support a more inclusive economy? A systematic review protocol.

BACKGROUND: The world is facing an unprecedented systemic shock to population health, the economy and society due to the devastating impact of the COVID-19 pandemic. As with most economic shocks, this is expected to disproportionately impact vulnerable groups in society such as those in poverty and those in precarious employment as well as marginalised groups such as women, the elderly, Black, Asian and Minority Ethnic (BAME) groups and those with health conditions. The current literature is rich in normative recommendations on plural ownership as a key building block of an inclusive economy rooted in communities and their needs. There is, however, a need for a rigorous synthesis of the available evidence on what impact (if any) plural ownership may potentially have on the inclusivity of the economy. This review seeks to synthesise and compare the available evidence across the three economic sectors (private, public and third). METHODS: We will search eight bibliographic databases (Sociological abstracts, EBSCO Econlit, OVID Embase, OVID Medline, Applied Social Sciences Index and Abstracts (ASSIA), ProQuest Public Health, Web of Science, Research Papers in Economics (Repec) - EconPapers) from the earliest data available in each database until January 2021. Grey literature will be identified from Google (advanced), Google Scholar and 37 organisational websites identified as relevant to the research question. We will include comparative studies of plural ownership from high-income countries that report outcomes on access to opportunities, distribution of benefits, poverty, and discrimination. A bespoke search strategy will be used for each website to account for the heterogeneity in content and search capabilities and will be fully documented. A standardised data extraction template based on the Population-Intervention-Context-Outcome (PICO) template will be developed. We will assess the strength of evidence for different forms of economic ownership identified in relation to the impact of each on the four economic outcomes of interest, paying particular attention to the role of wider contextual factors as they emerge through the evidence. DISCUSSION: The findings of this review are intended to inform policymaking at local, national and international level that prioritises and supports the development of different economic and business models. SYSTEMATIC REVIEW REGISTRATION: Open Science Framework registration DOI: https://doi.org/10.17605/OSF.IO/BYH5A.

Measuring disability-adjusted life years (DALYs) due to COVID-19 in Scotland, 2020.

BACKGROUND: Disability-adjusted life years (DALYs) combine the impact of morbidity and mortality and can enable comprehensive, and comparable, assessments of direct and indirect health harms due to COVID-19. Our aim was to estimate DALYs directly due to COVID-19 in Scotland, during 2020; and contextualise its population impact relative to other causes of disease and injury. METHODS: National deaths and daily case data were used. Deaths were based on underlying and contributory causes recorded on death certificates. We calculated DALYs based on the COVID-19 consensus model and methods outlined by the European Burden of Disease Network. DALYs were presented as a range, using a sensitivity analysis based on Years of Life Lost estimates using: cause-specific; and COVID-19 related deaths. All COVID-19 estimates were for 2020. RESULTS: In 2020, estimates of COVID-19 DALYs in Scotland ranged from 96,500 to 108,200. Direct COVID-19 DALYs were substantial enough to be framed as the second leading cause of disease and injury, with only ischaemic heart disease having a larger impact on population health. Mortality contributed 98% of total DALYs. CONCLUSIONS: The direct population health impact of COVID-19 has been very substantial. Despite unprecedented mitigation efforts, COVID-19 developed from a single identified case in early 2020 to a condition with an impact in Scotland second only to ischaemic heart disease. Periodic estimation of DALYs during 2021, and beyond, will provide indications of the impact of DALYs averted due to the national rollout of the vaccination programme and other continued mitigation efforts, although new variants may pose significant challenges.

Glossary: economics and health.

As we emerge from the COVID-19 pandemic, there is an increasing focus on how the economy is rebuilt and the impact this will have on population health. Many of the economic policy proposals being discussed have their own vocabulary, which is not always understood in the same way within or between disciplines. This glossary seeks to provide a common language and concise summary of the key economic terminology relevant for policymakers and public health at this time.

COVID-19 and prepandemic all-cause inequalities in disability-adjusted life-years due to multiple deprivation: a Scottish Burden of Disease study

Background COVID-19 has caused major social, environmental, and economic changes. The mechanisms that shape health inequalities have resulted in COVID-19 outcomes following the same pattern. We aimed to estimate overall, and inequalities in, COVID-19 disability-adjusted life-years (DALYs) in Scotland during 2020. These were scaled against prepandemic DALYs due to inequalities in multiple deprivation combined across all causes. Methods DALYs were estimated with an international consensus model with Scottish national deaths and daily cases as data inputs. Health loss valuation was defined with the aspirational reference life table and disability weights from the Global Burden of Disease Study 2019. Years of life lost were estimated for each area-based deprivation quintile of the Scottish population. Years lived with disability were distributed to deprivation quintiles, based on the distribution of estimates of years of life lost. Inequalities in rates were measured by the relative index of inequality (RII);slope index of inequality (SII);and attributable DALYs, with the least deprived quintile as a reference category. Prepandemic estimates were for 2018, derived from the Scottish Burden of Disease study. Permissions were granted by the Privacy Advisory Committee, National Health Service, National Services Scotland. Findings Marked inequalities were observed across several measures in 2020 (Jan 1 to Dec 31). The SII was 2048–2289 COVID-19 DALYs per 100 000 people. The COVID-19 DALYs rate in the most deprived areas (2748–3067 per 100 000 people) was around 58% higher than the mean population rate (RII=1·16), with 40% (n=38 925–43 284) of COVID-19 DALYs attributed to inequalities in multiple deprivation. In the wider context, overall COVID-19 DALYs (n=96 519–108 243) were approximately a fifth of the annual prepandemic DALYs (n=535 298) attributable to inequalities in multiple deprivation. Interpretation The impact of COVID-19 in Scotland was not shared equally across areas experiencing different levels of deprivation. The extent of COVID-19 inequality was similar to annual DALYs due to diabetes. Implementing effective policy interventions to reduce health inequalities must be at the forefront of plans to recover and improve population health. Communicating the effect of pre-existing inequalities by scaling against COVID-19 could be a useful means to retaining, and increasing, both policy and public engagement and response over tackling inequality. Funding None.

Inequalities in population health loss by multiple deprivation: COVID-19 and pre-pandemic all-cause disability-adjusted life years (DALYs) in Scotland.

BACKGROUND: COVID-19 has caused almost unprecedented change across health, education, the economy and social interaction. It is widely understood that the existing mechanisms which shape health inequalities have resulted in COVID-19 outcomes following this same, familiar, pattern. Our aim was to estimate inequalities in the population health impact of COVID-19 in Scotland, measured by disability-adjusted life years (DALYs) in 2020. Our secondary aim was to scale overall, and inequalities in, COVID-19 DALYs against the level of pre-pandemic inequalities in all-cause DALYs, derived from the Scottish Burden of Disease (SBoD) study. METHODS: National deaths and daily case data were input into the European Burden of Disease Network consensus model to estimate DALYs. Total Years of Life Lost (YLL) were estimated for each area-based deprivation quintile of the Scottish population. Years Lived with Disability were proportionately distributed to deprivation quintiles, based on YLL estimates. Inequalities were measured by: the range, Relative Index of Inequality (RII), Slope Index of Inequality (SII), and attributable DALYs were estimated by using the least deprived quintile as a reference. RESULTS: Marked inequalities were observed across several measures. The SII range was 2048 to 2289 COVID-19 DALYs per 100,000 population. The rate in the most deprived areas was around 58% higher than the mean population rate (RII = 1.16), with 40% of COVID-19 DALYs attributed to differences in area-based deprivation. Overall DALYs due to COVID-19 ranged from 7 to 20% of the annual pre-pandemic impact of inequalities in health loss combined across all causes. CONCLUSION: The substantial population health impact of COVID-19 in Scotland was not shared equally across areas experiencing different levels of deprivation. The extent of inequality due to COVID-19 was similar to averting all annual DALYs due to diabetes. In the wider context of population health loss, overall ill-health and mortality due to COVID-19 was, at most, a fifth of the annual population health loss due to inequalities in multiple deprivation. Implementing effective policy interventions to reduce health inequalities must be at the forefront of plans to recover and improve population health.

Knowing the goal: an inclusive economy that can address the public health challenges of our time.

OBJECTIVE: Inequality is deeply embedded in our economic structures-it is necessary to address these economic inequalities if we are to reduce health inequalities. An inclusive economic approach was conceptualised as a way to reduce these economic inequalities, although the attributes of this approach are unclear. Public health practitioners are increasingly asked to provide a health perspective on the economic recovery plans in the light of the COVID-19 pandemic. This paper aims to identify the attributes of an inclusive economy to enable the public health profession to influence an inclusive economic recovery. APPROACH: We conducted a rapid review of grey and peer-reviewed literature to identify the attributes of an inclusive economy as currently defined in the literature. ATTRIBUTES OF AN INCLUSIVE ECONOMY: Twenty-two concepts were identified from 56 reports and articles. These were collapsed into four distinct attributes of an inclusive economy: (1) an economy that is designed to deliver inclusion and equity, (2) equitable distribution of the benefits from the economy (eg, assets, power, value), (3) equitable access to the resources needed to participate in the economy (eg, health, education), and (4) the economy operates within planetary boundaries. CONCLUSION: As economies are (re)built following the COVID-19 pandemic, these attributes of an inclusive economy-based on the current literature-can be used to develop, and then monitor progress of, economic policy that will reduce health inequalities, improve health and mitigate against climate change.

COVID-19 - exploring the implications of long-term condition type and extent of multimorbidity on years of life lost: a modelling study.

Background: COVID-19 is responsible for increasing deaths globally. As most people dying with COVID-19 are older with underlying long-term conditions (LTCs), some speculate that YLL are low. We aim to estimate YLL attributable to COVID-19, before and after adjustment for number/type of LTCs, using the limited data available early in the pandemic. Methods: We first estimated YLL from COVID-19 using WHO life tables, based on published age/sex data from COVID-19 deaths in Italy. We then used aggregate data on number/type of LTCs in a Bayesian model to estimate likely combinations of LTCs among people dying with COVID-19. We used routine UK healthcare data from Scotland and Wales to estimate life expectancy based on age/sex/these combinations of LTCs using Gompertz models from which we then estimate YLL. Results: Using the standard WHO life tables, YLL per COVID-19 death was 14 for men and 12 for women. After adjustment for number and type of LTCs, the mean YLL was slightly lower, but remained high (11.6 and 9.4 years for men and women, respectively). The number and type of LTCs led to wide variability in the estimated YLL at a given age (e.g. at ≥80 years, YLL was >10 years for people with 0 LTCs, and <3 years for people with ≥6). Conclusions: Deaths from COVID-19 represent a substantial burden in terms of per-person YLL, more than a decade, even after adjusting for the typical number and type of LTCs found in people dying of COVID-19. The extent of multimorbidity heavily influences the estimated YLL at a given age. More comprehensive and standardised collection of data (including LTC type, severity, and potential confounders such as socioeconomic-deprivation and care-home status) is needed to optimise YLL estimates for specific populations, and to understand the global burden of COVID-19, and guide policy-making and interventions.

The contribution of changes to tax and social security to stalled life expectancy trends in Scotland: a modelling study.

BACKGROUND: Life expectancy (LE) improvements have stalled, and UK tax and welfare 'reforms' have been proposed as a cause. We estimated the effects of tax and welfare reforms from 2010/2011 to 2021/2022 on LE and inequalities in LE in Scotland. METHODS: We applied a published estimate of the cumulative income impact of the reforms to the households within Scottish Index of Multiple Deprivation (SIMD) quintiles. We estimated the impact on LE by applying a rate ratio for the impact of income on mortality rates (by age group, sex and SIMD quintile) and calculating the difference between inflation-only changes in benefits and the reforms. RESULTS: We estimated that changes to household income resulting from the reforms would result in an additional 1041 (+3.7%) female deaths and 1013 (+3.8%) male deaths. These deaths represent an estimated reduction of female LE from 81.6 years to 81.2 years (-20 weeks), and male LE from 77.6 years to 77.2 years (-23 weeks). Cuts to benefits and tax credits were modelled to have the most detrimental impact on LE, and these were estimated to be most severe in the most deprived areas. The modelled impact on inequalities in LE was widening of the gap between the most and least deprived 20% of areas by a further 21 weeks for females and 23 weeks for males. INTERPRETATION: This study provides further evidence that austerity, in the form of cuts to social security benefits, is likely to be an important cause of stalled LE across the UK.

Population health post-pandemic: critiquing the economic approach to recovery.

The COVID-19 pandemic has exposed that the economic crisis is inseparable from the health and inequalities crisis. This commentary identifies the key overarching economic decisions that governments will make that are likely have a larger impact on the health of nations than the direct impact of COVID-19 itself. We present these economic decisions to a health audience. The public health profession will need to develop opinions on these key economic decisions if we are to shape the environment that has such a large impact on the work we do.

Scaling COVID-19 against inequalities: should the policy response consistently match the mortality challenge?

BACKGROUND: The mortality impact of COVID-19 has thus far been described in terms of crude death counts. We aimed to calibrate the scale of the modelled mortality impact of COVID-19 using age-standardised mortality rates and life expectancy contribution against other, socially determined, causes of death in order to inform governments and the public. METHODS: We compared mortality attributable to suicide, drug poisoning and socioeconomic inequality with estimates of mortality from an infectious disease model of COVID-19. We calculated age-standardised mortality rates and life expectancy contributions for the UK and its constituent nations. RESULTS: Mortality from a fully unmitigated COVID-19 pandemic is estimated to be responsible for a negative life expectancy contribution of -5.96 years for the UK. This is reduced to -0.33 years in the fully mitigated scenario. The equivalent annual life expectancy contributions of suicide, drug poisoning and socioeconomic inequality-related deaths are -0.25, -0.20 and -3.51 years, respectively. The negative impact of fully unmitigated COVID-19 on life expectancy is therefore equivalent to 24 years of suicide deaths, 30 years of drug poisoning deaths and 1.7 years of inequality-related deaths for the UK. CONCLUSION: Fully mitigating COVID-19 is estimated to prevent a loss of 5.63 years of life expectancy for the UK. Over 10 years, there is a greater negative life expectancy contribution from inequality than around six unmitigated COVID-19 pandemics. To achieve long-term population health improvements it is therefore important to take this opportunity to introduce post-pandemic economic policies to 'build back better'.

COVID-19 – exploring the implications of long-term condition type and extent of multimorbidity on years of life lost: a modelling study [version 1;peer review: awaiting peer review]

Background: The COVID-19 pandemic is responsible for increasing deaths globally. Most estimates have focused on numbers of deaths, with little direct quantification of years of life lost (YLL) through COVID-19. As most people dying with COVID-19 are older with underlying long-term conditions (LTCs), some have speculated that YLL are low. We aim to estimate YLL attributable to COVID-19, before and after adjustment for number/type of LTCs. Methods: We first estimated YLL from COVID-19 using standard WHO life tables, based on published age/sex data from COVID-19 deaths in Italy. We then used aggregate data on number/type of LTCs to model likely combinations of LTCs among people dying with COVID-19. From these, we used routine UK healthcare data to estimate life expectancy based on age/sex/different combinations of LTCs. We then calculated YLL based on age, sex and type of LTCs and multimorbidity count. Results: Using the standard WHO life tables, YLL per COVID-19 death was 14 for men and 12 for women. After adjustment for number and type of LTCs, the mean YLL was slightly lower, but remained high (13 and 11 years for men and women, respectively). The number and type of LTCs led to wide variability in the estimated YLL at a given age (e.g. at ≥80 years, YLL was 10 years for people with 0 LTCs, and 3 years for people with ≥6). Conclusions: Deaths from COVID-19 represent a substantial burden in terms of per-person YLL, more than a decade, even after adjusting for the typical number and type of LTCs found in people dying of COVID-19. The extent of multimorbidity heavily influences the estimated YLL at a given age. More comprehensive and standardised collection of data on LTCs is needed to better understand and quantify the global burden of COVID-19 and to guide policy-making and interventions.