The science of creating wellness

Prof Carol Tannahill, Director,Glasgow Centre for Population Health

Scotland & other Western European countries

Male life expectancy: Scotland & other Western European Countries, 1851-2005Source: Human Mortality Database

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

1851

-185

3

1855

-185

7

1859

-186

1

1863

-186

5

1867

-186

9

1871

-187

3

1875

-187

7

1879

-188

1

1883

-188

5

1887

-188

9

1891

-189

3

1895

-189

7

1899

-190

1

1903

-190

5

1907

-190

9

1911

-191

3

1915

-191

7

1919

-192

1

1923

-192

5

1927

-192

9

1931

-193

3

1935

-193

7

1939

-194

1

1943

-194

5

1947

-194

9

1951

-195

3

1955

-195

7

1959

-196

1

1963

-196

5

1967

-196

9

1971

-197

3

1975

-197

7

1979

-198

1

1983

-198

5

1987

-198

9

1991

-199

3

1995

-199

7

1999

-200

1

2003

-200

5

Male life expectancy: Scotland & other Western European Countries, 1851-2005Source: Human Mortality Database

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

1851

-185

3

1855

-185

7

1859

-186

1

1863

-186

5

1867

-186

9

1871

-187

3

1875

-187

7

1879

-188

1

1883

-188

5

1887

-188

9

1891

-189

3

1895

-189

7

1899

-190

1

1903

-190

5

1907

-190

9

1911

-191

3

1915

-191

7

1919

-192

1

1923

-192

5

1927

-192

9

1931

-193

3

1935

-193

7

1939

-194

1

1943

-194

5

1947

-194

9

1951

-195

3

1955

-195

7

1959

-196

1

1963

-196

5

1967

-196

9

1971

-197

3

1975

-197

7

1979

-198

1

1983

-198

5

1987

-198

9

1991

-199

3

1995

-199

7

1999

-200

1

2003

-200

5

Not always the ‘Sick Man of Europe’

Comparison to WE Mean(Males)

Proportionate Contribution by Cause - Males

Coronary heart disease mortalityMen aged 15-74 years

100

200

300

400

500

600

1950 1960 1970 1980 1990

DenmarkFinlandNorwaySwedenScotland

Age

-sta

ndar

dise

d m

orta

lity

per

100

,000

Healthy Life ExpectancyLife Expectancy vs Healthy Life Expectancy* at Birth, Males , 1999-2000

Source: ISD Scotland

53.846.7 46.8 46.8 48.3 50.5 52.6 53.2 53.6 53.8 56.5 58.5

19.2

21.8 25.8 24.9 22.5 19.620.2 17.8 20.8 19.2

19.7 17.6

0

10

20

30

40

50

60

70

80

Scotla

nd

Glasgo

w City

East A

yrsh

ire

North

Lan

arks

hire

Wes

t Dun

barto

nshir

e

Inve

rclyd

e

North

Ayr

shire

Renfre

wshire

South

Ayr

shire

South

Lan

arks

hire

East D

unba

rtons

hire

East R

enfre

wshire

West of Scotland Council Area

Lif

e E

xpec

tan

cy a

t b

irth

HLE at birth Years of life with a LLI* defined as absence of Limiting Longterm Illness (LLI)

Percentage of adults aged 16 and over with a long-standing illness, disability or health problem

by SIMD quintile, 2007/08    (Scottish Household Survey)      

Percentage of adults aged 16 and over with a long-standing illness, disability or health problem

by SIMD quintile, 2007/08    (Scottish Household Survey)      

2001 Census figures.

Scotland: 20%;

NHSGGC range from 16% - 30%

A whistlestop tour around some concepts

1. Prevention• Reduce the incidence of health problems

(primary prevention)• Reduce the progression of health problems

(secondary prevention)• Reduce the impacts of disease (tertiary

prevention)• Reduce unnecessary health interventions

(quarternary prevention)BUT…

A whistlestop tour around some concepts

1. Prevention• Reduce the incidence of health problems

(primary prevention) health problems only?• Reduce the progression of health problems

(secondary prevention) • Reduce the impacts of disease (tertiary

prevention)• Reduce unnecessary health interventions

(quarternary prevention)

A whistlestop tour around some concepts

1. Prevention• Reduce the incidence of health problems

(primary prevention) health problems only?• Reduce the progression of health problems

(secondary prevention) covers almost all of health care activity

• Reduce the impacts of disease (tertiary prevention)

• Reduce unnecessary health interventions (quarternary prevention)

A whistlestop tour around some concepts

1. Prevention• Reduce the incidence of health problems (primary

prevention) health problems only?• Reduce the progression of health problems

(secondary prevention) covers almost all of health care activity

• Reduce the impacts of disease (tertiary prevention) covers almost all of social care activity

• Reduce unnecessary health interventions (quarternary prevention)

A whistlestop tour around some concepts

An alternative1. Prevention of the onset or first manifestation of

a disease process, or some other first occurrence, through risk reduction

2. Prevention of the progression of a disease process or other unwanted state, through early detection when this favourably affects outcome

3. Prevention of avoidable complications of a health problem or other unwanted state

4. Prevention of the recurrence of an illness or other unwanted phenomenon.

A whistlestop tour around some concepts

Preventative spend• Spending now that is expected to reduce

public spending demands in the future by reducing avoidable health and social problems

• Must increase healthy lifespan/compress morbidity

• Wanless: requirement for ‘fully engaged’ scenario

A whistlestop tour around some concepts

Wellness

Aaron AntonovskyAaron Antonovsky Sir Harry Burns

“.....expresses the extent to which one has a feeling of confidence that the stimuli deriving from one's internal and external environments in the course of living are structured, predictable and explicable, that one has the internal resources to meet the demands posed by these stimuli and, finally, that these demands are seen as challenges, worthy of investment and engagement."

Sense of coherence....

For the creation of health....For the creation of health....

....the social and physical environment must be:....the social and physical environment must be:• ComprehensibleComprehensible• ManageableManageable• MeaningfulMeaningful• ......or the individual would experience chronic ......or the individual would experience chronic

stressstress

Summary• Scotland’s health ranking is a relatively recent

phenomenon, and reflects a slower rate of improvement than other countries

• The outcomes for (young) working age men and women are particularly concerning

• For many causes of death, Scotland’s improvement is in line with other countries

• But ‘social dis-eases’ are increasing • Inequalities are also increasing• There is a lot of evidence (and more emerging all the

time) that traditional explanations of socio-economic deprivation (underpinned by effects of post-industrial decline) are not sufficient.

How do we respond?

1. Programmatically on individual issues?

• The most common response

• Evidence-based and often with a clear method

• Positive outcomes for (a proportion of) participants

• Tends to increase inequality

• Rarely achieves population-level impact

• Need to respond to each new issue afresh

-70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70

-70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70

2. Through national policyon individual issues?

• Smoking in public places• Alcohol minimum pricing• Screening and immunisation programmes• Housing quality standards• Social protection• School meal standards

• Less likely to increase inequality• More likely to achieve population-level impact• But still need to respond to each new issue afresh

3. On the cross-cutting determinants operating at individual & community

levels?• Fundamental influences that perpetuate

poorer health outcomes, regardless of the issue– Power distribution– Knowledge– Social networks– Access to (financial and other) resources

• Asset-based working

Creating wellbeing

Sense of coherence

Seeing the world as:StructuredPredictable

Feeling that it is:ManageableMeaningful

Wanting to engage

Sense of coherence

Seeing the world as:StructuredPredictable

Feeling that it is:ManageableMeaningful

Wanting to engage

Generalised resistance resources

Family Nurture

IntelligenceWork

Material resourceIdentity

Cultural stabilityOptimism

Stable set of answers

Generalised resistance resources

Family Nurture

IntelligenceWork

Material resourceIdentity

Cultural stabilityOptimism

Stable set of answers

Events

Stress

Tension

Resolution

Wellbeing

Events

Stress

Tension

Resolution

Wellbeing

Antonovsky. Health, stress and coping. 1979

Inflammation in plaquesInflammation in plaques

Inflammatory cellsInflammatory cells

MMPs, IL-6, MMPs, IL-6, IL-15, IL-18, CRPIL-15, IL-18, CRP

LumenLumen

CoreCore

CapCap

Thin Thin Fibrous CapFibrous Cap

InflammatoryInflammatoryCellsCells

SMCSMC apoptosisapoptosis

DegradedDegradedmatrixmatrix

UnstableUnstable

cytokinescytokines MMPMMP

Choice reaction timeChoice reaction time

p<0.001

mil

lise

con

ds

Age (years)

Depcat % smokers Never-smokers Smokers

1 36.8 0.71 1.42

2 35.9 1.00 2.34

3 39.1 1.11 2.25

4 44.1 1.21 2.44

5 46.6 1.13 2.53

6 49.3 1.25 3.07

7 55.5 1.48 3.29

Environmental determinants of Environmental determinants of inflammatory status inflammatory status

CRP (median) mg/dl

affluent

deprived

Implementing at scale….Implementing at scale….can it be done?can it be done?

The Early Years Collaborative - Aims1. To ensure that women experience positive pregnancies which result in the birth of more

healthy babies as evidenced by a reduction of 15% in the rates of stillbirthsreduction of 15% in the rates of stillbirths (from 4.9 per 1,000 births in 2010 to 4.3 per 1,000 births in 2015) and infant mortality (from 3.7 per 1,000 live births in 2010 to 3.1 per 1,000 live births in 2015).

2. To ensure that 85% of all children 85% of all children within each Community Planning Partnership

have reached all of the expected developmental milestones have reached all of the expected developmental milestones at the time of

the child’s 27-30 month child health review, by end-2016.child’s 27-30 month child health review, by end-2016.

3. To ensure that 90% of all children 90% of all children within each Community Planning Partnership

have reached all of the expected developmental milestones at the time reached all of the expected developmental milestones at the time the child starts primary school, by end-2017the child starts primary school, by end-2017.

Lochrin NurseryLochrin NurseryChildren receiving a bedtime story

MedianGoal

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M T W TH F M T W TH F M T W TH F M T W TH FDay of the week

Perc

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tag

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of

ch

ild

ren

.

Parents survey

Grassmarket changes

introduced.

Books available at collection time.

Research information handed to

parents.

weekly average displayed for parents

90% of children at Grassmarket nursery 90% of children at Grassmarket nursery school will receive a bedtime story at school will receive a bedtime story at least 3 times a week.least 3 times a week.

Children receiving a bedtime story

Median

Goal

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M T W TH F M T W TH F M T W TH F M T W TH FDay of the week

Perc

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ild

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Family garden party

A very hot weekend

AlfieAlfie

‘ ‘I like my I like my bedtime story bedtime story because it helps because it helps me to dreamme to dream’’

Do one brave thing today….then run like hell!