Compared with other Western European countries, Scotland has one of the highest mortality rates and lowest life expectancy. Scotland is also characterised by marked inequalities, with men from the poorest communities dying 13 years earlier and experiencing seven more years in poor health than men from the most affluent communities. A similar pattern is seen for women . There has been little change in these markers over the past decade, despite a plethora of short term policies and programmes that have largely focused on short term, small scale projects aimed at changing individual lifestyles, rather than the broader social determinants of health. Indeed, at national level, there is substantial evidence that health inequalities in youth and younger adults have increased, due to various forms of ‘self-harm’: alcohol and drug misuse, violence and suicide .
In Lothian, there is evidence that drugrelated harm and death is occurring at a later age than in the 1980s. Access to drug treatments and surgery are more equitable but there is less evidence of a real commitment to investing in programmes and policies that address the reasons why people turn to alcohol, drugs and food so easily as ways of escape from reality in the first place. Known in public health terms as the upstream social determinants of health, these include the built environment, transport policies, education, genetics, maternal and child health, racism and language barriers, physical activity, violence and community values. We can compare the level of our inequality, using the Gini-coefficient of inequality – the most commonly used measure of inequality, where 0 is total equality, and 1 is total inequality [3, 4] (see Figure 1). Scotland sits at 0.31 compared to the UK as a whole at 0.35, Denmark at 0.29, Sweden 0.25, Norway 0.26, Germany 0.27, Netherlands 0.30 and Canada at 0.33, these being the countries against which we benchmark performance . Given this comparison, local improvements in the socio-economic gap in mortality amenable to healthcare are welcome. Such interventions, however, may be vulnerable to the dramatic cuts in funding for the public sector that Scotland is likely to face in the near future. By developing an evidence-base about effective public health interventions, we are in a better position to provide a rational basis for prioritising investment that is likely to reduce rather than increase the burden of disease and health inequality gradient.
The Scottish Collaboration for Public Health Research and Policy (SCPHRP) was established in the summer of 2008. Its remit is:
- To identify areas for developing novel public health interventions that equitably address major Scottish health problems;
- To foster collaboration between government, researchers and the public health community to develop a national programme of intervention development, large-scale implementation and robust evaluation; and
- To build capacity within the public health community for high quality collaborative research that will have maximum impact on policies, programmes and practice.
The Collaboration’s initial work was to identify effective interventions that address the social determinants of health in a process that involved over 70 Scottish experts (see www.scphrp.ac.uk). Structured rapid reviews of these interventions have now been completed and in the rest of this article we summarise their main conclusions.
Evidence outlined in other articles in this report overwhelmingly shows that early life experience has a major impact on health and social outcomes. The roots of many of today’s health problems – addictions, mental health problems, obesity and coronary heart disease – lie in the early years . Sensitive periods in brain development in the first five years of life which make young children particularly susceptible to adverse conditions also make them amenable to intervention [7, 8]. Interventions that promote good parenting and attachment support social and cognitive development and improve outcomes . A recent strategic review of health inequalities in England suggests we need proportionate universalism. This is the provision of services for which everyone is eligible but where the scale and intensity of early intervention is proportionate to the level of disadvantage, equivalent to providing a higher or more frequent dose of a medicine to patients with more severe disease. Overall, this might amount to 1.5-2.0% of GDP to support children’s early development. In a structured review that followed, a mix of programmes was outlined that, building on existing work in Scotland, could turn around the life chances of children in a few years .
Analysis grid for environments linked to obesity (ANGELO) 
Adolescence and young adulthood
Investment in interventions in the early years alone will not ensure that children and young adults achieve their full potential. As children grow they are exposed to an increasing number of influences through school, their peer group and the community. Risk and protective factors from these domains have been shown to be common to a range of adolescent risk and deviant behaviours, including substance misuse, sexual risk behaviour and delinquency . The evidence-base is less well developed than that for interventions in early life but two US programmes have been identified:  the Seattle Social Development Project  which focuses on primary age school children; and the Strengthening Families Programme 10-14 . Both are effective in reducing multiple risk behaviours. In addition, the Gatehouse Project  from Australia, which focuses on school ethos and connectedness (a sense of belonging) shows promise. All three programmes are complex interventions that act on a range of factors simultaneously. Most intervention programmes in Scotland have focused on individual risk behaviours. The available evidence provides a strong argument for a collaborative, cross-sectoral, communitybased demonstration project that aims to reduce multiple risk behaviours . The equivalent approach in treatment services is the additional benefit following the shift to multi-disciplinary interventions in cancer and stroke.
Adult obesity has been confirmed as one of the most serious global public health problems. In Scotland, 22% of men and 24% of women are classified as obese (BMI >30) . On average, obese adults die nine years earlier than others. Changes in eating patterns at individual and population level will only be possible if accompanied by changes in the physical, economic, political and socio-cultural environment . Tackling obesity is a public health priority in Scotland . It is suggested that four types of intervention are likely to have the greatest impact on obesity . These include: interventions to increase walking and cycling; health interventions that target those at greatest risk; controlling the availability of and exposure to obesogenic (energy dense) foods and drink and workplace interventions. Obesogenic products include sugary soft drinks, sweetened breakfast cereals, confectionery, savoury snacks, cakes, pastries and biscuits, desserts, fatty spreads and sweetened dairy products.
The origins of illness and disability in later life can clearly be linked to early life experience and are strongly socially patterned. Older people in the lowest socio-economic group have a shorter life expectancy but also live more years in poor health . A recent professional literature review  concluded that there are large gaps in the evidence-base and where studies have been conducted, evidence on effectiveness is often conflicting. There is some evidence, however, for encouraging exercise which can improve aspects of functioning such as walking in older people and recent Scottish policy advocates many of the interventions reviewed such as falls prevention, tele-care and co-ordinated, integrated care delivery. The impact of many of these interventions for older people in Scotland is, as yet, unknown. This impact therefore, along with the feasibility, affordability, sustainability and effects on equity would need to be considered when developing any new and innovative interventions in this field.
- Over the last decade there has been little improvement in Scotland in many of the traditional markers of health inequalities, such as all cause mortality, hospitalisation and healthy life expectancy.
- For each life stage there are effective or promising interventions that focus on the social determinants of health and have the potential to reduce the future burden of disease.
- The four rapid reviews we have completed suggest profound changes in the social determinants of health are required if Scotland is to overcome its current public health problems.
- Major cultural changes will also be required to achieve this end, changes that influence child development, youth risk-related behaviour, adult eating and activity patterns and the way we approach maintaining the elderly in the community.
- Individuals and families need to consider the social determinants of health within their own control to improve what they can – diet, alcohol, tobacco and exercise.
- To better assess the impact public health programmes and policies have on health and health inequalities, we need more sensitive measures that are tractable and amenable to change.
- Surveillance should include sensitive measures of health and function that: occur earlier in the life-course; are amenable to change; reflect the future ‘life chances’ and health status; and are strongly patterned by socioeconomic position .
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