the science of creating wellness prof carol tannahill, director, glasgow centre for population...
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The science of creating wellness
Prof Carol Tannahill, Director,Glasgow Centre for Population Health
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Scotland & other Western European countries
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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’
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Comparison to WE Mean(Males)
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Proportionate Contribution by Cause - Males
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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
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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)
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Percentage of adults aged 16 and over with a long-standing illness, disability or health problem
by SIMD quintile, 2007/08 (Scottish Household Survey)
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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%
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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…
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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)
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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)
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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)
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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.
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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
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A whistlestop tour around some concepts
Wellness
Aaron AntonovskyAaron Antonovsky Sir Harry Burns
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“.....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....
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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
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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.
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How do we respond?
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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
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-70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70
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-70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70
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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
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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
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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
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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
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Choice reaction timeChoice reaction time
p<0.001
mil
lise
con
ds
Age (years)
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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
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Implementing at scale….Implementing at scale….can it be done?can it be done?
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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.
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Lochrin NurseryLochrin NurseryChildren receiving a bedtime story
MedianGoal
0
20
40
60
80
100
120
M T W TH F M T W TH F M T W TH F M T W TH FDay of the week
Perc
en
tag
e
of
ch
ild
ren
.
Parents survey
Grassmarket changes
introduced.
Books available at collection time.
Research information handed to
parents.
weekly average displayed for parents
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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
0
10
20
30
40
50
60
70
80
90
100
M T W TH F M T W TH F M T W TH F M T W TH FDay of the week
Perc
en
tag
e
of
ch
ild
ren
Family garden party
A very hot weekend
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AlfieAlfie
‘ ‘I like my I like my bedtime story bedtime story because it helps because it helps me to dreamme to dream’’
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Do one brave thing today….then run like hell!