Health, health inequalities and their determinants in Scotland


The past two decades can be characterised as having two distinct periods in changes to health and living standards. Through the 2000s there were robust improvements in period life expectancy (an indicator of health) and real earnings (an indicator of living standards). But this is followed by a period of stagnation and departure from historical growth trends through the 2010s (see Figure 4). The large fall in life expectancy in 2020 mainly reflects COVID-19 mortality.

These parallels between life expectancy and pay growth cannot be taken to indicate a direct causality in either direction, but the ways in which changes in standards of living affect health suggest, at the least, an association. Some negative changes in socioeconomic factors may have an immediate impact on health, such as stress and anxiety when struggling to budget on a limited income, or respiratory diseases due to living in damp and mouldy housing. However, such factors may not always immediately feed through to higher mortality rates in the short term. Rather, they exert a growing influence on health over the lifetime. This begins with deterioration in people’s physical and mental health, leading to more years spent in poor health and, ultimately, shorter lifespans.

It has been argued that reductions to the value of working-age social security since 2010 have contributed to an increase in mortality rates, with an effect on aspects of mortality such as drug deaths or infant mortality (which in large part reflect maternal health). Near-term changes in mortality are likely to relate to:

  • a sudden shock or disaster such as the COVID-19 pandemic – the impact of which will likely relate to the existing vulnerability of certain groups
  • deterioration or improvement in health services providing treatments that may extend life or diagnose otherwise terminal diseases early enough to treat, and
  • historical population-wide changes to health, such as immunisation or reduction in smoking rates.

While inequality in life expectancy has widened in the past decade, after improving in the decades before, income inequality widened in the 1980s and 1990s and has remained high since, with little change in the extent of inequality over the past two decades. Inequality in socioeconomic conditions interacts with other factors – such as the lack of availability of affordable healthy food – widening inequalities in health, as observed through increased mental ill health, obesity rates and non-communicable diseases.

Key trends in health outcomes

In the past two decades health outcomes have broadly followed a similar trend to life expectancy, although with some noticeable differences. This section shows the main trends by drawing on a set of metrics that track headline measures of health and then outcomes at different life stages.

We are concerned with both the overall change in health for the population and how different parts of the population fare. To enable consistent comparison across metrics we use a segmentation of the population by levels of deprivation, as measured by the SIMD. However, where data allow a similar pattern tends to exist across other measures such as occupation or income. There are also wide geographic inequalities which tend to align with where neighbourhoods with higher levels of deprivation are concentrated.

These are arranged from those where there has been steady improvement overall and a narrowing of inequalities through to others where outcomes have deteriorated, and inequalities widened. These are illustrated in Figure 6. It is important to note that inequalities in health measured on a relative or absolute basis may not always move in the same direction but a deterioration in either can be considered a worsening of inequality. We highlight the specific type of change in inequalities.

Sustained overall improvements and narrowing of absolute inequalities

Alcohol-related deaths

Deaths from alcohol are more common among men than women. The overall rate of alcohol deaths has fallen in the past two decades and both absolute and relative inequalities have fallen, driven by a reduction in mortality rates of around a third in the most deprived fifth of areas. Rates of alcohol-specific deaths are still higher in Scotland than the rest of the UK, at 21.5 deaths per 100,000 people in 2020 compared with 19.6 in Northern Ireland, 13.9 in Wales and 13.0 in England. Even with this improvement, people living in the most deprived fifth of areas are five times as likely to die due to alcohol than those living in the least deprived fifth of areas.

Smoking in pregnancy

Smoking in pregnancy increases the risk of babies being born small for their gestational age, post-natal mortality, and being hospitalised for respiratory illnesses in the early years. The proportion of women who report smoking at the time of their first antenatal booking has halved over the past two decades, falling from 29% in 2000 to 14% in 2020. This reduction occurred across all levels of area deprivation and the absolute difference between the most and least deprived fifths has fallen. However, the relative inequality has increased, with the prevalence of smoking during pregnancy now 11 times higher in the most deprived fifth compared with the least in 2020.

Earlier overall improvement followed by an overall stalling or deterioration and widening of inequalities

Healthy life expectancy

Healthy life expectancy provides a broader measure of health than life expectancy by reflecting how many people in the population report they are in good health. Healthy life expectancy increased between 1995 and 2009 by around 9 years, but then decreased by approximately 2 years between 2011 and 2019. Relative inequalities in healthy life expectancy remained broadly similar between 2013–15 and 2017–19, with people in the least deprived 10% of local areas expected to live 1.5 times longer in good health than people in the most deprived 10% of local areas. Absolute inequalities for men widened by 2.6 years to a gap of 25.1 years by 2017–19 (due to declining healthy life expectancy in the most deprived 10% of local areas). For women the gap narrowed slightly to 21.5 years over the same period.

Avoidable mortality

In 2020, 27% of deaths in Scotland were avoidable – higher than the overall UK share of 23%. The leading causes of avoidable deaths in Scotland were cancers, diseases of the circulatory system and alcohol and drug-related disorders. Avoidable mortality among men was falling up until 2013, but the trend has since been flat.

Absolute inequalities declined across the first decade or so of the 21st century, but then increased again slightly. Relative inequalities increased across the entire period, with the rate of avoidable mortality for men in the most deprived fifth of areas four times that of those in the least deprived fifth of areas in 2019.


Birthweight is an indicator of foetal health, the mother’s health and is also a predictor of health throughout the life course. In Scotland, the relative difference in low birthweight (excluding multiple births such as twins) between the least and most deprived 20% of local areas decreased between the early 2000s and 2014 but has since widened.

Absolute inequalities have increased since 2014. In 2020, those in the most deprived areas were twice as likely to have low birthweights than in the least. The causes of low birthweight may be driven by an increase in premature births (which may partly be down to improved survival rates) and declining maternal health.

Little change or gradually increasing prevalence and sustained inequalities

Infant mortality

The infant mortality rate is the number of infant deaths (before first birthday) for every 1,000 live births. This measure is an indicator of societal health and can act as an early indicator of future health trends. Since 2000 infant mortality has declined overall and in Scotland rates are lower than many other high-income countries. However, since around 2014 infant mortality rose in the most deprived fifth of areas and fell in the least deprived 60% of areas. By 2016–18 infant mortality rates in the most deprived areas were 2.6 times the rate in the least deprived areas.

Childhood obesity

At the population level, the proportion of childhood obesity has remained stable over the past 20 years in Scotland, with around 1 in 10 children at the start of school at risk of obesity. Risk of childhood obesity has fallen slightly in the least deprived areas, whereas it has increased slightly in the most deprived areas, leading to a widening of absolute and relative inequalities. By 2018/19 children living in the most deprived fifth of areas were twice as likely to be at risk of obesity, with an absolute gap of 7.2 percentage points.

Asthma hospitalisations

Asthma prevalence in Scotland is high, affecting around 17% of adults, a prevalence that has remained broadly stable over time. For severe instances of asthma (indicated by asthma-related hospitalisations), people in the most deprived fifth of areas were three times as likely to be hospitalised than those in the least deprived fifth in 2018–21, widening from 2.4 times as likely in 2002–05. Hospitalisations reflect uncontrolled or exacerbated asthma, likely occurring from air pollution, occupational exposures or damp housing – all of which are more common or worse in more deprived areas.

Mental health

Adult mental health, using a measure of psychological distress, has slightly increased in prevalence from 16% to 18% between 2012/13 and 2018/19. In 2018/19 people living in the most deprived fifth of areas were almost twice as likely to experience psychological distress as those in the least deprived fifth. This has remained broadly similar over time.

Overall deterioration and widening of inequalities

Drug deaths

While drug deaths are increasing for all socioeconomic groups, people in the most deprived areas face a far greater burden of the total drug deaths and have experienced a far faster rise in the problem. By 2019, those living in the most deprived fifth of Scottish areas were 20 times as likely to die from a drug-related death as those living in the least deprived fifth of areas (after accounting for age). This corresponds to an additional 65 per 100,000 deaths in the most compared with the least deprived areas.

The age and cohort patterns of drug-related deaths are similar in England and Wales, but overall rates are far higher in Scotland. In 2020, deaths from drugs were 3.6 times higher in Scotland than the UK average and 2.6 times higher than those in Northern Ireland and the Northeast of England (which had the next highest rates).

Socioeconomic influences on health

Beneath the overarching trend of much weaker growth in living standards over the past decade there are different trends across the individual socioeconomic factors that support good health. This section explores key aspects of living conditions and how they have changed over the past two decades.

The weak real-terms earnings growth over the past decade – now expected to fall in 2022 and 2023 due to high inflation – is a key driver of weakened income growth (which accounts for other forms of income, such as benefits) over the same time period.

The depth and duration of this wage stagnation is unprecedented and this has implications for current and future standards of living and health. Limited overall growth, however, does not mean progress cannot be made in closing inequalities because these are influenced by how existing resources are shared.


Having sufficient money and resources is important for health. It allows people to maintain an adequate standard of living, affording essentials such as food and a home, and to participate in society. Insufficient income, or problem debt, can have an additional impact on health through the stress and anxiety of trying to make ends meet. Stress itself can lead to physical health problems.

Income is perhaps the most key determinant of health because it also enables people to access other determinants of health, such as higher levels of educational achievement or high quality and secure housing. There is a strong association between income and health, which has potentially grown stronger in Scotland in the past decade as highlighted by Figure 7.

Income inequality

Driven by trends in earnings growth, income growth was relatively robust through the 2000s but weakened in the decade prior to the pandemic. Over the same period, inequalities in income have remained high compared with most western European countries. There have been some fluctuations in income inequality over the past two decades, but the most significant increase in inequality occurred through the 1980s and early 1990s. Although overall household income inequality did not widen during the 2000s, the growth for the very highest income households was faster than the rest, while the lowest tenth of incomes grew more slowly than the rest.

Sustained income inequality will be a factor in differential health outcomes. This will either be directly through day-to-day consumption, or through wider experiences, such as education, social, and cultural activities, to which a relatively higher income enables greater access. Through similar mechanisms, even wider inequalities in wealth will play a part in the scale of health inequalities: the 10% of households with most wealth in Scotland had median wealth of £1.65m compared with £7,600 in the 10% of households with the least wealth – this is over a 200-fold difference.

Figure 8 shows that there are income inequalities between family structure, education level, ethnicity, disability and housing tenure. Not having a degree, renting, having children and being from an ethnic minority background are all characteristics typically associated with a lower income. The relative differences within these groups have remained largely unchanged over the past two decades.


Compared with the rest of the UK Scotland has a slightly lower rate of relative poverty, largely because of lower housing costs – ie the cost of housing represents a smaller proportion of lower income household budgets. The proportion of the population living in relative poverty fell significantly from around 23% in 1999 to around 18% in 2012.

Since around 2015, however, the proportion of the population in both relative poverty and extreme poverty has been on a slow but persistent upward trend. This is particularly marked for child poverty. The share of children in relative poverty has gradually increased by two percentage points to reach 24% in 2017–20. The share of children in extreme poverty has increased from 13% in 2009–11 to 17% in 2017–20. These upward trends largely reflect changes to working-age social security benefits that have had a downward effect on working-age incomes.

Social security

Some changes to social security for working-age families by the UK government since 2010 have had a direct impact on income, and therefore indirectly on health, with lowest income families most negatively affected. Taken in their entirety, and once the policies are fully in place, reductions in the value of support are estimated to reduce the incomes of the poorest 10% of UK households by 10%, compared with a reduction of 2% for all families. These measures include the 1% cap on increases in most working-age benefits between April 2013 and 2015 and limiting support to two children.

The Scottish government has provided some mitigation of social security cuts through offsetting the ‘bedroom tax’ and cuts to council tax support that both started in 2013. For affected families this is likely to have had a significant impact. However, the estimated £50m a year spent on these measures is only a fraction of the estimated £3.7bn a year total UK government welfare cuts in Scotland. More recently, the introduction of the Scottish Child Payment is providing an important top-up for low-income families with children. That said, the size of the effect on poverty is not fully known, particularly given the cost-of-living crisis.

Compounding these income effects is the growing body of evidence that shows welfare reforms have increased the prevalence of mental health problems. This has been shown through higher prevalence of depression or anxiety among those at risk of having their benefits capped compared with those who have not; an increase in psychological distress from the introduction of Universal Credit (UC) in local areas; and evidence that becoming unemployed under UC is worse for mental health than becoming unemployed under the legacy system for lone parents and single adults (but not couples). Stress and anxiety can also eventually lead to deteriorating physical health.


Employment is the main route by which people can secure income and is also important for health by providing day-to-day routine, societal participation, and a sense of status and purpose. Employment rates have overall been high in Scotland over the past two decades, aside from the 2009 recession following the financial crisis. There has been a steady increase in female employment since 1999, especially at older ages. Growing levels of employment through the 2010s provided an income boost to lower income households.

Figure 9 shows a concerning reduction in employment for those younger than 24 years, particularly for men, where employment rates for 16–24 year olds have fallen from 65.1% to 57.4% between 2004 and 2019. This mirrors a broader trend in the UK of worsening labour market outcomes for young men.

Work quality and security

The quality of work people do – including whether it provides a lasting and stable income, the autonomy and flexibility it provides, or the extent to which it takes a physical toll or increases stress for employees – is also important for health. Working in a low-quality job can be more detrimental to health than remaining unemployed.

Part of the employment growth that followed the financial crisis was an increase in less secure zero-hour contracts and low-paid self-employed work. On subjective measures of job insecurity – such as whether workers feel they will lose their job in the next year, or negative emotions they associate with their job – there is little evidence of a sustained increase over the past decade. But there is evidence of a persistent level of insecurity.

A further measure to consider is underemployment – the extent to which there are workers who want to work longer hours. Underemployment rates in Scotland increased from 7% to 11% immediately after the financial crisis but had gradually reduced to 8% by 2021.

Insecure work and underemployment are much more likely to be experienced by younger people, particularly men, and workers in lower-paid occupations. Zero-hour contracts are also increasingly concentrated among migrants and workers from ethnic minority backgrounds.

Economic activity and health

There is a two-way relationship between health and employment, with good-quality employment supporting good health but poor health reducing chances of employment.

In Scotland, the working-age economic inactivity rate due to long-term health problems reduced from 7.5% in the mid-2000s to 5% in the mid-2010s, reflecting a fall in the prevalence of musculoskeletal and cardiovascular problems. Since the mid-2010s, the economic inactivity rate has increased, driven by a rise in the prevalence of depression and mental health problems. Both trends broadly follow the experience of the rest of the UK, where economic inactivity due to poor health has been gradually increasing and has become more apparent since the start of the pandemic.

Compared with the rest of the UK, the proportion of working-age people living in Scotland who are economically inactive for health reasons has consistently been around 1–2 percentage points higher. Scots appear to be more likely to cite health as the main reason for inactivity than other factors, such as caring responsibilities.


Housing has a significant influence on health, including the quality of housing and its affordability. Housing quality relates to the actual physical state of a property and how suitable it is for residents. This can encompass a wide range of potential flaws, such as lacking sufficient insulation, being damp or mouldy, or containing risks such as trip hazards.

Housing affordability is the extent to which a household can meet the direct and indirect costs of housing, including rent and mortgage repayments, council tax and utilities. Housing affordability is associated with housing security but can also contribute directly to poorer mental health through stress and anxiety. Affordability can also create pressure on other elements of household expenditure associated with health, such as food or social participation.

Over the past two decades, the private rented sector has become a larger part of the housing mix in Scotland, as shown in Figure 10. This has direct implications for health via its impact on housing quality and affordability.

The increase in private renting also has implications for household finances. Housing costs have increased for social and private renters in absolute terms and as a share of income since devolution. Overall housing costs have fallen as a proportion of income in Scotland, but they have increased for families with the lowest fifth of incomes. Relative to the rest of the UK, housing costs in Scotland tend to be lower, which has helped to keep poverty rates lower.

Inequalities in housing costs exist between other groups of the population. Younger people and people from minority ethnic backgrounds are more likely to have higher housing costs. Disabled people are more likely to live in owner occupied or social housing and therefore have housing costs that are slightly below average.

Housing quality is generally worse in the private rented sector, although in the case of damp and condensation, local authority owned social housing performs poorly. These differences between groups and tenures will contribute to health inequalities either directly (in the case of conditions such as damp) or indirectly (in the case of financial pressures on household finances from housing costs).

Two decades of change

Scotland’s health trends over the past two decades present cause for both optimism and alarm. There are clearly concerning trends that indicate a lack of improvement in the decade before the pandemic and, in many cases, widening inequalities, with signs that the most disadvantaged are being left behind. This is underlined by increasing rates of extreme poverty.

Trends in the socioeconomic factors that influence health outcomes provide little indication that health inequalities will improve in future. Large-scale income and wealth inequalities have not changed and levels of job insecurity persist, deepening for some workers in less secure forms of employment.

But the 2000s show that progress in health, inequalities and advances in wider living standards are possible. That some aspects of health inequalities continued to improve rather than deteriorate in the past decade shows that, even in a more difficult context, stagnation and decline are not inevitable and progress can be made on these complex issues.

Where data are an average of multiple years, we refer to the final year of the period, and in the case of financial years the year starting in April.

The two-child limit will take up to 19 years from implementation in April 2017 to have full effect because it applies to children born after 5 April 2017.

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