Scotland's Population Health Framework: Fairer Scotland Duty

Stage 2 – evidence

Evidence consistently highlights stark and persistent inequalities in health outcomes across Scotland often linked to the underlying social and economic conditions in which people live. Individuals living in the most affluent areas of Scotland experience significantly longer periods of good health compared to those in deprived areas. For men, the gap in healthy life expectancy is approximately 25.8 years and for women it is around 25.7 years^[1]. Relative inequalities in premature mortality in Scotland have widened considerably over the past 25 years as a result of rates of those living in least deprived areas falling much more than those living in deprived areas. ^[2]

The Scottish Burden of Disease study projects a 21% rise in the overall burden of disease in Scotland over the next 20 years.^[3] Significantly, up to a third of this increase is linked to health inequalities—making it largely preventable.^[4] Importantly, these inequalities are not limited to people living in the most deprived areas; they exist across a broad socioeconomic spectrum, affecting individuals at many levels of income and social status.^[5]

Recent data shows that 1 in 5 working-age people (20%) in Scotland were living in poverty between 2021 and 2024.^[6] Among pensioners, 15% were living in poverty during the same period. Notably, a majority (61%) of working-age adults living in relative poverty after housing costs were in households where someone was in paid employment, amounting to an estimated 410,000 adults per year.^[7] Whilst the proportion of children living in poverty is even higher at 23%.^[8] These figures underscore the reality of in-work poverty and the complexity of socioeconomic disadvantage.

Significant disparities are also evident from early childhood. Children living in Scotland’s most deprived areas are significantly more likely to experience concerns around early development compared to their peers in the least deprived areas. In 2023-24, Public Health Scotland reported that the proportion of children living in the most deprived areas recorded as having a concern at the 27-30 month review (26%) is more than twice that of children living in the least deprived areas (10%).^[9] Early childhood developmental issues are strongly linked to long-term health, educational, and social challenges. This inequality gap reinforces the need for targeted preventative action to support child development from the earliest years.

Evidence suggests that living in more deprived areas is linked with a higher risk of low birth weight^[10], and both low birth weight and prematurity are closely linked to poverty^[11]. A poor diet during early childhood is associated with child malnutrition^[12]and can have other negative effects including low energy, frequent illnesses, poor growth and cognitive and behavioural challenges^[13]. Over time, it can lead to developmental delays, chronic health conditions like obesity and diabetes, and long-term oral health issues.^[14]

Persistent poverty has been linked with childhood mental health problems.^[15] Analysis from the UK Millennium Cohort Study found that prolonged exposure to maternal distress was associated with an increased risk of child mental health problems at age three^[16]. Findings from the Millenium Cohort Study show that children born into poverty score significantly lower on cognitive tests at ages three, five, and seven.^[17] Persistent poverty was found to have a cumulative negative effect, and by age seven, the children included in this study scored lower than their peers who had never experienced poverty, even after accounting for family and parental factors^[18].

Analysis from Scotland’s Census 2022 highlights the strong link between deprivation and health inequalities. People living in the most deprived areas are significantly more likely to experience long-term health conditions or disabilities. ^[19]These health issues, in turn, contribute to higher levels of economic inactivity, as many individuals are unable to work due to poor health.

The impact of deprivation extends beyond health, influencing other key areas of life. Educational attainment is lower in these communities, with a greater proportion of people having no qualifications.^[20] Housing conditions are also poorer—residents are less likely to own their homes and more likely to live in overcrowded accommodation. These interconnected issues demonstrate how health inequalities are both a cause and a consequence of wider social and economic disadvantage.^[21]

The impact of deprivation is also evident in mental health outcomes. In 2023, the rate of suicide mortality in the most deprived areas was 2.4 times higher than in the least deprived areas^[22]. This is a more pronounced disparity than that observed for overall mortality rates, where the most deprived areas experienced a rate 1.8 times higher than the least deprived. Although the overall mortality rate in the most deprived areas has fallen by 1.4 times in 2001, the deprivation-related gap in mortality has remained relatively stable over time indicated.^[23]

An Evidence Paper which is published alongside the PHF indicates effective prevention has significant potential to improve population health and reduce health inequalities. The paper cites clear evidence that shows that achieving this impact of improved health and reduced inequalities requires systemic, long-term policy approaches. Policy approaches with the potential to improve population health in Scotland include:

• Those which seek to address the fundamental causes of health inequalities, which are inequalities in income, wealth, and power between groups. This includes, for example, the creation of a Wellbeing Economy, Community Wealth Building, and the adoption of proportionate universalism in the design and implementation of policies.
• Health in All Policies, a collaborative approach which involves incorporating health considerations into decision-making across sectors, policy and service areas, to address the social determinants of health.
• A life course approach, which acknowledges that health status reflects cumulative life conditions and considers the critical stages, transitions, and settings where large differences can be made in promoting health and wellbeing.
• Place-based approaches, which recognise the interconnected impact of physical, economic, and social environments on individuals and communities, and emphasise collaborative, locally tailored interventions.
• Structural approaches to reducing health risks, such as fiscal and legislative policies that modify environments to minimise exposure to health harming products, rather than those which rely on individual agency.