Pre-pandemic inequalities in the burden of disease: a Scottish Burden of Disease study

Background Health inequalities in Scotland are well documented, including the contribution of different causes to inequalities in mortality. Our aim was to estimate inequalities within a burden of disease framework, accounting for both premature mortality and the effects of morbidity, to understand the contribution of specific diseases to health inequalities prior to the COVID-19 pandemic. Methods Disability Adjusted Life Years (DALYs) for 70 individual causes of disease and injury were sourced from the Scottish Burden of Disease Study. Area-level deprivation was measured using the Scottish Index of Multiple Deprivation. Inequalities were measured by the range, Relative Index of Inequality, Slope Index of Inequality, and attributable DALYs were estimated by using the least deprived decile as a reference. Results The overall disease burden was double that in the most deprived areas (50,305 vs 20,955 DALYS per 100, 000), largely driven by inequalities in premature mortality. The rate in the most deprived decile was around 48% higher than the mean population rate (RII = 0.96), with 35% of DALYs attributed to differences in area-based deprivation. Many leading causes of disease burden in 2019 – heart disease, drug use disorders, lung cancer and COPD – were also the leading drivers of absolute and relative inequalities in the disease burden. Conclusion Our study evidences the extent of the stark levels of absolute and relative inequality prior to the COVID-19 pandemic. Given pre-pandemic stalling of mortality trend improvements and widening health inequalities, and the exacerbation of these caused by COVID-19, urgent policy attention is required to address this. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any funding ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors