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Trends in suicide in Scotland 1981 – 1999: age, method and geography

  • Cameron Stark1, 2Email author,
  • Paddy Hopkins2,
  • Diane Gibbs3,
  • Tracey Rapson3,
  • Alan Belbin4 and
  • Alistair Hay5
BMC Public Health20044:49

DOI: 10.1186/1471-2458-4-49

Received: 24 May 2004

Accepted: 20 October 2004

Published: 20 October 2004

Abstract

Background

Male suicide rates continued to increase in Scotland when rates in England and Wales declined. Female rates decreased, but at a slower rate than in England and Wales. Previous work has suggested higher than average rates in some rural areas of Scotland. This paper describes trends in suicide and undetermined death in Scotland by age, gender, geographical area and method for 1981 – 1999.

Methods

Deaths from suicide and undetermined cause in Scotland from 1981 – 1999 were identified using the records of the General Registrar Office. The deaths of people not resident in Scotland were excluded from the analysis. Death rates were calculated by area of residence, age group, gender, and method. Standardised Mortality Ratios (SMRs) and 95% confidence intervals were calculated for rates by geographical area.

Results

Male rates of death by suicide and undetermined death increased by 35% between 1981 – 1985 and 1996 – 1999. The largest increases were in the youngest age groups. All age female rates decreased by 7% in the same period, although there were increases in younger female age groups.

The commonest methods of suicide in men were hanging, self-poisoning and car exhaust fumes. Hanging in males increased by 96.8% from 45 per million to 89 per million, compared to a 30.7% increase for self-poisoning deaths. In females, the commonest method of suicide was self-poisoning. Female hanging death rates increased in the time period.

Male SMRs for 1981 – 1999 were significantly elevated in Western Isles (SMR 138, 95% CI 112 – 171), Highland (135, CI 125 – 147), and Greater Glasgow (120, CI 115 – 125). The female SMR was significantly high only in Greater Glasgow (120, CI 112 – 128).

Conclusion

All age suicide rates increased in men and decreased in women in Scotland in 1981 – 1999. Previous findings of higher than expected male rates in some rural areas were supported. Rates were also high in Greater Glasgow, one of the most deprived areas of Scotland. There were changes in the methods used, with an increase in hanging deaths in men, and a smaller increase in hanging in women. Altered choice of method may have contributed to the increased male deaths.

Background

Compared to the adjacent countries of England and Wales, Scotland had a low suicide rate through most of the twentieth century [1]. This did not appear to be explained by differences in recording of suicide [2]. Suicide rates in Scottish men increased in the 1970s and 1980s [3, 4]. Rates in younger men continued to increase in the late 1980s [5] and early 1990s [6], at a time when male rates in England declined [7, 8]. By contrast, female rates decreased in Scotland, although not as rapidly as in England and Wales [3].

Several authors have noted the importance of suicide in Scotland as a public health problem [9, 10]. There was an increase in hanging and motor vehicle exhaust fumes as methods of male suicide in 1970 – 1989 and Pounder [5] suggested that choice of method might contribute to the increase in Scottish male rates, as some methods are associated with higher case fatality rates. Crombie [11] found that some areas had higher rates of male suicide than the Scottish average, mainly in rural areas. Access to particular methods of suicide may contribute to this [12]. Gender, age, suicide method and geographical area therefore appear to be important considerations in the epidemiology of suicide in Scotland. No recent summary of suicide trends in Scotland has been available, and this paper describes trends in relation to these factors.

Methods

We used anonymised information on deaths by suicide and undetermined deaths provided by the General Register Office for Scotland (GROS). Deaths registered during 1981 – 1999 were included if the cause of death was recorded as suicide or as undetermined cause (ICD-9 E950-E959 and E980-E989 respectively). Undetermined deaths were included as suicide deaths may be misattributed [13, 14].

Population figures were taken from the GROS annual reports for the mid-year of each period. For analyses by area, if a death was registered away from the person's home address, the death was allocated to their area of residence, rather than the area in which they died. Deaths of people resident outside Scotland were identified using country codes, and were excluded. As far as possible, therefore, results reflect the rates of suicide and undetermined deaths of people resident in each area of Scotland. Standardised Mortality Ratios were calculated for National Health Service administrative areas, with 95% confidence intervals. In time period descriptions, the periods 1981 – 1985, 1986 – 1990, 1991 – 1995, and 1996 – 1999 were used. Data were analysed using Excel and SPSS.

Results

There were 14502 deaths recorded as suicide or undetermined cause in the time period. Of these deaths, 28.5% occurred in females (n = 4137) and 71.5% in males (n = 10365).

Gender and age group

Table 1 shows changes by gender. The male suicide rate for suicide and undetermined deaths increased from 187 per million in 1981 – 1985 to 252 per million in 1996 – 1999, an increase of 35%. In the same period, the female rate per million decreased from 88 to 82 per million, a 7% decrease. The female decline occurred between 1981 – 1985 and 1986 – 1999. By contrast, male rates increased between all time periods. The female: male rate ratio in 1981 – 1985 was 2.1:1 By 1996 – 1999 this had increased to 3.1:1.
Table 1

Suicide and Undetermined Deaths in Scotland 1981 – 1999 By Gender and Time Period Rate per Million Population

 

1981 to 1985

1986 to 1990

1991 to 1995

1996 to 1999

 

Gender

No. of deaths

Rate/million

No. of deaths

Rate/million

No. of deaths

Rate/million

No. of deaths

Rate/million

% change from first to last time period

Males

2324

187

2,587

210

2,948

238

2,506

252

35%

Females

1180

88

1,030

78

1,058

80

869

82

-7%

Total

3,504

136

3,617

142

4,006

156

3,375

165

21%

Examining changes by age group in males (Table 2), there are increases in male rates in the under 15 years, 15– 24 year, 25 – 34 year and 35 – 44 year age groups, of 137%, 97%, 86% and 26% respectively. The increase in the youngest male age group, although based on very small numbers of deaths, occurred between 1986 – 90 and 1991 – 95. In the 15–24 and 25 – 34 year age groups, increases occurred in every time period. There were decreases in the 45 – 54 and 55 – 64 year age groups and increases, of 4% and 10%, in the 65 – 74 and 75 years and over age groups.
Table 2

Suicide and Undetermined Deaths in Males in Scotland 1981 – 1999 By Age Group and Time Period

 

1981–1985

1986–1990

1991–1995

1996–1999

 

Age group

No. of deaths

Rate per million

No. of deaths

Rate per million

No. of deaths

Rate per million

No. of deaths

Rate per million

% change from first to last period

<15 years

11

4.1

11

4.5

25

10.1

19

9.7

137%

15–24

317

141.0

440

208.3

467

257.2

369

278.0

97%

25–34

410

226.1

536

276.1

736

355.9

677

421.4

86%

35–44

422

268.5

470

279.2

594

340.8

506

338.0

26%

45–54

437

311.0

420

301.6

473

313.6

377

290.6

-7%

55–64

382

290.7

339

263.3

306

241.3

229

226.4

-22%

65–74

228

244.6

223

238.5

212

216.0

200

254.3

4%

75+

117

253.6

148

287.8

135

253.6

129

278.8

10%

All Ages

2,324

187.0

2,587

209.7

2,948

237.8

2,506

252.1

35%

In women, there were increases in the three youngest age groups, with a 76% increase in rates in the under 15 year old group, 150% in the 15 – 24 year group and 37% in 25 – 34 year olds (Table 3). There were decreases in every older age group from 35 – 44 years to 75 years and over.
Table 3

Suicide and Undetermined Deaths in Females in Scotland 1981 – 1999 By Age Group and Time Period

 

1981–1985

1986–1990

1991–1995

1996–1999

 

Age group

No. of deaths

Rate per million

No. of deaths

Rate per million

No. of deaths

Rate per million

No. of deaths

Rate per million

% change from first to last period

<15 years

7

2.7

7

3.0

7

3.0

9

4.8

76%

15–24

70

32.4

89

44.1

100

57.6

103

81.0

150%

25–34

141

78.9

174

91.4

217

106.4

172

108.3

37%

35–44

179

112.3

158

93.3

192

109.1

157

103.9

-8%

45–54

231

154.9

151

103.3

179

115.0

153

115.1

-26%

55–64

264

176.3

187

129.6

138

98.4

96

86.7

-51%

65–74

174

136.5

153

122.5

107

84.8

101

102.6

-25%

75+

114

114.3

111

103.0

118

108.3

78

87.0

-24%

All Ages

1,180

88.4

1,030

78.1

1,058

80.1

869

82.4

-7%

Method of suicide

The commonest methods of suicide and undetermined deaths in men were hanging, strangulation and suffocation, poisoning with solid or liquid substances, drowning, use of gases and vapours and jumping from high places (Table 4). Hanging, strangulation and suffocation in males had a similar rate to poisoning with solid or liquid substances in 1981 – 1985, but by 1996 – 1999 it had increased by 96.8% from 45 per million to 89 per million, compared to a 30.7% increase for self-poisoning deaths, from 46 per million to 60 per million. Deaths from jumping and cutting also increased, by 44.2% and 18.8% respectively. 'Other gases and vapours', predominantly car exhaust deaths (data not presented), decreased slightly from the first to last periods, but this concealed a substantial increase between 1981 – 1985 and 1986 – 1990, followed by a decrease in 1996 – 1999. Unspecified means increased by 70.9% from 14 to 23 per million.
Table 4

Methods of Suicide and Undetermined Death in Males in Scotland 1981 – 1999 By Time Period

 

1981 to 1985

1986 to 1990

1991 to 1995

1996 to 1999

 

Primary Cause

No. of Deaths

Rate/million

No. of Deaths

Rate/million

No. of Deaths

Rate/million

No. of Deaths

Rate/million

% change from first to last time period

Solid or liquid substances

572

46

594

48

768

62

598

60

30.7

Hanging, strangulation and suffocation

562

45

630

51

774

62

880

89

96.8

Submersion(drowning)

353

28

417

34

358

29

268

27

-5.1

Other gases and vapours

288

23

428

35

448

36

225

23

-2.3

Other, unspecified means

169

14

170

14

226

18

231

23

70.9

Firearms and explosives

166

13

119

10

114

9

66

7

-50.3

Jumping from high place

163

13

176

14

203

16

188

19

44.2

Cutting and piercing instruments

40

3

38

3

38

3

38

4

18.8

Gases in domestic use

8

1

7

1

7

1

8

1

33.4

Late effects of injury

3

. 4

8

1

12

1

4

1

99.9

Total

2,324

187

2,587

210

2,948

238

2,506

252

34.8

In females, the commonest methods of suicide and undetermined death were poisoning with solid or liquid substances, hanging, strangulation and suffocation, and drowning (Table 5). Self-poisoning decreased by 4.8% between first and last periods from 45 to 43 per million, while drowning, and jumping from high places decreased by 54.1% and 30.3% respectively. Gases and vapours showed an increase but, as in males, the rate was higher in the middle two time periods. The rate of hanging, strangulation and suffocation deaths increased by 53.5%. There was an increase in unspecified means of suicide, from 4 to 8 per million.
Table 5

Methods of Suicide and Undetermined Death in Females in Scotland 1981 – 1999 By Time Period

 

1981 to 1985

1986 to 1990

1991 to 1995

1996 to 1999

 

Primary Cause

No. of Deaths

Rate/million

No. of Deaths

Rate/million

No. of Deaths

Rate/million

No. of Deaths

Rate/million

% change from first to last time period

Solid or liquid substances

601

45

577

44

570

43

452

43

-4.8

Submersion(drowning)

248

19

159

12

132

10

90

9

-54.1

Hanging, strangulation and suffocation

127

10

95

7

134

10

154

15

53.5

Jumping from high place

89

7

77

6

67

5

49

5

-30.3

Other, unspecified means

60

4

53

4

81

6

83

8

75.1

Other gases and vapours

31

2

51

4

50

4

30

3

22.5

Firearms and explosives

13

1

10

1

6

0.5

3

0.4

-68.9

Cutting and piercing instruments

9

1

8

1

9

1

5

1

-25.0

Late effects of injury

2

0.4

-

-

7

1

3

0.4

1.4

Gases in domestic use

-

-

-

-

2

0.4

-

-

-

Total

1,180

88

1,030

78

1,058

80

869

82

-6.8

Geographical areas

In the nineteen-year period as a whole, there was substantial geographical variation (Figures 1 and 2). The highest male rates were in Western Isles, Highland, Orkney, Greater Glasgow and Tayside (Table 6). When considered as Standardised Mortality Ratios, Western Isles, Highland and Greater Glasgow were statistically significantly elevated (Table 6). Six areas, Fife, Ayrshire and Arran, Forth Valley, Lothian, Borders and Lanarkshire had significantly lower SMRs than the Scottish average.
https://static-content.springer.com/image/art%3A10.1186%2F1471-2458-4-49/MediaObjects/12889_2004_Article_135_Fig1_HTML.jpg
Figure 1

Male Standardised Mortality Ratios for Suicide and Undetermined Deaths in Scotland, 1981 – 1999 by Area

https://static-content.springer.com/image/art%3A10.1186%2F1471-2458-4-49/MediaObjects/12889_2004_Article_135_Fig2_HTML.jpg
Figure 2

Female Standardised Mortality Ratios for Suicide and Undetermined Deaths in Scotland, 1981 – 1999 by Area

Table 6

Male Standardised Mortality Ratios by Health Service Area Suicide and Death by Undetermined Cause in Scotland 1981 – 1999

Health Board of Residence

No. of Deaths

Rate/million

Standardised Mortality Ratio

   

Ratio

LCI

UCI

Argyll & Clyde

909

225

103

97

110

Ayrshire & Arran

676

197

91

84

98

Borders

176

186

84

72

97

Dumfries & Galloway

301

223

101

90

113

Fife

634

197

90

83

97

Forth Valley

496

197

89

82

98

Grampian

1,050

219

99

93

105

Greater Glasgow

2,252

264

120

115

125

Highland

555

294

135

125

147

Lanarkshire

907

174

81

75

86

Lothian

1,399

202

90

85

95

Orkney

50

274

124

92

164

Shetland

47

214

99

72

133

Tayside

828

231

105

98

112

Western Isles

85

300

138

112

171

Scotland

10,365

220

100

-

-

In women, the highest rates were in Glasgow, Tayside, Highland and Dumfries and Galloway (Table 7). Only the Greater Glasgow SMR was significantly elevated. One area, Lanarkshire, had a significantly low female SMR.
Table 7

Female Standardised Mortality Ratios by Health Service Area Suicide and Death by Undetermined Cause in Scotland 1981 – 1999

Health Board of Residence

No. of Deaths

Rate/million

Standardised Mortality Ratio

   

Ratio

LCI

UCI

Argyll & Clyde

330

77

93

84

104

Ayrshire & Arran

290

78

95

84

106

Borders

83

81

95

77

118

Dumfries & Galloway

122

85

101

84

120

Fife

277

82

100

89

112

Forth Valley

195

73

89

77

102

Grampian

383

77

95

86

105

Greater Glasgow

921

99

120

112

128

Highland

169

86

105

91

123

Lanarkshire

366

66

83

75

92

Lothian

598

81

97

90

105

Orkney

15

80

98

55

162

Shetland

16

74

95

54

154

Tayside

357

92

110

99

122

Western Isles

15

53

65

36

107

Scotland

4,137

82

100

-

-

There were changes within areas over the period studied. Male rates increased in all fifteen NHS Board areas (Table 8). The smallest percentage increases were in Orkney, Highland and Greater Glasgow, three of the areas with the highest male rates in the first time period. Shetland and Western Isles had large percentage increases, but this was based on small numbers of suicide and undetermined cause deaths. The largest increases in mainland Scottish Board areas were in Argyll and Clyde (62%), Borders (60%), Forth Valley 59%), Ayrshire and Arran (56%) and Grampian (49%).
Table 8

Male Deaths from Suicide and Undetermined Cause in Scotland 1981 – 1999 Rates By Health Service Area and Time Period

 

1981 to 1985

1986 to 1990

1991 to 1995

1996 to 1999

 

Primary Cause

No. of Deaths

Rate/million

No. of Deaths

Rate/million

No. of Deaths

Rate/million

No. of Deaths

Rate/million

% change from first to last time period

Argyll & Clyde

190

175

212

199

272

259

235

283

62

Ayrshire & Arran

143

158

161

178

194

214

178

246

56

Borders

31

128

41

167

62

245

42

205

60

Dumfries & Galloway

71

201

74

209

79

220

77

269

34

Fife

148

177

155

183

169

198

162

239

35

Forth Valley

102

154

127

192

136

205

131

245

59

Grampian

219

181

258

208

291

224

282

270

49

Greater Glasgow

551

234

565

252

666

304

470

270

15

Highland

131

273

155

315

144

284

125

305

12

Lanarkshire

195

140

242

177

255

187

215

197

40

Lothian

307

172

350

195

408

223

334

222

29

Orkney

13

275

11

233

15

308

11

281

2

Shetland

12

202

10

179

7

121

18

388

92

Tayside

193

205

200

214

230

242

205

272

33

Western Isles

18

230

26

343

20

274

21

376

64

Scotland

2,324

187

2,587

210

2,948

238

2,506

252

35

In females, rates changed little or decreased in all mainland Boards other than Argyll and Clyde (16.9% increase) (Table 9). Rates increased in Orkney, Shetland and Western Isles, although these were based on very small numbers of deaths. The greatest declines in mainland Board areas were in Ayrshire and Arran (30% decrease) and Grampian (27.9% decrease).
Table 9

Female Deaths from Suicide and Undetermined Cause in Scotland 1981 – 1999 Rates By Health Service Area and Time Period

 

1981 to 1985

1986 to 1990

1991 to 1995

1996 to 1999

 

Primary Cause

No. of Deaths

Rate/million

No. of Deaths

Rate/million

No. of Deaths

Rate/million

No. of Deaths

Rate/million

% change from first to last time period

Argyll & Clyde

96

82

73

64

76

68

85

96

17

Ayrshire & Arran

88

90

73

75

80

82

49

63

-30

Borders

26

98

20

75

18

66

19

86

-12

Dumfries & Galloway

34

91

29

77

32

84

27

89

-2

Fife

79

89

76

85

69

77

53

74

-18

Forth Valley

53

75

44

63

55

78

43

76

0.3

Grampian

133

105

85

66

84

63

81

76

-28

Greater Glasgow

270

104

238

97

235

98

178

94

-10

Highland

41

82

40

79

59

112

29

68

-17

Lanarkshire

98

67

93

64

93

64

82

71

7

Lothian

165

85

156

81

143

73

134

84

-0.3

Orkney

2

41

2

41

3

60

8

202

390

Shetland

1

17

4

72

7

125

4

88

412

Tayside

91

88

93

92

101

99

72

89

0.6

Western Isles

3

38

4

53

3

41

5

88

130

Scotland

1,180

88

1,030

78

1,058

80

869

82

-7

Discussion

The epidemiology of suicide in Scotland has changed greatly between 1981 and 1999. Male suicide rates have increased in all age groups up to and including 35 – 44 years. The highest male suicide and undetermined death rates in 1996 – 1999 were in the 25 – 34 year age group. In women, rates dropped in age groups from 35 – 44 years up to and including 75 years and over. Rates increased in younger women.

There is limited information on the factors underlying individual deaths from suicide in Scotland. Squires and Gorman [15] reviewed the deaths by suicide of a group of young men in Lothian, and reported that a third had experienced recent relationship difficulties with a partner. Half of the group studied had a previous history of attempted suicide. Cavanagh et al [16] reported largely similar findings in a case control study in south-east Scotland. The group who had died by suicide had an odds ratio of 9.0 (95% CI 1.3 – 399) for current family problems, and an odds ratio of 5.0 (95% CI 1.1 – 47) for physical health problems. There was felt to be limited scope to intervene in suicide and deliberate self-harm through family health services because of limited contact, and non-specific presentation of problems [15, 17].

Some methods of self-harm have higher case fatality rates [18]. Firearms have the highest case fatality rates, followed by drowning and hanging [19, 20]. The most striking changes in male suicide methods in Scotland were the marked increase in hanging deaths, and the increase and subsequent decrease in deaths from 'other gases and vapours', which are mainly car exhausts. It seems likely that the decrease in motor vehicle exhaust fume deaths was related to the introduction of catalytic converters. Not all countries have reported a decrease in suicide from motor vehicle exhausts after catalytic converter introduction [21], but deaths in England decreased [22]. The reduction in deaths from motor vehicle exhaust fumes in England and Wales was associated with an increase in hanging deaths [7]. In Scotland, our data suggest that hanging deaths were increasing in men before deaths from motor vehicle exhaust fumes began to decline. The increase in hanging also appears greater than the decrease in motor vehicle exhaust deaths. The relationship between vehicle exhaust fume and hanging deaths in Scotland does not appear to be identical to that reported in England and Wales, and deserves further investigation.

The difference between areas was also of note. The lower rates of increase in the areas with the highest initial rates may reflect to regression to the mean. Method availability [23] may be important in rural/urban differences. Obafunwa and Busuttil [24] reported that, within the Lothian region of Scotland, hanging was commoner in younger deaths, while use of car exhaust fumes for suicide was particularly important in rural areas [24, 25]. In Lothian, an area that includes the capital city of Scotland, suicide by firearms was uncommon. Previous work has suggested higher rates of male suicide in some rural parts of Scotland [11]. Stark et al [12] have suggested that this may be related to the use of methods of self-harm in rural areas, such as firearms, with a high case fatality rate. Gunnell and colleagues [26] have argued, in relation to England and Wales, that changes in method preference, and therefore in case fatality, should be considered before concluding that changes must relate to social trends.

Availability of method would not explain the differences between apparently similar rural areas. Previous work has found that deprived areas of Scotland tend to have higher suicide rates [27, 28]. Deprived areas in Scotland were reported to have had the greatest increase in young male suicide between 1981 – 3 and 1991 – 3 [29]. Greater Glasgow, the non-rural area with the highest rate over the time period, is an area with substantial deprivation. Rural deprivation is difficult to measure, and recent work suggests that rural areas of Scotland may suffer greater levels of deprivation than had been realised. It is possible that rural deprivation is underestimated, and deprivation may explain more of the elevation in some rural areas than has been assumed in the past.

Using routine information allowed a large number of suicide and undetermined deaths to be included in this series. There are, however, limitations to the use of anonymised routine data. No qualitative information was available, and our exploration of the data was limited to trends with no examination of possible underlying causes. The increase in the rate of deaths recorded as suicide or undetermined cause of death, but where no detail on method was included, could conceal recent trends. The increase as a percentage of relevant registrations was small, however, increasing from 7.5% in the first period to 9.1% in the last period studied. The classification of deaths as suicide is often difficult, but the inclusion of undetermined deaths as well as deaths recorded as suicide should have helped to minimise bias from under identification [14, 30]. Squires et al [31] reported that improved communication between pathologists and the Registrar General for Scotland from 1994 on was associated with a decrease in undetermined deaths and in increase in deaths coded as being caused by dependent or non-dependent use of drugs. It is possible, therefore, that the figures for the final two periods may under-represent deaths that would have been identified as 'unidentified' in the earlier periods. Using information on Scottish residents only allowed identification of the suicide rates of local populations. Deaths of non-residents can account for up to 10% of all suicide and undetermined cause deaths in some rural areas of Scotland [12]. Our findings indicate that, even when these deaths are excluded, rates remain increased in some rural areas.

Conclusions

A divergence between male rates in England and Wales and in Scotland, and in male and female rates within Scotland, had been identified for the first part of the time period described here. This work found that male rates of suicide and undetermined death continued to increase in Scotland, but also identifies increases in younger female age groups. Examination of changes in method by male and female age group will help to establish whether changes in case fatality because of altered method choice [26] may be part of the explanation for these findings. The shift to hanging seems to be a significant trend in men in Scotland. It will be important to understand the reasons for this to allow appropriate intervention strategies to be considered.

Some rural areas of Scotland had significantly elevated male suicide rates. We have suggested that access to lethal means of suicide may be one contributing mechanism for this, and have also noted the higher than expected suicide numbers in some rural occupations [12]. Rural areas are subject to poverty of income and opportunity, so it is also possible that rural deprivation may play an important part. Occupational associations of suicide in Scotland deserve further exploration. Examination of the association between deprivation, rurality and suicide may assist in the identification of possible interventions in rural Scotland.

Declarations

Acknowledgements

This work was undertaken with a grant awarded by the Scottish Executive's Remote and Rural Areas Resource Initiative. NHS Highland supplied staff time from CS and PH. Prof. David Gunnell of the University of Bristol, Mike Muirhead of ISD, Professor David Godden of the University of Aberdeen and Brodie Paterson of the University of Stirling provided helpful advice during the study.

Authors’ Affiliations

(1)
Centre for Rural Health, University of Aberdeen, The Green House, Beechwood Business Park North
(2)
NHS Highland
(3)
Information and Statistics Division, NHS Scotland
(4)
Health Centre
(5)
New Craigs Hospital

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  32. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/4/49/prepub

Copyright

© Stark et al; licensee BioMed Central Ltd. 2004

This article is published under license to BioMed Central Ltd. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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