Evgueni M. Andreev

The changing relation between education and life expectancy in central and eastern Europe in the 1990s

Background: The political and social transition in central and eastern Europe has been generally associated with widening educational differences in life expectancy. However, interpretation of these findings is complicated because the size of educational categories within the population has also changed. It is therefore important to disentangle these two phenomena. Setting: The Czech Republic, Estonia, the Russian Federation and, as a western European reference, Finland, in two periods, 1988–89 and 1998–99. Methods: Life tables were calculated in three categories: university; secondary; and less than secondary education. Changes in life expectancy were decomposed into contributions of population composition and within-category mortality. Results: In Finland and the Czech Republic improvements are seen in all educational groups, with only a slight widening of the educational differences. Over 80% of the total life expectancy increase is attributable to improved mortality within educational categories. In Estonia and Russia, less favourable overall trends coincide with a dramatic widening of the educational gap. A decrease in life expectancy in those with low and middle education has been compensated for, to a small degree in Russia but a greater extent in Estonia, by improvements among those with higher education and by the improved population composition. For highly educated Estonians, the gains were seen at all ages, the greatest at age ⩾60 years. In Russia mortality increased in those <60 years although compensated for by improvements at older ages. Conclusions: Russia and Estonia exhibit much less equitable transitions compared with the Czech Republic. Analyses of trends in health inequalities should capture the changing population composition. In Russia and Estonia an improved educational structure prevented an even greater decline in life expectancy. The highly educated Estonians can potentially catalyse a wider health progress.

Increasing absolute mortality disparities by education in Finland, Norway and Sweden, 1971–2000

Background and objectives Studies on socioeconomic health disparities often suffer from a lack of uniform data and methodology. Using high quality, census-linked data and sensible inequality measures, this study documents the changes in absolute and relative mortality differences by education in Finland, Norway and Sweden over the period 1971 to 2000. Methods The age-standardised mortality rates and the population exposures for three educational categories were computed from detailed data provided by the national statistical offices. Mortality disparities by education were assessed using two range measures (rate differences and rate ratios), and two Gini-like measures (the average inter-group difference (AID) and the Gini coefficient (G)). The formulae for the decomposition of the change in the AID into (1) the contribution of change in population composition by education, and (2) the contribution of mortality change were introduced. Results Mortality decreases were often greater for high than for medium and low education. Both relative and absolute mortality disparities tend to increase over time. The magnitude and timing of the increases in absolute disparities vary by country. Both the rate differences and the AIDs have increased since the 1970s in Norway and Sweden, and since the 1980s in Finland. The contributions of the changes in population composition to the total AID increase were substantial in all countries, and for both sexes. The mortality contributions were substantial for males in Norway and Sweden. Conclusions The study reports increases in absolute mortality disparity, and its components. This trend needs to be further studied and addressed by policies.

Health expectancy in the Russian Federation: a new perspective on the health divide in Europe

OBJECTIVES To compare life expectancy and healthy life expectancy in the Russian Federation and in countries of Eastern and Western Europe. METHODS WHO mortality data and data on self-reported health from the World Values Survey and the Russian Longitudinal Monitoring Survey were used to compare the above three regions. Life expectancy was calculated using Sullivans method, with years of life lived divided into healthy and unhealthy. The gap in healthy life expectancy between the Russian Federation and Western Europe was examined by decomposing the difference by gender and age. FINDINGS The probability of remaining alive and healthy declines faster in the Russian Federation than in Western Europe, with the gap between Eastern Europe and the Russian Federation widening at older ages. In the Russian Federation, this rapid decline is due mainly to the high probability of death or of poor health for men and women, respectively. CONCLUSIONS There is a large toll of premature male mortality in the Russian Federation but there also appears to be a substantial burden of ill-health among women. As in other countries, the responses of men and women to adversity differ, leading to premature death in men but survival in a poor state of health in women. Epidemiological studies including objective measures of health would help policy-makers to estimate more precisely the scale and nature of this problem. Policy-makers must recognize that health expectancy in the Russian Federation is reduced in both men and women.

Losses of expected lifetime in the United States and other developed countries: methods and empirical analyses.

Patterns of diversity in age at death are examined using e†, a dispersion measure that equals the average expected lifetime lost at death. We apply two methods for decomposing differences in e†. The first method estimates the contributions of average levels of mortality and mortality age structures. The second (and newly developed) method returns components produced by differences between age- and cause-specific mortality rates. The United States is close to England and Wales in mean life expectancy but has higher life expectancy losses and lacks mortality compression. The difference is determined by mortality age structures, whereas the role of mortality levels is minor. This is related to excess mortality at ages under 65 from various causes in the United States. Regression on 17 country-series suggests that e† correlates with income inequality across countries but not across time. This result can be attributed to dissimilarity between the age- and cause-of-death structures of temporal mortality reduction and intercountry mortality variation. It also suggests that factors affecting overall mortality decrease differ from those responsible for excess lifetime losses in the United States compared with other countries. The latter can be related to weaknesses of health system and other factors resulting in premature death from heart diseases, amenable causes, accidents and violence.

Identifying the determinants of premature mortality in Russia: overcoming a methodological challenge

BackgroundIt is thought that excessive alcohol consumption is related to the high mortality among working age men in Russia. Moreover it has been suggested that alcohol is a key proximate driver of the very sharp fluctuations in mortality seen in this group since the mid-1980s. Designing an individual-level study suitable to address the potential acute effects of alcohol consumption on mortality in Russia has posed a challenge to epidemiologists, especially because of the need to identify factors that could underlie the rapid changes up and down in mortality rates that have been such a distinctive feature of the Russian mortality crisis. In order to address this study question which focuses on exposures acting shortly before sudden death, a cohort would be unfeasibly large and would suffer from recruitment bias.MethodsAlthough the situation in Russia is unusual, with a very high death rate characterised by many sudden and apparently unexpected deaths in young men, the methodological problem is common to research on any cause of death where many deaths are sudden.ResultsWe describe the development of an innovative approach that has overcome some of these challenges: a case-control study employing proxy informants and external data sources to collect information about proximate determinants of mortality.ConclusionThis offers a set of principles that can be adopted by epidemiologists studying sudden and unexpected deaths in other settings.

Biological mechanisms of disease and death in Moscow: rationale and design of the survey on Stress Aging and Health in Russia (SAHR)

BackgroundPrior research has revealed large differences in health and mortality across countries, socioeconomic groups, and individuals. Russia experiences one of the worlds highest levels of all-cause and cardiovascular mortality, great mortality differences within the population, and a heavy burden of ill health. Psychological stress has been suggested as a likely explanation of health loss and premature death in Russia and Eastern Europe. However, physiological mechanisms connecting stress with health in Russia remain unclear since existing epidemiological data are scarce and limited to conventional risk factors.Method and DesignThe survey on Stress Aging and Health in Russia (SAHR) is addressing this knowledge gap by collecting an unusually rich database that includes a wide range of reported information, physical and cognitive health outcomes, and biomarkers in a sample of Muscovite men and women aged 55 and older. The total planned sample size is 2,000 individuals. The sample was randomly selected from epidemiological cohorts formed in Moscow between the mid-1970s and the 1990s and from medical population registers. The baseline data collection was carried out from December 2006 to June 2009. Interviews and medical tests were administered at hospital or at home according to standardized protocol. Questionnaire information includes health, socio-demographic characteristics, economic well-being, cognitive functioning, and batteries on stress and depression. Biomarkers include anthropometry, grip strength, resting ECG, conventional cardiovascular factors of risk such as lipid profile and blood pressure, and other biochemical parameters such as those related to inflammation, glucose and insulin resistance, coagulation, fibrinolysis, and stress hormones. In addition to these measurements, SAHR includes dynamic biomarkers provided by 24-hour ECG (Holter) monitoring. This method continuously registers the beat-to-beat heart rate in naturalistic conditions without restrictions on normal daily activities. It provides information about heart functioning, including heart rate variability and ischemic and arrhythmic events.Re-examination of the study subjects will be conducted in 2009–2011 and will focus on health, functional status, economic conditions, behaviors, and attitudes towards aging. The subjects are also followed up for mortality and non-fatal health events.DiscussionThe SAHR will produce a valuable set of established and novel biomarkers combined with self-reported data for the international research community and will provide important insights into factors and biological mechanisms of mortality and health losses in Russia.

CONCENTRATION OF WORKING-AGE MALE MORTALITY AMONG MANUAL WORKERS IN URBAN LATVIA AND RUSSIA, 1970–1989

ABSTRACT Until recently data on mortality by socioeconomic status were not available for the initial period of mortality increase in the former Soviet Union from 1965 to 1979. Newly discovered data from the Russian State Archive of Economics allow us to close this gap and to compare mortality trends in urban Latvia and several urban areas of Russia with the concentration of rising male mortality among manual workers already found in several eastern European countries. A similar trend appears in these data for rising mortality to concentrate among manual workers over time. Unfavorable trends in the life expectancy of the total population were largely driven by mortality increase among manual workers. Possible determinants of the pattern include a special type of economic growth in the USSR in the 1970s and 1980s associated with dominance of heavy industries and military sector, and low consumer goods’ production, high prevalence of hard manual labor, massive rural–urban migrations and poor living conditions of new coming industrial workers, growing psychosocial stress and high prevalence of adverse health behaviors. These characteristics are discussed in the framework of an incomplete modernization and distinct health life styles in state socialist countries.

Prevalence, components, and correlates of metabolic syndrome (MetS) among elderly Muscovites

The goal of this study is to estimate the prevalence of MetS, together with its components and correlates, among elderly Russians. Our population-based sample included randomly selected residents of Moscow aged 55 and older: 955 women with an average age of 67.6, and 833 men with an average age of 68.9. MetS was defined according to National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATPIII). The prevalence of MetS was found to be 41.7% in women and 26.8% in men. It tended to decrease with age in men, but not in women. MetS was inversely related to education in women, but not in men. The most prevalent individual components of MetS were as follows: hypertension (64.4%), abdominal obesity (55%), and decreased high density lipoprotein cholesterol (HDL C) (46%) for women; and hypertension (71%) and fasting hyperglycemia (35.2%) for men. An elevated level of triglycerides (TG) was the rarest MetS component, affecting 23.5% of women and 22.1% of men. The higher female prevalence of MetS was attributable to abdominal obesity. MetS was found to be associated with markers of insulin resistance (IR), low-grade inflammation, and insufficient fibrinolysis. Although the metabolic burden is an important contributor to high levels of ill-health and cardiovascular mortality among elderly Russians (especially women), it does not explain why cardiovascular mortality is much higher in Russia than in other industrialized countries.

Change in marital status structure as an obstacle for health improvement: evidence from six developed countries.

The aim of this study is to estimate the contributions of changes in population distribution by marital status to the changes in adult mortality in six developed countries. The change in total mortality was decomposed into the contributions of: (i) mortality changes within each marital status category; and (ii) changes in population composition by marital status. The study provides evidence that changes in population composition contributed to increases in male mortality in Russia and Lithuania, whereas in the remaining male populations this was a significant obstacle for faster health improvements. The compositional changes had only small impacts on female mortality.

Commentary: The study by Leinsalu et al. on mortality differentials in Eastern Europe highlights the need for better data

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