Laura Reques

Educational differences in mortality and the relative importance of different causes of death: a 7-year follow-up study of Spanish adults

Background The evidence on mortality patterns by education in Spain comes from regional areas. This study aimed to estimate these patterns in the whole Spanish population. Methods All citizens aged 25 years and over and residing in Spain in 2001 were followed during 7 years to determine their vital status, resulting in a total of 196 470 401 person-years and 2 379 558 deaths. We estimated the age-adjusted total and cause-specific mortality by educational level—primary, lower secondary, upper secondary and university education—and then calculated the relative and absolute measures of inequality in mortality and contribution of the leading causes of death to absolute inequalities. Results Except for some cancer sites, the mortality rate for the leading causes of death shows an inverse gradient with educational level. The leading causes of death with the highest relative index of inequality ratios were HIV disease (9.81 in women and 11.61 in men), diabetes in women (4.02) and suicide in men (3.52). The leading causes of death that contribute most to the absolute inequality in mortality are cardiovascular diseases (48.8%), respiratory diseases (9.3%) and diabetes mellitus (8.8%) in women, and cardiovascular diseases (20.8%), respiratory diseases (19.8%) and cancer (19.6%) in men. Conclusions Although the causes of death with the strongest gradient in mortality rate are HIV disease in both sexes, diabetes mellitus in women and suicide in men, most of the absolute education-related inequalities in total mortality are due to cardiovascular diseases, respiratory diseases and diabetes mellitus in women and to cardiovascular diseases, respiratory diseases and cancer in men.

Inequalities in mortality at older ages decline with indicators of material wealth but persist with educational level

OBJECTIVE This study aimed to investigate the relationship between education and different indicators of material wealth with mortality, and to analyze whether this relationship varies with the leading causes of death. METHODS All persons aged 65 and older residing in Spain in 2001 were followed up for 7 years to determine their vital status. The relationship between mortality and four indicators of socioeconomic position (education, number of rooms in home, surface area of home and number of vehicles) was estimated in three age groups: 65-74, 75-84 and 85 and older. Rate ratios and relative index of inequality (RII) were calculated for general mortality and for the leading causes of death by Poisson regression. RESULTS In women, the mortality rate ratio for low vs. high educational level was 1.48 for persons aged 65-74, 1.43 for those aged 75-84 and 1.40 for those aged 85 and older. The respective rates for men were 1.30, 1.25 and 1.29. For the indicators of material wealth, the differences between morality rates in the lower vs. the higher socioeconomic categories decline with age. Mortality differences by the leading causes of death decline with age, except in the case of cancer in women and cardiovascular and digestive mortality in men according to educational level. CONCLUSIONS Relative socioeconomic differences in mortality in the older Spanish population decrease with age using indicators of material wealth but not using educational level. The variation in the pattern of mortality by cause of death by level of education may be responsible for these findings.

Impacto del Real Decreto de la Troncalidad en la formación en medicina preventiva y salud pública y en otras especialidades del tronco común médico

OBJECTIVE The purpose of the Core Training Law (CTL) is to amend specialised medical training to include 24 months of common training. The aim of this study is to assess its potential impact on the Preventive Medicine and Public Health (PM&PH) training programme and other medical specialties. METHOD The programmes of the 21 common medical specialties were analysed and the recommended training periods for each specialty collected, before the information was agreed upon by three observers. The training impact was calculated as the percentage of months that should be amended per specialty to adapt to the common training schedule. RESULTS The Preventive Medicine and Public Health training programme is the specialty most affected by the Core Training Law (100%, 24 months). Intensive medicine (0%, 0 months) and medical oncology (17%, 4 months) is the least affected. CONCLUSIONS The CTL affects the common medical specialties in different ways and requires a complete reorganisation of the activities and competencies of PM&PH professionals.

Area-level socioeconomic context, total mortality and cause-specific mortality in Spain: Heterogeneous findings depending on the level of geographic aggregation.

The objective of this study was to estimate the association between area-level socioeconomic context and mortality in Spain, using two different geographic aggregations. Nation-wide prospective study covering all persons living in Spain in 2001. Mortality was analysed in Spanish citizens by province of residence and in citizens of Madrid by neighbourhood of residence. Provinces and neighbourhoods were grouped into quartiles according to two socioeconomic indicators: percentage of the population with university education and unemployment rate. The measure of association was the rate ratio for total mortality and cause-specific mortality, by each socioeconomic indicator in two age groups, 25-64 years (adult population) and 65 years and over (elderly population). After adjustment for all individual socioeconomic variables, the rate ratio for total mortality among residents in the provinces with the worst versus best socioeconomic context was 0.92 (95% CI 0.88-0.97) when the indicator was percentage of university population and 0.89 (0.85-0.93) when it was unemployment rate in the adult population, and 1.05 (1.00-1.11) and 1.08 (1.03-1.13), respectively, in the elderly population. No significant differences in mortality were observed between adults residing in neighbourhoods with the worst versus best socioeconomic context, but in the elderly population the mortality rate ratios for the two socioeconomic indicators were 1.04 (1.01-1.07) and 1.06 (1.03-1.09), respectively. Residents in provinces with the worst socioeconomic context had the lowest mortality from cancer and external causes and the highest mortality from cardiovascular diseases, while residents in neighbourhoods with the worst socioeconomic context had the highest mortality from respiratory and digestive diseases. Further research should find out the reasons for the lower total mortality in adult population residing in the Spanish provinces with the most adverse socioeconomic context and the reasons for excess mortality from digestive diseases and respiratory diseases among residents in neighbourhoods with the worst socioeconomic context.

Patrones Geográficos de la Mortalidad y de las Desigualdades Socioeconómicas en Mortalidad en España

Fundamentos: Las estimaciones sobre desigualdades socioeconomicas en mortalidad a partir de registros individuales de defunciones y poblacion son escasas y proceden unicamente de la la ciudad de Barcelona, la Comunidad de Madrid y el Pais Vasco. El objetivo del presente estudio fue mostrar el patron geografico de mortalidad en diferentes grupos socioeconomicos, asi como el de las desigualdades en mortalidad en el conjunto del territorio espanol. Metodos: Se realizo el seguimiento de todos los individuos mayores de 25 anos del censo de poblacion 2001 durante siete anos y dos meses para conocer su estado vital (196.470.401 personas-ano a riesgo y 2.379.558 defunciones). Se calculo la tasa de mortalidad ajustada por edad en hombres y mujeres por provincia y nivel de estudios. Las desigualdades en mortalidad provinciales se estimaron mediante la razon de tasas de mortalidad en los sujetos con nivel de estudios primarios o inferiores respecto a los sujetos con estudios universitarios. Resultados: En mujeres, las razones de tasas mas bajas -entre 1,06 y 1,16- se observaron Palencia, Segovia, Guadalajara y Avila. Las mas altas -entre 1,53 y 1,75- en Malaga, Las Palmas, Ceuta, Toledo y Melilla. En hombres, las razones de tasas mas bajas -entre 1,00 y 1,12- se observan en Guadalajara, Teruel, Cuenca, La Rioja y Avila y las mas altas -entre 1,47 y 1,73- en Las Palmas, Cantabria, Murcia, Melilla y Ceuta. Conclusiones: El patron geografico de las tasas de mortalidad en Espana varia segun el nivel educativo. Las desigualdades en mortalidad muestran menor magnitud en las provincias del centro peninsular.

Desigualdades en mortalidad prematura según indicadores de bienestarmaterial en Navarra. Estudio poblacional de seguimiento 2001-2008

BACKGROUND To show the inequalities in premature mortality according to indicators of material welfare in Navarre. METHODS All citizens under 75 years of age living in Navarre in 2001 were monitored for seven years to determine their vital status. House size and number of household vehicles was used as the socioeconomic status indicator. The age-adjusted total mortality rate and mortality rate from cause-specific mortality were estimated by these indicators. RESULTS The rate ratio for all causes of death in the lower categories depending on house size is 1.14 (IC 95%: 1.05-1.24) and 1.25 (IC 95%: 1.18-1.32) in women and men respectively and 1.46 (IC 95%: 1.36-1.57) and 1.97 (IC 95%: 1.89-2.05) depending on the number of vehicles. AIDS is the leading cause of death having a greater difference in mortality rates among people with lower and higher material welfare. Other causes of death with a high difference in mortality rates are digestive diseases and diabetes mellitus in women and digestive diseases and respiratory diseases in men. CONCLUSIONS The mortality rate in the Navarre population shows an inverse gradient to material welfare,except for some cancer sites. This gradient is higher among men than among women.BACKGROUND To show the inequalities in premature mortality according to indicators of material welfare in Navarre. METHODS All citizens under 75 years of age living in Navarre in 2001 were monitored for seven years to determine their vital status. House size and number of household vehicles was used as the socioeconomic status indicator. The age-adjusted total mortality rate and mortality rate from cause-specific mortality were estimated by these indicators. RESULTS The rate ratio for all causes of death in the lower categories depending on house size is 1.14 (IC 95%: 1.05-1.24) and 1.25 (IC 95%: 1.18-1.32) in women and men respectively and 1.46 (IC 95%: 1.36-1.57) and 1.97 (IC 95%: 1.89-2.05) depending on the number of vehicles. AIDS is the leading cause of death having a greater difference in mortality rates among people with lower and higher material welfare. Other causes of death with a high difference in mortality rates are digestive diseases and diabetes mellitus in women and digestive diseases and respiratory diseases in men. CONCLUSIONS The mortality rate in the Navarre population shows an inverse gradient to material welfare,except for some cancer sites. This gradient is higher among men than among women.

Desigualdades en mortalidad total y por causa de muerte según el nivel de estudios en Navarra: hallazgos de un estudio longitudinal 2001-2008

Fundamentos: Dada la ausencia de evidencia cientifica, el objetivo fue mostrar las desigualdades en mortalidad segun el nivel de estudios en Navarra y la contribucion de las principales causas de defuncion a la magnitud de desigualdades en la mortalidad por todas las causas de muerte. Metodos: Todos los ciudadanos de 25 anos y mayores residentes en Navarra en 2001 fueron seguidos durante 7 anos para conocer su estado vital. El indicador de posicion socioeconomica utilizado fue el nivel de estudios. Se estimaron las tasas de mortalidad general y por causa de muerte ajustadas por edad segun la educacion. Posteriormente, se calcularon la diferencia relativa (razon) y la diferencia absoluta de tasas entre las categorias mas baja y mas alta de nivel de estudios y la contribucion de las principales causas de muerte a la diferencia absoluta. Resultados: La razon de tasas por todas las causas de muerte fue 1,37 en hombres y 1,23 en mujeres. El virus de la inmunodeficiencia humana (VIH) (25,84) y los accidentes no intencionales (3,78) presentaron las razones de tasas mas altas en los hombres y la diabetes mellitus (4,92) y el VIH (4,38) en las mujeres. Las enfermedades cardiovasculares constituyeron la causa de muerte que mas contribuyo a la diferencia absoluta en mortalidad: 26% en hombres y 48% en mujeres. Conclusiones: La tasa de mortalidad en la poblacion navarra muestra un gradiente inverso con el nivel educativo, a excepcion de algunas localizaciones de cancer. Las enfermedades cardiovasculares son la causa de muerte que mas contribuye a las desigualdades absolutas en mortalidad, mientras que otras causas de muerte que muestran importantes desigualdades relativas contribuyen poco a las desigualdades absolutas.

The Association of Geographic Coordinates with Mortality in People with Lower and Higher Education and with Mortality Inequalities in Spain.

Objective Geographic patterns in total mortality and in mortality by cause of death are widely known to exist in many countries. However, the geographic pattern of inequalities in mortality within these countries is unknown. This study shows mathematically and graphically the geographic pattern of mortality inequalities by education in Spain. Methods Data are from a nation-wide prospective study covering all persons living in Spains 50 provinces in 2001. Individuals were classified in a cohort of subjects with low education and in another cohort of subjects with high education. Age- and sex-adjusted mortality rate from all causes and from leading causes of death in each cohort and mortality rate ratios in the low versus high education cohort were estimated by geographic coordinates and province. Results Latitude but not longitude was related to mortality. In subjects with low education, latitude had a U-shaped relation to mortality. In those with high education, mortality from all causes, and from cardiovascular, respiratory and digestive diseases decreased with increasing latitude, whereas cancer mortality increased. The mortality-rate ratio for all-cause death was 1.27 in the southern latitudes, 1.14 in the intermediate latitudes, and 1.20 in the northern latitudes. The mortality rate ratios for the leading causes of death were also higher in the lower and upper latitudes than in the intermediate latitudes. The geographic pattern of the mortality rate ratios is similar to that of the mortality rate in the low-education cohort: the highest magnitude is observed in the southern provinces, intermediate magnitudes in the provinces of the north and those of the Mediterranean east coast, and the lowest magnitude in the central provinces and those in the south of the Western Pyrenees. Conclusion Mortality inequalities by education in Spain are higher in the south and north of the country and lower in the large region making up the central plateau. This geographic pattern is similar to that observed in mortality in the low-education cohort.