Matthias Bopp

Educational inequalities in cause-specific mortality in middle-aged and older men and women in eight western European populations

BACKGROUND Studies of socioeconomic disparities in patterns of cause of death have been limited to single countries, middle-aged people, men, or broad cause of death groups. We assessed contribution of specific causes of death to disparities in mortality between groups with different levels of education, in men and women, middle-aged and old, in eight western European populations. METHODS We analysed data from longitudinal mortality studies by cause of death, between Jan 1, 1990, and Dec 31, 1997. Data were included for more than 1 million deaths in 51 million person years of observation. FINDINGS Absolute educational inequalities in total mortality peaked at 2127 deaths per 100000 person years in men, and at 1588 deaths per 100000 person years in women aged 75 years and older. In this age-group, rate ratios were greater than 1.00 for total mortality and all specific causes of death, apart form prostate cancer in men and lung cancer in women, showing increased mortality in low versus high educational groups. In men, cardiovascular diseases accounted for 39% of the difference between low and high educational groups in total mortality, cancer for 24%, other diseases for 32%, and external causes for 5%. Among women, contributions were 60%, 11%, 30%, and 0%, respectively. The contributions of cerebrovascular disease, other cardiovascular diseases, pneumonia, and COPD strongly increased by age, whereas those of cancer and external causes declined. Although relative inequalities in total mortality were closely similar in all populations, we noted striking differences in the contribution of specific causes to these inequalities. INTERPRETATION Research needs to be broadened to include older populations, other diseases, and populations from different parts of Europe. Effective interventions should be developed and implemented to reduce exposure to cardiovascular risk factors in low-educational groups.

Socioeconomic inequalities in mortality among elderly people in 11 European populations

Study objective: To describe mortality inequalities related to education and housing tenure in 11 European populations and to describe the age pattern of relative and absolute socioeconomic inequalities in mortality in the elderly European population. Design and Methods: Data from mortality registries linked with population census data of 11 countries and regions of Europe were acquired for the beginning of the 1990s. Indicators of socioeconomic status were educational level and housing tenure. The study determined mortality rate ratios, relative indices of inequality (RII), and mortality rate differences. The age range was 30 to 90+ years. Analyses were performed on the pooled European data, including all populations, and on the data of populations separately. Data were included from Finland, Norway, Denmark, England and Wales, Belgium, France, Austria, Switzerland, Barcelona, Madrid, and Turin. Main results: In Europe (populations pooled) relative inequalities in mortality decreased with increasing age, but persisted. Absolute educational mortality differences increased until the ages 90+. In some of the populations, relative inequalities among older women were as large as those among middle aged women. The decline of relative educational inequalities was largest in Norway (men and women) and Austria (men). Relative educational inequalities did not decrease, or hardly decreased with age in England and Wales (men), Belgium, Switzerland, Austria, and Turin (women). Conclusions: Socioeconomic inequalities in mortality among older men and women were found to persist in each country, sometimes of similar magnitude as those among the middle aged. Mortality inequalities among older populations are an important public health problem in Europe.

Methods of suicide: international suicide patterns derived from the WHO mortality database

OBJECTIVE Accurate information about preferred suicide methods is important for devising strategies and programmes for suicide prevention. Our knowledge of the methods used and their variation across countries and world regions is still limited. The aim of this study was to provide the first comprehensive overview of international patterns of suicide methods. METHODS Data encoded according to the International Classification of Diseases (10th revision) were derived from the WHO mortality database. The classification was used to differentiate suicide methods. Correspondence analysis was used to identify typical patterns of suicide methods in different countries by providing a summary of cross-tabulated data. FINDINGS Poisoning by pesticide was common in many Asian countries and in Latin America; poisoning by drugs was common in both Nordic countries and the United Kingdom. Hanging was the preferred method of suicide in eastern Europe, as was firearm suicide in the United States and jumping from a high place in cities and urban societies such as Hong Kong Special Administrative Region, China. Correspondence analysis demonstrated a polarization between pesticide suicide and firearm suicide at the expense of traditional methods, such as hanging and jumping from a high place, which lay in between. CONCLUSION This analysis showed that pesticide suicide and firearm suicide replaced traditional methods in many countries. The observed suicide pattern depended upon the availability of the methods used, in particular the availability of technical means. The present evidence indicates that restricting access to the means of suicide is more urgent and more technically feasible than ever.

Socioeconomic status and ischaemic heart disease mortality in 10 western European populations during the 1990s

Objective: To assess the association between socioeconomic status and ischaemic heart disease (IHD) mortality in 10 western European populations during the 1990s. Design: Longitudinal study. Setting: 10 European populations (95 009 822 person years). Methods: Longitudinal data on IHD mortality by educational level were obtained from registries in Finland, Norway, Denmark, England/Wales, Belgium, Switzerland, Austria, Turin (Italy), Barcelona (Spain), and Madrid (Spain). Age standardised rates and rate ratios (RRs) of IHD mortality by educational level were calculated by using Poisson regression. Results: IHD mortality was higher in those with a lower socioeconomic status than in those with a higher socioeconomic status among men aged 30–59 (RR 1.55, 95% confidence interval (CI) 1.51 to 1.60) and 60 years and over (RR 1.22, 95% CI 1.21 to 1.24), and among women aged 30–59 (RR 2.13, 95% CI 1.98 to 2.29) and 60 years and over (RR 1.36, 95% CI 1.33 to 1.38). Socioeconomic disparities in IHD mortality were larger in the Scandinavian countries and England/Wales, of moderate size in Belgium, Switzerland, and Austria, and smaller in southern European populations among men and younger women (p < 0.0001). For elderly women the north–south gradient was smaller and there was less variation between populations. No socioeconomic disparities in IHD mortality existed among elderly men in southern Europe. Conclusions: Socioeconomic disparities in IHD mortality were larger in northern than in southern European populations during the 1990s. This partly reflects the pattern of socioeconomic disparities in cardiovascular risk factors in Europe. Population wide strategies to reduce risk factor prevalence combined with interventions targeted at the lower socioeconomic groups can contribute to reduce IHD mortality in Europe.

Socioeconomic inequalities in diabetes mellitus across Europe at the beginning of the 21st century

Aims/hypothesisThe aim of this study was to determine and quantify socioeconomic position (SEP) inequalities in diabetes mellitus in different areas of Europe, at the turn of the century, for men and women.MethodsWe analysed data from ten representative national health surveys and 13 mortality registers. For national health surveys the dependent variable was the presence of diabetes by self-report and for mortality registers it was death from diabetes. Educational level (SEP), age and sex were independent variables, and age-adjusted prevalence ratios (PRs) and risk ratios (RRs) were calculated.ResultsIn the overall study population, low SEP was related to a higher prevalence of diabetes, for example men who attained a level of education equivalent to lower secondary school or less had a PR of 1.6 (95% CI 1.4–1.9) compared with those who attained tertiary level education, whereas the corresponding value in women was 2.2 (95% CI 1.9–2.7). Moreover, in all countries, having a disadvantaged SEP is related to a higher rate of mortality from diabetes and a linear relationship is observed. Eastern European countries have higher relative inequalities in mortality by SEP. According to our data, the RR of dying from diabetes for women with low a SEP is 3.4 (95% CI 2.6–4.6), while in men it is 2.0 (95% CI 1.7–2.4).Conclusions/interpretationIn Europe, educational attainment and diabetes are inversely related, in terms of both morbidity and mortality rates. This underlines the importance of targeting interventions towards low SEP groups. Access and use of healthcare services by people with diabetes also need to be improved.

Cohort Profile: The Swiss National Cohort—a longitudinal study of 6.8 million people

For many years research on socio-economic inequalities in health in Switzerland was based on crosssectional data. Cross-sectional studies are problematic for several reasons. For example, results may be affected by numerator/denominator bias. Furthermore, occupational information from death certificates was used to describe the socio-economic position of individuals. However, this meant that those who do not work, older men and a substantial proportion of women, had to be excluded. Decennial censuses, conducted at the beginning of December every 10 years, have been done in Switzerland since 1850 (exceptions were 1890 and 1940, which were replaced by a census in 1888 and 1941, respectively). Deaths and causes of death have been registered since 1876, with data stored electronically since 1969. Death registration is anonymous. However, the date of death and birth are available, as well as gender, marital status, place of residence, date of birth of spouse and other variables. The 1990 census for the first time included the exact date of birth, which opened the possibility of linking census and mortality data. Based on the promising results of a pilot study that was done for one Canton at University of Zurich, the project was extended to cover the whole of Switzerland, linking the 1990 census with mortality records up to the end of 1997. The results indicated that linkage was less successful for foreign nationals and young adults, and led to the inclusion of additional data sources, including data on immigrants and emigrants and, importantly, the 2000 census. In 2005, an application by all five University Institutes of Social and Preventive Medicine (ISPMs) to obtain long-term funding for a Swiss National Cohort study (SNC) was successful within the framework of a Swiss National Science Foundation initiative to support longitudinal studies. Approval was obtained from the Ethics Committees of the Cantons of Zurich and Bern and a data centre was established at ISPM Bern.

Trends in inequalities in premature mortality: a study of 3.2 million deaths in 13 European countries

Background Over the last decades of the 20th century, a widening of the gap in death rates between upper and lower socioeconomic groups has been reported for many European countries. For most countries, it is unknown whether this widening has continued into the first decade of the 21st century. Methods We collected and harmonised data on mortality by educational level among men and women aged 30–74 years in all countries with available data: Finland, Sweden, Norway, Denmark, England and Wales, Belgium, France, Switzerland, Spain, Italy, Hungary, Lithuania and Estonia. Results Relative inequalities in premature mortality increased in most populations in the North, West and East of Europe, but not in the South. This was mostly due to smaller proportional reductions in mortality among the lower than the higher educated, but in the case of Lithuania and Estonia, mortality rose among the lower and declined among the higher educated. Mortality among the lower educated rose in many countries for conditions linked to smoking (lung cancer, women only) and excessive alcohol consumption (liver cirrhosis and external causes). In absolute terms, however, reductions in premature mortality were larger among the lower educated in many countries, mainly due to larger absolute reductions in mortality from cardiovascular disease and cancer (men only). Despite rising levels of education, population-attributable fractions of lower education for mortality rose in many countries. Conclusions Relative inequalities in premature mortality have continued to rise in most European countries, and since the 1990s, the contrast between the South (with smaller inequalities) and the East (with larger inequalities) has become stronger. While the population impact of these inequalities has further increased, there are also some encouraging signs of larger absolute reductions in mortality among the lower educated in many countries. Reducing inequalities in mortality critically depends upon speeding up mortality declines among the lower educated, and countering mortality increases from conditions linked to smoking and excessive alcohol consumption such as lung cancer, liver cirrhosis and external causes.

Lower Mortality From Coronary Heart Disease and Stroke at Higher Altitudes in Switzerland

Background— Studies assessing the effect of altitude on cardiovascular disease have provided conflicting results. Most studies were limited because of the heterogeneity of the population, their ecological design, or both. In addition, effects of place of birth were rarely considered. Here, we examine mortality from coronary heart disease and stroke in relation to the altitude of the place of residence in 1990 and at birth. Methods and Results— Mortality data from 1990 to 2000, sociodemographic information, and places of birth and residence in 1990 (men and women between 40 and 84 years of age living at altitudes of 259 to 1960 m) were obtained from the Swiss National Cohort, a longitudinal, census-based record linkage study. The 1.64 million German Swiss residents born in Switzerland provided 14.5 million person-years. Relative risks were calculated with multivariable Poisson regression. Mortality from coronary heart disease (−22% per 1000 m) and stroke (−12% per 1000 m) significantly decreased with increasing altitude. Being born at altitudes higher or lower than the place of residence was associated with lower or higher risk. Conclusions— The protective effect of living at higher altitude on coronary heart disease and stroke mortality was consistent and became stronger after adjustment for potential confounders. Being born at high altitude had an additional and independent beneficial effect on coronary heart disease mortality. The effect is unlikely to be due to classic cardiovascular disease risk factors and rather could be explained by factors related to climate.

Educational Level and Stroke Mortality A Comparison of 10 European Populations During the 1990s

Background and Purpose— Variations between countries in occupational differences in stroke mortality were observed among men during the 1980s. This study estimates the magnitude of differences in stroke mortality by educational level among men and women aged ≥30 years in 10 European populations during the 1990s. Methods— Longitudinal data from mortality registries were obtained for 10 European populations, namely Finland, Norway, Denmark, England/Wales, Belgium, Switzerland, Austria, Turin (Italy), Barcelona (Spain), and Madrid (Spain). Rate ratios (RRs) were calculated to assess the association between educational level and stroke mortality. The life table method was used to estimate the impact of stroke mortality on educational differences in life expectancy. Results— Differences in stroke mortality according to educational level were of a similar magnitude in most populations. However, larger educational differences were observed in Austria. Overall, educational differences in stroke mortality were of similar size among men (RR, 1.27; 95% CI, 1.24 to 1.30) and women (RR, 1.29; 95% CI, 1.27 to 1.32). Educational differences in stroke mortality persisted at all ages in all populations, although they generally decreased with age. Eliminating these differences would on average reduce educational differences in life expectancy by 7% among men and 14% among women. Conclusions— Educational differences in stroke mortality were observed across Europe during the 1990s. Risk factors such as hypertension and smoking may explain part of these differences in several countries. Other factors, such as socioeconomic differences in healthcare utilization and childhood socioeconomic conditions, may have contributed to educational differences in stroke mortality across Europe.

Educational inequalities in avoidable mortality in Europe

Background The magnitude of educational inequalities in mortality avoidable by medical care in 16 European populations was compared, and the contribution of inequalities in avoidable mortality to educational inequalities in life expectancy in Europe was determined. Methods Mortality data were obtained for people aged 30–64 years. For each country, the association between level of education and avoidable mortality was measured with the use of regression-based inequality indexes. Life table analysis was used to calculate the contribution of avoidable causes of death to inequalities in life expectancy between lower and higher educated groups. Results Educational inequalities in avoidable mortality were present in all countries of Europe and in all types of avoidable causes of death. Especially large educational inequalities were found for infectious diseases and conditions that require acute care in all countries of Europe. Inequalities were larger in Central Eastern European (CEE) and Baltic countries, followed by Northern and Western European countries, and smallest in the Southern European regions. This geographic pattern was present in almost all types of avoidable causes of death. Avoidable mortality contributed between 11 and 24% to the inequalities in Partial Life Expectancy between higher and lower educated groups. Infectious diseases and cardiorespiratory conditions were the main contributors to this difference. Conclusions Inequalities in avoidable mortality were present in all European countries, but were especially pronounced in CEE and Baltic countries. These educational inequalities point to an important role for healthcare services in reducing inequalities in health.