Ramune Kalediene

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.

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.

Educational inequalities in mortality in four Eastern European countries: divergence in trends during the post-communist transition from 1990 to 2000

BACKGROUND Post-communist transition has had a huge impact on mortality in Eastern Europe. We examined how educational inequalities in mortality changed between 1990 and 2000 in Estonia, Lithuania, Poland and Hungary. METHODS Cross-sectional data for the years around 1990 and 2000 were used. Age-standardized mortality rates and mortality rate ratios (for total mortality only) were calculated for men and women aged 35-64 in three educational categories, for five broad cause-of-death groups and for five (seven among women) specific causes of death. RESULTS Educational inequalities in mortality increased in all four countries but in two completely different ways. In Poland and Hungary, mortality rates decreased or remained the same in all educational groups. In Estonia and Lithuania, mortality rates decreased among the highly educated, but increased among those of low education. In Estonia and Lithuania, for men and women combined, external causes and circulatory diseases contributed most to the increasing educational gap in total mortality. CONCLUSIONS Different trends were observed between the two former Soviet republics and the two Central Eastern European countries. This divergence can be related to differences in socioeconomic development during the 1990s and in particular, to the spread of poverty, deprivation and marginalization. Alcohol and psychosocial stress may also have been important mediating factors.

Duration of unemployment and depression: a cross-sectional survey in Lithuania

BackgroundIn spite of a growing economy, unemployment is still a severe socio-economic problem in Lithuania. Nonetheless, no studies have been performed about the associations between unemployment and mental health in Lithuania. The aim of this study was to evaluate the associations between unemployment duration and depression in Lithuania.MethodsThe data was collected in a cross-sectional study in 2005. There were 429 filled-in questionnaires received (53.6% response rate) from unemployed persons registered with the Kaunas Labour Market Office. The severity of depression symptoms was evaluated using the Beck Depression Inventory (BDI). Logistic regression was used to estimate the risk factors for occurrence of depression. Sex, age, place of residence, marital status, education, income and practiced religion were the independent variables. Long-term unemployment was defined as lasting a duration of 12 months or more.ResultsThe findings showed that long-term unemployed persons had more episodes of a depressive mood in the past 12 months in comparison with the group of the short-term unemployed. In addition, the BDI score mean was higher among the long-term unemployed compared with the short-term unemployed (10.1 ± 8.8 and 14.2 ± 9.5 respectively, p < 0.001). It was estimated that the duration of unemployment and BDI score had a positive correlation (r = 0.1968, p < 0.001). Among the short-term unemployed, the risk of depression increased significantly when the person was female, had an older age and had experienced more episodes of unemployment. Among the long-term unemployed, an older age was the risk factor for development of depression. However, higher education and income were the factors that significantly decreased the risk of developing depression for-short term as well as for long-term unemployed.ConclusionThe results indicated that depression is a severe problem in the unemployed population. Depression is more elevated among the long-term unemployed. This leads to arguing for common efforts in providing needed social support and health care to reduce the effects of unemployment on mental health.

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.

Socioeconomic inequalities in lung cancer mortality in 16 European populations

OBJECTIVES This paper aims to describe socioeconomic inequalities in lung cancer mortality in Europe and to get further insight into socioeconomic inequalities in lung cancer mortality in different European populations by relating these to socioeconomic inequalities in overall mortality and smoking within the same or reference populations. Particular attention is paid to inequalities in Eastern European and Baltic countries. METHODS Data were obtained from mortality registers, population censuses and health interview surveys in 16 European populations. Educational inequalities in lung cancer and total mortality were assessed by direct standardization and calculation of two indices of inequality: the Relative Index of Inequality (RII) and the Slope Index of Inequality (SII). SIIs were used to calculate the contribution of inequalities in lung cancer mortality to inequalities in total mortality. Indices of inequality in lung cancer mortality in the age group 40-59 years were compared with indices of inequalities in smoking taking into account a time lag of 20 years. RESULTS The pattern of inequalities in Eastern European and Baltic countries is more or less similar as the one observed in the Northern countries. Among men educational inequalities are largest in the Eastern European and Baltic countries. Among women they are largest in Northern European countries. Whereas among Southern European women lung cancer mortality rates are still higher among the high educated, we observe a negative association between smoking and education among young female adults. The contribution of lung cancer mortality inequalities to total mortality inequalities is in most male populations more than 10%. Important smoking inequalities are observed among young adults in all populations. In Sweden, Hungary and the Czech Republic smoking inequalities among young adult women are larger than lung cancer mortality inequalities among women aged 20 years older. CONCLUSIONS Important socioeconomic inequalities exist in lung cancer mortality in Europe. They are consistent with the geographical spread of the smoking epidemic. In the next decades socioeconomic inequalities in lung cancer mortality are likely to persist and even increase among women. In Southern European countries we may expect a reversal from a positive to a negative association between socioeconomic status and lung cancer mortality. Continuous efforts are necessary to tackle socioeconomic inequalities in lung cancer mortality in all European countries.

Changes in mortality inequalities over two decades: register based study of European countries

Objective To determine whether government efforts in reducing inequalities in health in European countries have actually made a difference to mortality inequalities by socioeconomic group. Design Register based study. Data source Mortality data by level of education and occupational class in the period 1990-2010, usually collected in a census linked longitudinal study design. We compared changes in mortality between the lowest and highest socioeconomic groups, and calculated their effect on absolute and relative inequalities in mortality (measured as rate differences and rate ratios, respectively). Setting All European countries for which data on socioeconomic inequalities in mortality were available for the approximate period between years 1990 and 2010. These included Finland, Norway, Sweden, Scotland, England and Wales (data applied to both together), France, Switzerland, Spain (Barcelona), Italy (Turin), Slovenia, and Lithuania. Results Substantial mortality declines occurred in lower socioeconomic groups in most European countries covered by this study. Relative inequalities in mortality widened almost universally, because percentage declines were usually smaller in lower socioeconomic groups. However, as absolute declines were often smaller in higher socioeconomic groups, absolute inequalities narrowed by up to 35%, particularly among men. Narrowing was partly driven by ischaemic heart disease, smoking related causes, and causes amenable to medical intervention. Progress in reducing absolute inequalities was greatest in Spain (Barcelona), Scotland, England and Wales, and Italy (Turin), and absent in Finland and Norway. More detailed studies preferably using individual level data are necessary to identify the causes of these variations. Conclusions Over the past two decades, trends in inequalities in mortality have been more favourable in most European countries than is commonly assumed. Absolute inequalities have decreased in several countries, probably more as a side effect of population wide behavioural changes and improvements in prevention and treatment, than as an effect of policies explicitly aimed at reducing health inequalities.

Seasonal patterns of suicides over the period of socio-economic transition in Lithuania

BackgroundIn Lithuania, suicides are a grave public health problem, requiring more extensive investigation. The aim of the study was to assess the seasonal variations of suicides in Lithuania throughout the years 1993–2002, describing patterns by gender, age and method of suicide.MethodsThe study material consisted of all registered suicides (n = 16,147) committed throughout 1993–2002 in Lithuania. Smoothed trends were inspected. The seasonal effect was explored using monthly ratio statistics and spectral analysis.ResultsSuicides in Lithuania have a distinct annual rhythm with peaks in summer and troughs in December. The December frequencies fell by more than 23% in men and 30% in women, while June peak reached nearly 23% in men and July peak exceeded 29% in women, compare with the average levels, (p < 0.05). Hanging was the most common method of suicide both in men and women comprising up to 90% among all suicides in 1998–2002. Among different methods, only hanging suicides showed significant seasonal variations, especially in men. The seasonal amplitude has decreased over time.ConclusionSubstantial seasonal variations in suicides were associated with a high proportion of hanging. Extremely high suicide rates in Lithuania require further extensive studies and urgent preventive programs, taking into account the suggestions of this survey.

Inequalities in life expectancy in Lithuania by level of education

The purpose of this study was to examine educational inequalities in life expectancy of the Lithuanian population. The life-tables by level of education were calculated on the basis of the individual records of the 1989 census, which were linked to the death records of males and females, aged 25 - 70 years. In comparison with the group with university education, the life expectancy of males with primary or lower education was 11.7 years shorter, and of females 4.3 years shorter. The greatest impact of educational differentials on life expectancy was the inequality found in the mortality of the population, aged 25-44 years. Sex differences in life expectancy were greatest among those with primary or lower education. External causes of death contributed most to educational differences in life expectancy of males, whereas cardiovascular diseases had a major impact to educational differences in females.

Socioeconomic inequalities in mortality from conditions amenable to medical interventions: do they reflect inequalities in access or quality of health care?

BackgroundPrevious studies have reported large socioeconomic inequalities in mortality from conditions amenable to medical intervention, but it is unclear whether these can be attributed to inequalities in access or quality of health care, or to confounding influences such as inequalities in background risk of diseases. We therefore studied whether inequalities in mortality from conditions amenable to medical intervention vary between countries in patterns which differ from those observed for other (non-amenable) causes of death. More specifically, we hypothesized that, as compared to non-amenable causes, inequalities in mortality from amenable causes are more strongly associated with inequalities in health care use and less strongly with inequalities in common risk factors for disease such as smoking.MethodsCause-specific mortality data for people aged 30–74 years were obtained for 14 countries, and were analysed by calculating age-standardized mortality rates and relative risks comparing a lower with a higher educational group. Survey data on health care use and behavioural risk factors for people aged 30–74 years were obtained for 12 countries, and were analysed by calculating age-and sex-adjusted odds ratios comparing a low with a higher educational group. Patterns of association were explored by calculating correlation coefficients.ResultsIn most countries and for most amenable causes of death substantial inequalities in mortality were observed, but inequalities in mortality from amenable causes did not vary between countries in patterns that are different from those seen for inequalities in non-amenable mortality. As compared to non-amenable causes, inequalities in mortality from amenable causes are not more strongly associated with inequalities in health care use. Inequalities in mortality from amenable causes are also not less strongly associated with common risk factors such as smoking.ConclusionsWe did not find evidence that inequalities in mortality from amenable conditions are related to inequalities in access or quality of health care. Further research is needed to find the causes of socio-economic inequalities in mortality from amenable conditions, and caution should be exercised in interpreting these inequalities as indicating health care deficiencies.