Tapani Valkonen

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.

Socioeconomic inequalities in mortality among women and among men: an international study

OBJECTIVES This study compared differences in total and cause-specific mortality by educational level among women with those among men in 7 countries: the United States, Finland, Norway, Italy, the Czech Republic, Hungary, and Estonia. METHODS National data were obtained for the period ca. 1980 to ca. 1990. Age-adjusted rate ratios comparing a broad lower-educational group with a broad upper-educational group were calculated with Poisson regression analysis. RESULTS Total mortality rate ratios among women ranged from 1.09 in the Czech Republic to 1.31 in the United States and Estonia. Higher mortality rates among lower-educated women were found for most causes of death, but not for neoplasms. Relative inequalities in total mortality tended to be smaller among women than among men. In the United States and Western Europe, but not in Central and Eastern Europe, this sex difference was largely due to differences between women and men in cause-of-death pattern. For specific causes of death, inequalities are usually larger among men. CONCLUSIONS Further study of the interaction between socioeconomic factors, sex, and mortality may provide important clues to the explanation of inequalities in health.

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.

Mortality trends and setbacks: global convergence or divergence?

Health trends over much of the past century have been generally, and notably, positive throughout the world. In several regions, however, life expectancy has declined over the past 1-2 decades. This trend suggests that the expectation that emerged in the 1960s and 1970s of worldwide gains and convergence in population health status is not guaranteed by a general deterministic process. National populations can now be clearly grouped into those that have achieved rapid gains in life expectancy; those whose gains are slower or are perhaps plateauing; and those in which the trends have reversed. Over the past two centuries, outside times of war and famine, such reversals have been rare. Exploration of these varied population health trends elucidates better the close relation between population health and the processes of economic, social, and technological change. Such analysis has shown that the health status of human populations should be a guiding criterion in the debate on sustainable development.

Effects of the characteristics of neighbourhoods and the characteristics of people on cause specific mortality: a register based follow up study of 252 000 men

Study objective: To assess the strength of the associations between neighbourhood characteristics and mortality, after adjusting for individual characteristics. Design and setting: 1990 census records of over 25 year old men in the Helsinki Metropolitan area linked to death records in 1991–1995; almost 1.22 million person years and 15 000 deaths. Individual characteristics were education, occupation based social class, housing tenure, housing density, and living arrangements. Proportion of manual workers, proportion of over 60 year olds, and social cohesion were measured for 55 small areas, and SAS Glimmix was used to fit multilevel models. Main results: Men in areas with high proportion of manual workers and low social cohesion have high mortality, particularly among 25–64 year olds. About 70% of this excess mortality is explained by compositional differences of people living in these areas. Accidents and violence, circulatory diseases, and alcohol related causes contribute most to these area effects. Area characteristics do not consistently modify or mediate the effects of individual socioeconomic characteristics on mortality. Conclusions: As compared with individual characteristics neighbourhood characteristics have modest independent effects on male mortality. Furthermore, individual socioeconomic characteristics are associated with mortality independently of area characteristics. Rather than the characteristics of areas, other social contexts, such as peer groups and family settings may be more fruitful targets for further research and policy on contextual effects on mortality.

Mortality after death of spouse in relation to duration of bereavement in Finland.

STUDY OBJECTIVES: (1) To assess the extent to which death of a spouse causes excess mortality by controlling for the effects of confounding and other sources of bias. Three possible sources of bias are considered: accidents common to spouses, common socioeconomic environment, and common lifestyles. (2) To assess the duration specific effects of death of a spouse on mortality. DESIGN AND SETTING: Prospective study of mortality in Finland among all 35-84 year old married Finnish men and women (1,580,000 people). Baseline sociodemographic measurement from the 1985 census records. Follow up by computerised record linkage to death certificate registers for the period 1986-91 (about 116,000 deaths, of which almost 10,000 among the bereaved) using personal identification codes. RESULTS: (1) After controlling for confounding effects, excess mortality was 17% in men and 6% in women. (2) Excess mortality was higher for short durations than long durations of bereavement. (3) Excess mortality after bereavement was higher in men than women. CONCLUSIONS: Controlling for confounding does not seem to have a crucial modifying effect on the relationship between spousal bereavement and mortality. It seems that death of a spouse has a causal effect on mortality. However, although spousal bereavement is a major stressful life event, this causal effect seems to be relatively small and short lived.

Occupational class and ischemic heart disease mortality in the United States and 11 European countries.

OBJECTIVES Twelve countries were compared with respect to occupational class differences in ischemic heart disease mortality in order to identify factors that are associated with smaller or larger mortality differences. METHODS Data on mortality by occupational class among men aged 30 to 64 years were obtained from national longitudinal or cross-sectional studies for the 1980s. A common occupational class scheme was applied to most countries. Potential effects of the main data problems were evaluated quantitatively. RESULTS A north-south contrast existed within Europe. In England and Wales, Ireland, and Nordic countries, manual classes had higher mortality rates than nonmanual classes. In France, Switzerland, and Mediterranean countries, manual classes had mortality rates as low as, or lower than, those among nonmanual classes. Compared with Northern Europe, mortality differences in the United States were smaller (among men aged 30-44 years) or about as large (among men aged 45-64 years). CONCLUSIONS The results underline the highly variable nature of socioeconomic inequalities in ischemic heart disease mortality. These inequalities appear to be highly sensitive to social gradients in behavioral risk factors. These risk factor gradients are determined by cultural as well as socioeconomic developments.

Change in male and female life expectancy by social class: decomposition by age and cause of death in Finland 1971–95

STUDY OBJECTIVE To quantify the contribution of different causes of death and age groups for trends in life expectancy for two major social classes. DESIGN AND SETTING Prospective study of mortality in Finland among all over 35 year old men and women. Baseline social class (manual/non-manual) was from the 1970, 1975, 1980, 1985 and 1990 census records, and follow up was by computerised record linkage to death certificates for 1971–1995. MAIN RESULTS From the early 1970s to the early 1990s life expectancy at age 35 increased by about five and four years among Finnish men and women respectively, with largest gains among 55–74 year old men and 65–84 year old women. Life expectancy increase was 5.1 years among non-manual and 3.8 years among manual men; corresponding figures for women were 3.6 and 3.0 years. In the 1980s, when differences in life expectancy increased most rapidly, decline in cardiovascular disease mortality was more rapid in the non-manual than the manual class. Furthermore, increasing mortality for alcohol associated causes, “other diseases”, and accidents and violence were most prominent in the manual class. CONCLUSIONS Explanations of increasing social inequalities in mortality that are based on one underlying factor are difficult to reconcile with the variability in the cause specific trends in social inequalities in mortality. The contribution of older ages to social inequalities in mortality should be more widely recognised.

Health expectancy by level of education in Finland

Using the method first presented by Sullivan, the article presents results on health expectancy by level of education and gender in the late 1980s in Finland. The life tables by level of education cover the years 1986-90. Indicators of disability and poor health were based on three variables from the nationwide 1986 Survey on Living Conditions (N = 12,057): limiting long-standing illness, functional disability or poor self-perceived health. Two cutting points indicating different levels of severity of disability or poor health were used for each measure, giving six dichotomous indicators. Disability-free life expectancy and life expectancy with disability were found to depend strongly on the indicator of disability, but the patterns of differences both between genders and between educational categories were largely independent of the indicators used. Life expectancy as well as disability-free life expectancy showed a systematic relationship with level of education: the higher the level of education, the higher the life expectancy and disability-free life expectancy. The differences between educational categories in disability-free life expectancy were markedly larger than in total life expectancy. Life expectancy with disability was shortest among the more educated and longest among the less educated. Due to the higher life expectancy and the higher prevalence of disability among women, life expectancy with disability was longer among women than men according to all indicators.