Kunst, A.E.

A cross-national comparative study of metabolic syndrome among non-diabetic Dutch and English ethnic groups (Article)

2013-01-01T00:00:00Z

Background: Evidence suggests a higher prevalence of type 2 diabetes (T2D) in The Netherlands than in England, although generalized obesity prevalence is substantially lower in The Netherlands. Metabolic syndrome (MS) is more strongly associated with the risk of progression to T2D than generalized obesity. Therefore examining MS may help to better understand the differences in T2D between the two countries. We assessed whether the Dutch and English differences in T2D prevalence reflect similar differences in MS in Whites, South-Asian Indians and African-Caribbeans living in these two countries. Methods: Secondary analyses of population-based studies of 3010 participants aged 35–60 years. Metabolic syndrome was defined according to the International Diabetes Federation criteria. Prevalence ratios (PRs) were estimated using regression models. Results: In general, the Dutch ethnic groups had a higher prevalence of MS than their English counterparts. Adjusted PRs were 1.37[95% confidence interval (CI)1.03–1.82] and 1.52 (1.06–2.19) in White-Dutch men and women compared to White-English men and women; 2.20 (1.14–4.26) and 1.46 (0.96–2.24) in Dutch-African-Caribbean men and women compared to English-African-Caribbean men and women and 0.97 (0.74–1.27) and 1.42 (1.00–2.03) in Dutch-Indian men and women compared with their English-Indian peers, respectively. Similar patterns were also observed for some MS components, e.g. raised fasting glucose in men and central obesity in women. Conclusion: The comparatively high prevalence of MS among Dutch ethnic groups may contribute to their high prevalence of T2D. The high levels of some MS components, e.g. raised fasting glucose in men and central obesity in women add to the high prevalence of MS in Dutch ethnic groups.

Small socio-economic differences in mortality in Spanish older people (Article)

2012-02-01T00:00:00Z

Background: Previous studies found smaller mortality inequalities in Southern Europe than in other European populations. This study used a sample of older Spanish adults to identify possible factors explaining these findings. Methods: A cohort of 4008 persons aged 60 years was selected in 2000-01 and followed prospectively until 2008. At baseline, data were collected on education, occupation and major mortality risk factors: social network, lifestyles, diet, obesity and hypertension. Analyses were conducted with Cox regression, and adjusted for the risk factors at baseline. Results: The hazard ratio (HR) and 95% confidence interval (95% CI) for mortality adjusted for age, marital status, region and place of residence in people with low vs. high educational level was 1.13 (0.86-1.50) in men and 1.23 (0.83-1.80) in women. The HR in the manual vs. non-manual occupational class was 0.92 (0.74-1.15) in men and 1.07 (0.86-1.33) in women. Adjustment for the different risk factors decreased or did not change the HR. After full adjustment for all risk factors the mortality HR in those with low education was 0.99 (0.74-1.32) in men and 1.18 (0.80-1.76) in women, while the mortality HR in the manual occupational class was 0.85 (0.68-1.06) in men and 1.04 (0.83-1.30) in women. Conclusions: From a European perspective, mortality inequalities in Spanish older adults are small. The ubiquitous presence of social networks and the widespread adherence to the Mediterranean diet may be responsible for this finding.

Educational inequalities in blood pressure and cholesterol screening in nine European countries (Article)

2012-01-12T00:00:00Z

Background: To perform the first European overview of educational inequalities in the use of blood pressure and cholesterol screening. Methods: Data were obtained on the use of screening services according to educational level from nationally representative cross-sectional surveys in Belgium, Czech Republic, Denmark, Estonia, Finland, Hungary, Italy, Latvia and Lithuania. Screening rates were examined in the preceding 12 months and 5 years, for respondents 35+ years (45+ for women). ORs comparing low- to high-educated respondents were estimated using logistic regression controlling for age. Results: Inequalities in cholesterol screening favouring higher socioeconomic groups were demonstrated with statistical significance among men in four countries, whereby men with higher education were more likely to receive screening, with 1.22 as the highest OR. Among women, a similar pattern was found. Inequalities in blood pressure screening were even smaller and less often statistically significant. Hungary was the only country with higher rates of both types of screening in the low-educated group. In other countries, pro-high inequalities were slightly increased after controlling for self-rated health. Conclusions: All European countries in this study had small educational inequalities in the utilisation of blood pressure and cholesterol screening. These inequalities are smaller than those previously observed in the USA. Further comparative studies need to distinguish between screening for preventive purposes and screening for treatment and control. Copyright Article author (or their employer) 2012.

More variation in lifespan in lower educated groups: Evidence from 10 European countries (Article)

2011-12-01T00:00:00Z

Background Whereas it is well established that people with a lower socio-economic position have a shorter average lifespan, it is less clear what the variability surrounding these averages is. We set out to examine whether lower educated groups face greater variation in lifespans in addition to having a shorter life expectancy, in order to identify entry points for policies to reduce the impact of socio-economic position on mortality. Methods: We used harmonized, census-based mortality data from 10 European countries to construct life tables by sex and educational level (low, medium, high). Variation in lifespan was measured by the standard deviation conditional upon survival to age 35 years. We also decomposed differences between educational groups in lifespan variation by age and cause of death. Results: Lifespan variation was higher among the lower educated in every country, but more so among men and in Eastern Europe. Although there was an inverse relationship between average life expectancy and its standard deviation, the first did not completely predict the latter. Greater lifespan variation in lower educated groups was largely driven by conditions causing death at younger ages, such as injuries and neoplasms. Conclusions: Lower educated individuals not only have shorter life expectancies, but also face greater uncertainty about the age at which they will die. More priority should be given to efforts to reduce the risk of an early death among the lower educated, e.g. by strengthening protective policies within and outside the health-care system.

Inequalities in utilisation of general practitioner and specialist services in 9 European countries (Article)

2011-11-01T00:00:00Z

Background: The aim of this study is to describe the magnitude of educational inequalities in utilisation of general practitioner (GP) and specialist services in 9 European countries. In addition to West European countries, we have included 3 Eastern European countries: Hungary, Estonia and Latvia. To cover the gap in knowledge we pay a special attention to the magnitude of inequalities among patients with chronic conditions. Methods. Data on the use of GP and specialist services were derived from national health surveys of Belgium, Estonia, France, Germany, Hungary, Ireland, Latvia, the Netherlands and Norway. For each country and education level we calculated the absolute prevalence and relative inequalities in utilisation of GP and specialist services. In order to account for the need for care, the results were adjusted by the measure of self-assessed health. Results: People with lower education used GP services equally often in most countries (except Belgium and Germany) compared with those with a higher level of education. At the same time people with a higher education used specialist care services significantly more often in all countries, except in the Netherlands. The general pattern of educational inequalities in utilisation of specialist care was similar for both men and women. Inequalities in utilisation of specialist care were equally large in Eastern European and in Western European countries, except for Latvia where the inequalities were somewhat larger. Similarly, large inequalities were found in the utilisation of specialist care among patients with chronic diseases, diabetes, and hypertension. Conclusions: We found large inequalities in the utilisation of specialist care. These inequalities were not compensated by utilisation of GP services. Of particular concern is the presence of inequalities among patients with a high need for specialist care, such as those with chronic diseases.

The decline in ischaemic heart disease mortality in seven European countries: Exploration of future trends (Article)

2011-08-01T00:00:00Z

Background To assess the implication of a possible continuation of the decline in ischaemic heart disease (IHD) mortality in the future. Methods Annual rates of decline in IHD mortality from 1980-2005 were determined for the national populations of the Netherlands, UK, France and four Nordic countries through regression analysis and used to extrapolate mortality rates until 2030. Through cause-elimination life tables we determined the impact of IHD on life expectancy at birth. Results In all countries, IHD mortality rates among both sexes declined incessantly until 2005. Age-adjusted mortality rates would have declined by about 50% in 2030 compared to 2005 if past trends were to continue. The impact of IHD on life expectancy at birth would decline by about 25-50% in most populations. The absolute numbers of IHD deaths would decline slowly or even increase in some countries mainly because of population ageing. Conclusions If current IHD mortality trends continued, IHD would lose much of its importance as a cause of premature death in the near future. As the incidence and disabling impact of IHD might decline much less, prevention of IHD-related disability instead of mortality may become increasingly important in the future.

The decline in stroke mortality: Exploration of future trends in 7 Western European Countries (Article)

2011-08-01T00:00:00Z

Background and Purpose-This article aims to make projections of future trends in stroke mortality in the Year 2030 based on recent trends in stroke mortality in 7 Western European countries. Methods-Mortality data were obtained from national cause of death registries. Annual rates of decline in stroke mortality of 1980 to 2005 were determined for men and women in the United Kingdom, France, the Netherlands, and 4 Nordic countries on the basis of regression analysis. Estimated rates of decline were extrapolated until 2030. Cause-elimination life tables were used to determine the effect of stroke in 2030 in terms of potential gain in life expectancy. The absolute numbers of stroke deaths in 2030 were estimated using national population projections of Eurostat. Results-In all countries, stroke mortality rates declined incessantly until 2005 among both men and women. If these trends were to continue, age-adjusted mortality rates would decline by approximately half between 2005 and 2030 with larger declines in France (approximately two thirds) and smaller declines in the Netherlands, Denmark, and Sweden (approximately one fourth). Similar rates of decline would be observed in terms of potential gain in life expectancy. Because of population aging, the absolute number of stroke deaths would decline slowly in the United Kingdom and France and stabilize or even increase in other countries. Conclusions-In the near future, stroke may lose much of its effects on life expectancy but remain a frequent cause of death among elderly populations. The prevention of stroke-related disability instead of mortality may become increasingly more important.

Life expectancy and life expectancy with disability of normal weight, overweight, and obese smokers and nonsmokers in Europe (Article)

2011-07-01T00:00:00Z

The goal of this study was to estimate life expectancy (LE) and LE with disability (LwD) among normal weight, overweight, and obese smokers and nonsmokers in Western Europe. Data from four waves (1998-2001) of the European Community Household Panel (ECHP) were used; a standardized multipurpose annual longitudinal survey. Self-reported health and socioeconomic information was collected repeatedly using uniform questionnaires for 66,331 individuals in nine countries. Health status was measured in terms of disability in daily activities. Multistate Markov (MSM) models were applied to obtain hazard ratios (HRs) and age-specific transition rates according to BMI and smoking status. Multistate life tables were computed using the predicted transition probabilities to estimate LE and LwD. Significant associations were observed between disability incidence and BMI (HR = 1.15 for overweight, HR = 1.64 for obese, compared to normal weight). The risk of mortality was negatively associated with overweight status among disabled (HR = 0.77). Overweight people had higher LE than people with normal-weight and obesity. Among women, overweight and obese nonsmokers expect 3.6 and 6.1 more years of LwD than normal weight persons, respectively. In contrast, daily smokers expect lower LE but a similar LwD. The same patterns were observed among people with high education and those with low education. To conclude, daily smoking is associated with mortality more than with disability, whereas obesity is associated with disability more than with mortality. The findings suggest that further tobacco control would contribute to increasing LE, while tackling the obesity epidemic is necessary to prevent an expansion of disability.

Diabetes prevalence in populations of South Asian Indian and African origins: A comparison of england and the Netherlands (Article)

2011-07-01T00:00:00Z

Background: We determined whether the overall lower prevalence of type II diabetes in England versus the Netherlands is observed in South-Asian-Indian and African-Caribbean populations. Additionally, we assessed the contribution of health behavior, body size, and socioeconomic position to observed differences between countries. Methods: Secondary analyses of population-based standardized individual-level data of 3386 participants were conducted. Results: Indian and African-Caribbean populations had higher prevalence rates of diabetes than whites in both countries. In crosscountry comparisons (and similar to whites), Indians residing in England had a lower prevalence of diabetes than those residing in the Netherlands; the prevalence ratio (PR) was 0.35 (95% confidence interval = 0.22 to 0.55) in women and 0.74 (0.50 to 1.10) in men after adjustment for other covariates. Among people of African descent as well, diabetes prevalence was lower in England than in the Netherlands; for women, PR = 0.43 (0.20 to 0.89) and for men, 0.57 (0.21 to 1.49). Conclusions: The increasing prevalence of diabetes after migration may be modified by the context in which ethnic minority groups live.

Obesity, smoking, alcohol consumption and years lived with disability: A Sullivan life table approach (Article)

2011-05-26T00:00:00Z

Background: To avoid strong declines in the quality of life due to population ageing, and to ensure sustainability of the health care system, reductions in the burden of disability among elderly populations are urgently needed. Life style interventions may help to reduce the years lived with one or more disabilities, but it is not fully understood which life style factor has the largest potential for such reductions. Therefore, the primary aim of this paper is to compare the effect of BMI, smoking and alcohol consumption on life expectancy with disability, using the Sullivan life table method. A secondary aim is to assess potential improvement of the Sullivan method by using information on the association of disability with time to death. Methods. Data from the Dutch Permanent Survey of the Living Situation (POLS) 1997-1999 with mortality follow-up until 2006 (n = 6,446) were used. Using estimated relative mortality risks by risk factor exposure, separate life tables were constructed for groups defined in terms of BMI, smoking status and alcohol consumption. Logistic regression models were fitted to predict the prevalence of ADL and mobility disabilities in relationship to age and risk factor exposure. Using the Sullivan method, predicted age-specific prevalence rates were included in the life table to calculate years lived with disability at age 55. In further analysis we assessed whether adding information on time to death in both the regression models and the life table estimates would lead to substantive changes in the results. Results: Life expectancy at age 55 differed by 1.4 years among groups defined in terms of BMI, 4.0 years by smoking status, and 3.0 years by alcohol consumption. Years lived with disability differed by 2.8 years according to BMI, 0.2 years by smoking and 1.6 by alcohol consumption. Obese persons could expect to live more years with disability (5.9 years) than smokers (3.8 years) and drinkers (3.1 years). Employing information on time to death led to lower estimates of years lived with disability, and to smaller differences in these years according to BMI (2.1 years), alcohol (1.2 years), and smoking (0.1 years). Conclusions: Compared with smoking and drinking alcohol, obesity is most strongly associated with an increased risk of spending many years of life with disability. Although employing information on the relation of disability with time to death improves the precision of Sullivan life table estimates, the relative importance of risk factors remained unchanged.

Economic costs of health inequalities in the European Union (Article)

2011-05-01T00:00:00Z

Background: In order to support the case for inter-sectoral policies to tackle health inequalities, the authors explored the economic costs of socioeconomic inequalities in health in the European Union (EU). Methods: Using recent data on inequalities in selfassessed health and mortality covering most of the EU, health losses due to socioeconomic inequalities in health were calculated by applying a counterfactual scenario in which the health of those with lower secondary education or lower (roughly 50% of the population) would be improved to the average level of health of those with at least higher secondary education. We then calculated various economic effects of those health losses: healthcare costs, costs of social security schemes, losses to Gross Domestic Product (GDP) through reduced labour productivity and the monetary value of total losses in welfare. Results: Inequality related losses to health amount to more than 700 000 deaths per year and 33 million prevalent cases of ill health in the EU as a whole. These losses account for 20% of the total costs of healthcare and 15% of the total costs of social security benefits. Inequality related losses to health reduce labour productivity and take 1.4% off GDP each year. The monetary value of health inequality related welfare losses is estimated to be €980 billion per year or 9.4% of GDP. Conclusion Our results suggest that the economic costs of socioeconomic inequalities in health in Europe are substantial. As this is a first attempt at quantifying the economic implications of health inequalities, the estimates are surrounded by considerable uncertainty and further research is needed to reduce this. If our results are confirmed in further studies, the economic implications of health inequalities warrant significant investments in policies and interventions to reduce them.

Future disability projections could be improved by connecting to the theory of a dynamic equilibrium (Article)

2011-04-01T00:00:00Z

Objective: Projections of future trends in the burden of disability could be guided by models linking disability to life expectancy, such as the dynamic equilibrium theory. This article tests the key assumption of this theory that severe disability is associated with proximity to death, whereas mild disability is not. Study Design and Setting: Using data from the GLOBE study (Gezondheid en Levensomstandigheden Bevolking Eindhoven en omstreken), the association of three levels of self-reported disabilities in activities of daily living with age and proximity to death was studied using logistic regression models. Regression estimates were used to estimate the number of life years with disability for life spans of 75 and 85 years. Results: Odds ratios of 0.976 (not significant) for mild disability, 1.137 for moderate disability, and 1.231 for severe disability showed a stronger effect of proximity to death for more severe levels of disability. A 10-year increase of life span was estimated to result in a substantial expansion of mild disability (4.6 years) compared with a small expansion of moderate (0.7 years) and severe (0.9 years) disability. Conclusion: These findings support the theory of a dynamic equilibrium. Projections of the future burden of disability could be substantially improved by connecting to this theory and incorporating information on proximity to death.

Reducing inequalities in lung cancer incidence through smoking policies (Article)

2011-02-17T00:00:00Z

Introduction: Lower social class has higher lung cancer incidence, largely attributable to higher smoking prevalence among the lower social classes. We assessed the magnitude and time dimension of potential impact of targeted interventions on smoking on socioeconomic inequalities in lung cancer. Methods: Using population dynamic modelling, we projected lung cancer incidence up to 2050 in lowest and highest socioeconomic groups under two intervention scenarios (annual 10% increase in cigarette prices and health advertisement) and compared this to a scenario of no intervention. For the analysis we retrieved smoking prevalence data from the General Household Survey of England and Wales between 1980 and 2006 and cancer incidence data from the national cancer registry. Results: By 2050, the model projected that lung cancer incidence inequality would almost double (Incidence Rate Ratio (IRR) = 4.2 in 2050 vs. 2.5 in 2005) in men and slightly decrease (IRR = 2.4 in 2050 vs. 2.7 in 2005) in women compared to what was observed in 2005. If annual increase in cigarette price targeting the lowest socioeconomic group was implemented, socioeconomic inequality in lung cancer incidence in 2050 might be largely reduced (IRR = 1.5 and 1.4 among men and women, respectively). If in addition to annual price increase (targeted to the lowest socioeconomic group) health advertisement was implemented and successfully reduced smoking prevalence in the highest socioeconomic group, the lung cancer gap between the socioeconomic groups would be reduced by 78% and 58% in men and women by 2050. Conclusion: Even under the best scenarios, inequality in lung cancer was not fully eliminated within 45 years period. Though the process is lengthy, rigorous interventions may reduce the expected widening of the future inequalities in lung cancer. Modelling exercise such as ours relies heavily on the quality of the input data and the assumptions, thus caution is needed in interpretation of our findings and should consider all the assumptions taken in the analysis.

Dutch versus English advantage in the epidemic of central and generalised obesity is not shared by ethnic minority groups: comparative secondary analysis of cross-sectional data (Article)

2011-02-15T00:00:00Z

Background:Ethnic minority groups in Western European countries tend to have higher levels of overweight than the majority populations for reasons that are poorly understood. Investigating relative differences between countries could enable an investigation of the importance of national context in determining these inequalities. Objective:To explore: (1) whether Indian and African origin populations in England and the Netherlands are similarly disadvantaged compared with the White populations in terms of the prevalence of overweight and central obesity; (2) whether the previously known Dutch advantage of relatively low overweight prevalence is also observed in Dutch ethnic minority groups and (3) the contribution of health behaviour and socio-economic position to the differences observed. Methods:Secondary analyses of population-based studies of 16 406 participants from England and the Netherlands. Prevalence ratios were estimated using regression models. Results:Except for African men, ethnic minority groups in both countries had higher rates of overweight and central obesity than their White counterparts. However, the Dutch minority groups were relatively more disadvantaged than English minority groups as compared with the majority populations. The Dutch advantage of the low prevalence of obesity was only seen in White men and women and African men. In contrast, English-Indian (prevalence ratio=0.87, 95% confidence interval (CI): 0.81-0.93) and English-Caribbean (prevalence ratio=0.82, 95% CI: 0.76-0.89) women were less centrally obese than their Dutch equivalents. The Dutch-Indian men were very similar to the English-Indian men. The contribution of health behaviour and socio-economic position to the observed differences were small. Conclusion:Contrary to the patterns in White groups, the Dutch ethnic minority women were more obese than their English equivalents. More work is needed to identify factors that may contribute to these observed differences.International Journal of Obesity advance online publication, 15 February 2011; doi:10.1038/ijo.2010.281.

Is income or employment a stronger predictor of smoking than education in economically less developed countries? A cross-sectional study in Hungary (Article)

2011-02-15T00:00:00Z

Background: In developed European countries in the last phase of the smoking epidemic, education is a stronger predictor of smoking than income or employment. We examine whether this also applies in economically less developed countries. Methods. Data from 7218 respondents in the 25-64 age group came from two National Health Interview Surveys conducted in 2000 and 2003 in Hungary. Independent effects of educational level, income and employment status were studied in relation to smoking prevalence, initiation and continuation for all age groups combined and separately for 25-34, 35-49 and 50-64 years old. Absolute levels were evaluated by using age-standardized prevalence rates. Relative differences were assessed by means of logistic regression. Results: Education and income, but not employment, were associated with equally large differences in smoking prevalence in Hungary in the 25-64 age group. Among men, smoking initiation was related to low educational level, whereas smoking continuation was related to low income. Among women, low education and low income were associated with both high initiation and high continuation rates. Considerable differences were found between the age groups. Inverse social gradients were generally strongest in the youngest age groups. However, smoking continuation among men had the strongest association with low income for the middle-aged group. Conclusions: Patterns of inequalities in smoking in Hungary can be best understood in relation to two processes: the smoking epidemic, and the additional effects of poverty. Equity orientated tobacco control measures should target the low educated to prevent their smoking initiation, and the poor to improve their cessation rates.

The contribution of risk factors to the higher incidence of invasive and in situ breast cancers in women with higher levels of education in the European prospective investigation into cancer and nutrition (Article)

2011-01-01T00:00:00Z

The authors investigated the role of known risk factors in educational differences in breast cancer incidence. Analyses were based on the European Prospective Investigation Into Cancer and Nutrition and included 242,095 women, 433 cases of in situ breast cancer, and 4,469 cases of invasive breast cancer. Reproductive history (age at first full-term pregnancy and parity), exposure to endogenous and exogenous hormones, height, and health behaviors were accounted for in the analyses. Relative indices of inequality (RII) for education were estimated using Cox regression models. A higher risk of invasive breast cancer was found among women with higher levels of education (RII = 1.22, 95% confidence interval (CI): 1.09, 1.37). This association was not observed among nulliparous women (RII = 1.13, 95% CI: 0.84, 1.52). Inequalities in breast cancer incidence decreased substantially after adjusting for reproductive history (RII = 1.11, 95% CI: 0.98, 1.25), with most of the association being explained by age at first full-term pregnancy. Each other risk factor explained a small additional part of the inequalities in breast cancer incidence. Height accounted for most of the remaining differences in incidence. After adjusting for all known risk factors, the authors found no association between education level and risk of invasive breast cancer. Inequalities in incidence were more pronounced for in situ breast cancer, and those inequalities remained after adjustment for all known risk factors (RII = 1.61, 95% CI: 1.07, 2.41), especially among nulliparous women.

Socioeconomic inequalities in life and health expectancies around official retirement age in 10 Western-European countries (Article)

2010-11-23T00:00:00Z

Background: Discussions on raising pension eligibility age focus more on improvement in life expectancy (LE) and health expectancy measures than on socioeconomic differences in these measures. Therefore, this study assesses the level of socioeconomic differences in these two measures in Western-Europe. Methods: Data from seven annual waves (1995-2001) of the European Community Household Panel were used. Health and socioeconomic information was collected using standardised questionnaires. Health was measured in terms of disability in daily activities. Socioeconomic status was determined as education level at baseline. Multi-state Markov modelling was applied to obtain age-specific transition rates between health states for every country, educational level and gender. The multi-state life table method was used to estimate LE and disability free life expectancy (DFLE) according to country, educational level and gender. Results: When comparing high and low educational levels, differences in partial DFLE between the ages 50 and 65 years were 2.1 years for men and 1.9 years for women. At age 65 years, for LE the difference between high and low educated groups was 3 years for men and 1.9 years for women, and for DFLE the difference between high and low educated groups was 4.6 years for men and 4.4 years for women. Similar patterns were observed in all countries, although inequalities tended to be greater in the southern countries. Conclusions: Educational inequalities, favouring the higher educated, exist on both sides of the retirement eligibility age. Higher educated persons live longer in good health before retirement and can expect to live longer afterwards.

The decline in stomach cancer mortality: exploration of future trends in seven European countries (Article)

2010-11-18T00:00:00Z

Mortality from stomach cancer has fallen steadily during the past decades. The aim of this paper is to assess the implication of a possible continuation of the decline in stomach cancer mortality until the year 2030. Annual rates of decline in stomach cancer mortality from 1980 to 2005 were determined for the Netherlands, United Kingdom, France, and four Nordic countries on the basis of regression analysis. Mortality rates were extrapolated until 2030, assuming the same rate of decline as in the past, using three possible scenarios. The absolute numbers of deaths were projected taking into account data on the ageing of national populations. Stomach cancer mortality rates declined between 1980 and 2005 at about the same rate (3.6–4.9% per year) for both men and women in all countries. The rate of decline did not level off in recent years, and it was not smaller in countries with lower overall mortality rates in 1980. If this decline were to continue into the future, stomach cancer mortality rates would decline with about 66% between 2005 and 2030 in most populations, while the absolute number of stomach cancer deaths would diminish by about 50%. Thus, in view of the strong, stable and consistent mortality declines in recent decades, and despite population ageing, stomach cancer is likely to become far less important as a cause of death in Europe in the future.

Educational inequalities in avoidable mortality in Europe (Article)

2010-10-01T00:00:00Z

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 30e64 years. Foreach 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 contributionof 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 conditionsthat 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 intheSouthern 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 LifeExpectancy between higher and lower educated groups.Infectious diseases and cardiorespiratory conditions were the main contributors to this difference. Conclusions Inequalities in avoidable mortality werepresent in all European countries, but were especially pronounced inCEE and Baltic countries. Theseeducational inequalities point to an important role for healthcare services in reducing inequalities in health.

Socioeconomic status and changing inequalities in colorectal cancer? A review of the associations with risk, treatment and outcome (Article)

2010-10-01T00:00:00Z

Background: Upcoming mass screening for colorectal cancer (CRC) makes a review of recent literature on the association with socioeconomic status (SES) relevant, because of marked and contradictory associations with risk, treatment and outcome. Methods: The Pubmed database using the MeSH terms 'Neoplasms' or 'Colorectal Neoplasms' and 'Socioeconomic Factors' for articles added between 1995 and 1st October 2009 led to 62 articles. Results: Low SES groups exhibited a higher incidence compared with high SES groups in the US and Canada (range risk ratio (RR) 1.0-1.5), but mostly lower in Europe (RR 0.3-0.9). Treatment, survival and mortality all showed less favourable results for people with a lower socioeconomic status: Patients with a low SES received less often (neo)adjuvant therapy (RR ranging from 0.4 to 0.99), had worse survival rates (hazard ratio (HR) 1.3-1.8) and exhibited generally the highest mortality rates up to 1.6 for colon cancer in Europe and up to 3.1 for rectal cancer. Conclusions: A quite consistent trend was observed favouring individuals with a high SES compared to those with a low SES that still remains in terms of treatment, survival and thus also mortality. We did not find evidence that the low/high SES gradients for treatment chosen and outcome are decreasing. To meet increasing inequalities in mortality from CRC in Europe for people with a low SES and to make mass screening successful, a high participation rate needs to be realised of low SES people in the soon starting screening program.

Scenarios of future lung cancer incidence by educational level: Modelling study in Denmark (Article)

2010-09-01T00:00:00Z

Objective: To model future trends in lung cancer incidence in Denmark by education under different scenarios for cigarette smoking. Methods: Lung cancer incidence until 2050 was modelled using Prevent software. We estimated lung cancer incidence under a baseline scenario and under four alternative scenarios for smoking reduction: decreasing initiation rates among the young, increasing cessation rates among smokers, a scenario combining both changes and a levelling-up scenario in which people with low and medium levels of education acquired the smoking prevalence of the highly educated. Danish National Health Interview Surveys (1987-2005) and cancer registry data combined with individual education status from Statistics Denmark were used for empirical input. Results: Under the baseline scenario, lung cancer rates are expected to decrease for most educational groups during the next few decades, but educational inequalities will increase further. Under the alternative scenarios, an additional decrease in lung cancer rates will be observed from 2030 onwards, but only from 2050 onwards it will be observed under the initiation scenario. The cessation and the combined scenarios show the largest decrease in lung cancer rates for all educational groups. However, in none of these scenarios would the relative differences between educational groups be reduced. A modest decrease in these inequalities will be observed under the levelling-up scenario. Discussion: Our analyses show that relative inequalities in lung cancer incidence rates will tend to increase. They may be reduced to a small extent if the smoking prevalence of people with a low level of education was to converge towards those more highly educated people. An important decrease in lung cancer rates will be observed in all educational groups, however, especially when focusing on both initiation and cessation strategies.

A systematic review of studies on socioeconomic inequalities in dietary intakes associated with weight gain and overweight/obesity conducted among European adults (Article)

2010-06-01T00:00:00Z

This Review examined socioeconomic inequalities in intakes of dietary factors associated with weight gain, overweight/obesity among adults in Europe. Literature searches of studies published between 1990 and 2007 examining socioeconomic position (SEP) and the consumption of energy, fat, fibre, fruit, vegetables, energy-rich drinks and meal patterns were conducted. Forty-seven articles met the inclusion criteria. The direction of associations between SEP and energy intakes were inconsistent. Approximately half the associations examined between SEP and fat intakes showed higher total fat intakes among socioeconomically disadvantaged groups. There was some evidence that these groups consume a diet lower in fibre. The most consistent evidence of dietary inequalities was for fruit and vegetable consumption; lower socioeconomic groups were less likely to consume fruit and vegetables. Differences in energy, fat and fibre intakes (when found) were small-to-moderate in magnitude; however, differences were moderate-to-large for fruit and vegetable intakes. Socioeconomic inequalities in the consumption of energy-rich drinks and meal patterns were relatively under-studied compared with other dietary factors. There were no regional or gender differences in the direction and magnitude of the inequalities in the dietary factors examined. The findings suggest that dietary behaviours may contribute to socioeconomic inequalities in overweight/obesity in Europe. However, there is only consistent evidence that fruit and vegetables may make an important contribution to inequalities in weight status across European regions.

Occupational exposures contribute to educational inequalities in lung cancer incidence among men: Evidence from the EPIC prospective cohort study (Article)

2010-04-15T00:00:00Z

The aim of this study is to investigate to what extent occupational exposures may explain socioeconomic inequalities in lung cancer incidence after adjusting for smoking and dietary factors. Analyses were based on a subsampie of the European Prospective Investigation into Cancer and Nutrition (EPIC study), a prospective cohort. The analyses included 703 incident lung cancer cases among men in Denmark, the United Kingdom, Germany, Italy, Spain and Greece. The socioeconomic position was measured using the highest level of education. The estimates of relative indices of inequality (Ril) were computed with Cox regression models. We first adjusted for smoking (with detailed information on duration and quantity) and dietary factors (fruits and vegetables consumption) and then for occupational exposures. The exposure to three carcinogens [asbestos, heavy metals and polycyclic aromatic hydrocarbons (PAH)] was analyzed. The occupational exposures explained 14% of the socioeconomic inequalities remaining after adjustment for smoking and fruits and vegetables consumption. The inequalities remained nevertheless statistically significant The RII decreased from 1.87 (95% Cl: 1.36-2.56) to 1.75 (1.27-2.41). The decrease was more pronounced when adjusting for asbestos than for heavy metals or PAH. Analyses by birth cohort suggested an effect of occupational exposures among older men, while due to small number of endpoints, no conclusion could be drawn about the role of occupational exposures in educational inequalities among younger men. Our study revealed that the impact of occupational exposures on socioeconomic inequalities in cancer incidence, rarely studied until now, exists while of modest magnitude.

The impact of interventions to improve attendance in female cancer screening among lower socioeconomic groups: A review (Article)

2010-04-01T00:00:00Z

Objective: To review the scientific evidence on the effectiveness of interventions to promote attendance to breast and cervical cancer screening among lower socioeconomic groups. Methods: We performed a computerized literature search looking for relevant papers published between 1997 and 2006. Papers were classified into three groups based on the type of intervention evaluated: (1) implementation of organized population screening programs; (2) different strategies of enhancing attendance within an organized program; (3) local interventions in disadvantaged populations. Results: The available evidence supports the hypothesis that while organized population screening programs are successful in increasing overall participation rates, they may not per se substantially reduce social inequalities. Some strategies were consistently found to enhance access to screening among lower socioeconomic groups, including cost-reducing interventions (e.g. offering free tests and eliminating geographical barriers), a greater involvement of primary-care physicians and individually tailored pro-active communication that addresses barriers to screening. Conclusions: Evidence from studies suggests that the attendance of deprived women to cancer screening can be improved with organized screening programs tailored to their needs. The same may apply to the prevention of adverse outcomes of other health conditions, such as hypertension, hypercholesterolemia, and diabetes.

Answer to the commentary: Politics and public health-some conceptual considerations concerning welfare state characteristics and public health outcomes (Article)

2010-04-01T00:00:00Z

Comparative appraisal of educational inequalities in overweight and obesity among adults in 19 European countries (Article)

2010-04-01T00:00:00Z

Background: In Western societies, a lower educational level is often associated with a higher prevalence of overweight and obesity. However, there may be important international differences in the strength and direction of this relationship, perhaps in respect of differing levels of socio-economic development. We aimed to describe educational inequalities in overweight and obesity across Europe, and to explore the contribution of level of socio-economic development to crossnational differences in educational inequalities in overweight and obese adults in Europe. Methods: Cross-sectional data, based on self-reports, were derived from national health interview surveys from 19 European countries (N=127 018; age range=25-44 years). Height and weight data were used to calculate the body mass index (BMI). Multivariate regression analysis was employed to measure educational inequalities in overweight and obesity, based on BMI. Gross domestic product (GDP) per capita was used as a measure of level of socio-economic development. Results: Inverse educational gradients in overweight and obesity (i.e. higher education, less overweight and obesity) are a generalized phenomenon among European men and even more so among women. Baltic and eastern European men were the exceptions, with weak positive associations between education and overweight and obesity. Educational inequalities in overweight and obesity were largest in Mediterranean women. A 10 000-euro increase in GDP was related to a 3% increase in overweight and obesity for low-educated men, but a 4% decrease for high-educated men. No associations with GDP were observed for women. Conclusion: In most European countries, people of lower educational attainment are now most likely to be overweight or obese. An increasing level of socio-economic development was associated with an emergence of inequalities among men, and a persistence of these inequalities among women.

Socio-economic inequalities in childhood mortality in low- and middle-income countries: A review of the international evidence (Article)

2010-03-01T00:00:00Z

Introduction: In low- and middle-income countries (LMICs), the probability of dying in childhood is strongly related to the socio-economic position of the parents or household in which the child is born. This article reviews the evidence on the magnitude of socio-economic inequalities in childhood mortality within LMICs, discusses possible causes and highlights entry points for intervention. Sources of data: Evidence on socio-economic inequalities in childhood mortality in LMICs is mostly based on data from household surveys and demographic surveillance sites. Areas of agreement: Childhood mortality is systematically and considerably higher among lower socio-economic groups within countries. Also most proximate mortality determinants, including malnutrition, exposure to infections, maternal characteristics and health care use show worse levels among more deprived groups. The magnitude of inequality varies between countries and over time, suggesting its amenability to intervention. Reducing inequalities in childhood mortality would substantially contribute to improving population health and reaching the Millennium Development Goals (MDGs). Areas of controversy: The contribution of specific determinants, including national policies, to childhood mortality inequalities remains uncertain. What works to reduce these inequalities, in particular whether policies should be universal or targeted to the poor, is much debated. Areas timely for developing research: The increasing political attention for addressing health inequalities needs to be accompanied by more evidence on the contribution of specific determinants, and on ways to ensure that interventions reach lower socio-economic groups.

Disability occurrence and proximity to death (Article)

2010-01-01T00:00:00Z

Purpose: This paper aims to assess whether disability occurrence is related more strongly to proximity to death than to age. Method: Self reported disability and vital status were available from six annual waves and a subsequent 12-year mortality follow-up of the Dutch GLOBE longitudinal study. Logit and Poisson regression methods were used to study associations of disability occurrence with age and with proximity to death. Results: For disability in activities of daily living (ADL), regression models with proximity to death had better goodness of fit than models with age. With approaching death, the odds for ADL disability prevalence and incidence rates increased 20.0% and 18.9% per year, whereas severity increased 4.1% per year. For the ages younger than 60, 60-69 and older than 70 years, the odds for ADL disability prevalence increased 6.4%, 16.0% and 23.0% per year. Among subjects with asthma/COPD, heart disease and diabetes increases were 25.1%, 19.5% and 22.72% per year. Functional impairments were more strongly related to age. Conclusions: The strong association of (ADL) disability occurrence with proximity to death implies that a substantial part of the disability burden may shift to older ages with further increases in life expectancy.

Mortality and disability: The effect of overweight and obesity (Article)

2009-12-01T00:00:00Z

Context: Prevalence of obesity is increasing globally. The effect of obesity on mortality and morbidity and its implication on the future prevalence of disability in the older population has not been conclusively analyzed. Objective: To determine the influence of overweight and obesity on mortality and disability by quantifying the effect in terms of disability-free life expectancy and years lost to disability (YLD) in the older people.Design, Setting and Participants: For 5980 participants from the Rotterdam Study cohort, regression techniques were used to estimate the association of body mass index (BMI) and waist circumference (WC) separately with mortality, incident disability and recovery from disability. Disability was assessed using the Stanford Health Assessment Questionnaire Disability Index, an activity of daily living scale. Multistate life table methodology was used to calculate life expectancies. Main Outcome Measures: In total, 15-year mortality risk, 6-year disability incidence, total life expectancy, healthy life expectancy and years of disabled life expectancy. Results: We observed 2388 deaths. Our analysis revealed no association between body mass index, or WC and mortality in the healthy population. Body mass index and WC were related to disability (overweight 25 ≤BMI<30, odd ratio (OR)=1.33, 95% confidence interval (CI) (1.10; 1.61), obesity I 30≤BMI <35, OR=2.03, 95% CI (1.55; 2.65)) and negatively to recovery from disability. We observed an increase of years lost to disability with increasing weight for men (normal weight-4.69 years, 'overweight'-5.87 years and 'obesity I'-7.06 years) and for women ('normal weight'-10.95 years, 'overweight'-12.82 years, 'obesity I'-15.17 years and obesity II/III'-13.13 years).Conclusion:Results do not support the hypothesis that an increased body weight reduces total life expectancy in the older people. Although increased body weight was associated with a higher risk of becoming and remaining disabled. These results remained using WC.

Educational inequalities in smoking cessation trends in Italy, 1982-2002 (Article)

2009-10-01T00:00:00Z

Background/aim: Smoking prevalence rates are declining in most industrialised countries, partly because of growing cessation rates. However, little is known on recent time-trends in smoking cessation by socioeconomic position. This study aims to estimate educational inequalities in smoking cessation trends in Italy between 1982 and 2002. Methods: Data were derived from two national health interview surveys carried out in Italy in 1999-2000 (n=34 789) and in 2004-2005 (n =33 135). On the basis of respondents' age at starting and age at quitting smoking, we computed age-standardised smoking cessation rates at ages 20-44 years for subjects who were current smokers between 1982 and 2002. Results: Smoking quit rates were approximately constant at a figure of about 2 per 100 person-years until the period 2000-2002, when they rapidly increased up to 3-4 per 100 person-years. Higher educated smokers constantly showed higher cessation rates than lower educated subjects (rate ratio 1.33; 95% CI 1.25 to 1.41 for men and 1.41; 95% CI 1.30 to 1.53 for women). The relative size of educational difference in smoking cessation did not significantly vary by period. However, in absolute terms, the increase in cessation rates in 2000-2002 was larger among higher educated smokers. Conclusion: Educational inequalities in smoking cessation persisted in both relative and absolute terms. The increase in smoking cessation rates in 2000-2002 suggests that tobacco control policies may have reached more disadvantaged smokers, although smokers of higher socioeconomic groups seem to have benefited the most.

Socio-economic inequalities in suicide: a European comparative study. (Article)

2009-08-17T00:00:00Z

Ethnic differences in unemployment and ill health. (Article)

2009-08-17T00:00:00Z

Objective The aim of the study is to evaluate whether health inequalities associated with unemployment are comparable across different ethnic groups. Method A random sample of inhabitants of the city of Rotterdam filled out a questionnaire on health and its determinants, with a response of 55.4% (n = 2,057). In a cross-sectional design the associations of unemployment, ethnicity, and individual characteristics with a perceived poor health were investigated with logistic regression analysis. The associations of these determinants with physical and mental health, measured by the Short Form 36 Health Survey, were evaluated with linear regression analyses. Interactions between ethnicity and unemployment were investigated to determine whether associations of unemployment and health differed across ethnic groups. Results Ill health was more common among unemployed persons [odds ratio (OR) 2.6; 95% CI 1.7–3.8] than workers in paid employment. Health inequalities between employed and unemployed persons were largest among native Dutch persons (OR = 3.2) and Surinamese/Antillean persons (OR = 2.6), and smaller in Turkish/Moroccan persons (OR = 1.6) and overseas refugees (OR = 1.6). The proportions of persons with poor health that could be attributed to unemployment were 14, 26, 14, and 13%, respectively. Conclusions Differences in ill health between employed and unemployed persons were less profound in ethnic groups compared to the majority population, but the prevalence of unemployment was much higher in ethnic groups. The population attributable fractions varied between 14 and 28%, supporting the argument that policies for health equity should pay more attention to measures that include persons in the labour market and that prevent workers with ill health from dropping out of the workforce.

Female ever-smoking, education, emancipation and economic development in 19 European countries. (Article)

2009-08-17T00:00:00Z

Large differences in ever-smoking rates among women are found between countries and socio-economic groups. This study examined the socio-economic inequalities in female ever-smoking rates in 19 European countries, and explored the association between cross-national differences in these inequalities and economic development and women's emancipation. Data on smoking were derived from national health interview surveys from 19 European countries. For each country, age group (25-39, 40-59 and 60+ years), educational level (4 standard levels), and cumulative ever-smoking rates were calculated as the proportion of current and former smokers of the total survey population. A Relative Index of Inequality was estimated for women in the three age groups to measure the magnitude of educational differences. In regression analyses the association of ever-smoking rates of women age 25-39 years with the gross domestic product (GDP) and the Gender Empowerment Measure (GEM) was explored. Less educated women aged 25-39 years were more likely to have ever smoked than more educated women in all countries, except Portugal. In the age groups 40-59 years the educational pattern differed between countries. Women aged 60+ years who were less educated were less likely to have ever smoked in all countries, except Norway and England. The size of inequalities varied considerably between countries and reversed within three age groups. For women 25-39 years, the association of ever-smoking rates with GDP was positive, especially for more educated women. The association of ever-smoking rates with GEM was positive for less educated women, but negative for more educated women. The results are consistent with the idea that economic development and social-cultural processes related to gender empowerment have affected the diffusion of smoking in different ways for more and less educated women.

Preventing socioeconomic inequalities in health behaviour in adolescents in Europe: background, design and methods of project TEENAGE. (Article)

2009-06-02T00:00:00Z

BACKGROUND: Higher prevalence rates of unhealthy behaviours among lower socioeconomic groups contribute substantially to socioeconomic inequalities in health in adults. Preventing the development of these inequalities in unhealthy behaviours early in life is an important strategy to tackle socioeconomic inequalities in health. Little is known however, about health promotion strategies particularly effective in lower socioeconomic groups in youth. It is the purpose of project TEENAGE to improve knowledge on the prevention of socioeconomic inequalities in physical activity, diet, smoking and alcohol consumption among adolescents in Europe. This paper describes the background, design and methods to be used in the project. METHODS/DESIGN: Through a systematic literature search, existing interventions aimed at promoting physical activity, a healthy diet, preventing the uptake of smoking or alcohol, and evaluated in the general adolescent population in Europe will be identified. Studies in which indicators of socioeconomic position are included will be reanalysed by socioeconomic position. Results of such stratified analyses will be summarised by type of behaviour, across behaviours by type of intervention (health education, environmental interventions and policies) and by setting (individual, household, school, and neighbourhood). In addition, the degree to which effective interventions can be transferred to other European countries will be assessed. DISCUSSION: Although it is sometimes assumed that some health promotion strategies may be particularly effective in higher socioeconomic groups, thereby increasing socioeconomic inequalities in health-related behaviour, there is little knowledge about differential effects of health promotion across socioeconomic groups. Synthesizing stratified analyses of a number of interventions conducted in the general adolescent population may offer an efficient guidance for the development of strategies and interventions to prevent socioeconomic inequalities in health early in life.

Association between forgone care and household income among the elderly in five Western European countries analyses based on survey data from the SHARE-study (Article)

2009-04-16T00:00:00Z

Background. Studies on the association between access to health care and household income have rarely included an assessment of 'forgone care', but this indicator could add to our understanding of the inverse care law. We hypothesize that reporting forgone care is more prevalent in low income groups. Methods. The study is based on the 'Survey of Health, Ageing and Retirement in Europe (SHARE)', focusing on the non-institutionalized population aged 50 years or older. Data are included from France, Germany, Greece, Italy and Sweden. The dependent variable is assessed by the following question: During the last twelve months, did you forgo any types of care because of the costs you would have to pay, or because this care was not available or not easily accessible? The main independent variable is household income, adjusted for household size and split into quintiles, calculating the quintile limits for each country separately. Information on age, sex, self assessed health and chronic disease is included as well. Logistic regression models were used for the multivariate analyses. Results. The overall level of forgone care differs considerably between the five countries (e.g. about 10 percent in Greece and 6 percent in Sweden). Low income groups report forgone care more often than high income groups. This association can also be found in analyses restricted to the subsample of persons with chronic disease. Associations between forgone care and income are particularly strong in Germany and Greece. Taking the example of Germany, forgone care in the lowest income quintile is 1.98 times (95% CI: 1.083.63) as high as in the highest income quintile. Conclusion. Forgone care should be reduced even if it is not justified by an 'objective' need for health care, as it could be an independent stressor in its own right, and as patient satisfaction is a strong predictor of compliance. These efforts should focus on population groups with particularly high prevalence of forgone care, for example on patients with poor self assessed health, on women, and on low income groups. The inter-country differences point to the need to specify different policy recommendations for different countries.

Class-related health inequalities are not larger in the East: a comparison of four European regions using the new European socioeconomic classification (Article)

2009-04-10T00:00:00Z

Background: The article investigates whether people in Eastern Europe have larger health inequalities than their counterparts in three West European regions (North, Central and the South). Methods: Data were obtained for 63 754 individuals in 23 countries from the first (2002) and second (2004) waves of the European Social Survey. The health outcomes were self-reported limiting longstanding illness and fair/poor general health. Occupational class was defined according to the European Socioeconomic Classification (ESeC). The magnitude of absolute and relative inequalities according to nine occupational classes for men and women separately were identified, analysed and compared in all four regions of Europe. Results: For both sexes and within all European regions, the higher and lower professionals, self-employed and higher service workers reported fewer cases of ill health than other occupational classes. In contrast, lower technical and routine workers reported the poorest health, excluding the relatively small number of farmers. Income and education did not explain more, or less, of the class-related health inequalities in the East compared with the other regions. Conclusions: Little evidence was found for the hypothesis that East European countries have larger class-related health inequalities than other European regions. People’s income and educational attainment both contribute to occupational health inequalities in the East as well as in the West.

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

2009-04-10T00:00:00Z

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.

Socioeconomic differences in smoking trends among pregnant women at first antenatal visit in sweden 1982 2001: Increasing importance of educational level for the total burden of smoking (Article)

2009-04-01T00:00:00Z

Background: There was a decrease in smoking during early pregnancy in Swedish women between 1982 and 2001. We sought to determine whether there was a parallel decrease in socioeconomic inequality in smoking. Methods: Registry data indicating educational level and smoking status at first antenatal visit in all 2 022 469 pregnancies in Sweden 1982-2001 were analysed. Prevalence differences, odds ratios based on prevalences and total attributable fractions were compared for five-year intervals. Results: The prevalence differences of smoking showed a greater decrease at the lowest and middle educational level compared with the highest educational level (14.5%, 15.7% and 10.2%, respectively) indicating reduced inequality in absolute terms. However, odds ratios regarding low educational attainment versus high, increased from 5.6 to 14.2, signifying increased inequality in relative terms. Moreover, the total attributable fraction of low and intermediate educational level regarding smoking at first antenatal visit increased from 61% to 76% during the period studied. Conclusions: Smoking at first antenatal visit in Sweden between 1982 to 2001 decreased in a way that conclusions regarding trends in inequalities in smoking at first antenatal visit depend on the type of measure applied. However, using the measure of total attributable fraction, which takes into consideration the impact of the exposure on the individual as well as the effect of the varying size of the group of exposed, the growing importance of educational level for the behaviour in the population was demonstrated.

Socioeconomic inequalities in lung cancer mortality in 16 European populations (Article)

2009-03-01T00:00:00Z

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.

The role of smoking and diet in explaining educational inequalities in lung cancer incidence (Article)

2009-03-01T00:00:00Z

Background: Studies in many countries have reported higher lung cancer incidence and mortality in individuals with lower socioeconomic status. Methods: To investigate the role of smoking in these inequalities, we used data from 391 251 participants in the European Prospective Investigation into Cancer and Nutrition study, a cohort of individuals in 10 European countries. We collected information on smoking (history and quantity), fruit and vegetable consumption, and education through questionnaires at study entry and gathered data on lung cancer incidence for a mean of 8.4 years. Socioeconomic status was defined as the highest attained level of education, and participants were grouped by sex and region of residence (Northern Europe, Germany, or Southern Europe). Relative indices of inequality (RIIs) of lung cancer risk unadjusted and adjusted for smoking were estimated using Cox regression models. Additional analyses were performed by histological type. Results: During the study period, 939 men and 692 women developed lung cancer. Inequalities in lung cancer risk (RIImen= 3.62, 95% confidence interval [CI] = 2.77 to 4.73, 117 vs 52 per 100 000 person-years for lowest vs highest education level; RIIwomen= 2.39, 95% CI = 1.77 to 3.21, 46 vs 25 per 100 000 person-years) decreased after adjustment for smoking but remained statistically significant (RIImen= 2.29, 95% CI = 1.75 to 3.01; RIIwomen= 1.59, 95% CI = 1.18 to 2.13). Large RIIs were observed among men and women in Northern European countries and among men in Germany, but inequalities in lung cancer risk were reverse (RIIs < 1) among women in Southern European countries. Inequalities differed by histological type. Adjustment for smoking reduced inequalities similarly for all histological types and among men and women in all regions. In all analysis, further adjustment for fruit and vegetable consumption did not change the estimates. Conclusion: Self-reported smoking consistently explains approximately 50% of the inequalities in lung cancer risk due to differences in education.

Social inequalities in the use of health care services after 8 years of health care reforms - A comparative study of the Baltic countries (Article)

2009-02-12T00:00:00Z

Objective: In nineties, Estonia, Latvia and Lithuania have implemented a wide range of changes to health systems. The objective of this paper was to assess social inequalities in utilisation of, and access to, health care services in the late nineties. Methods: The comparative NORBALT Survey conducted in 1999 is used. Direct standardization and logistic regression was applied to analyse primary, out-patient and hospital care utilisation, and self reported financial barriers, by socio-demographic and geographical variables. Results: In all three countries social inequalities in utilization were large for out-patient specialist care, smaller or absent with regards to primary care or to hospitalisations. Inequalities were large and consistent in relationship to household income, less so in relationship to educational level. Inequalities in utilization of care were larger in Latvia as well in the self reported barriers to health care in absolute and relative terms were larger. Conclusions: After 8 years of reforms, important pro-rich inequalities in the use of health services existed. In Latvia, these inequalities were largest, possibly due to higher ratio of cost sharing as compared to Estonia and Lithuania.

Monitoring of socio-economic inequalities in smoking: Learning from the experiences of recent scientific studies (Article)

2009-02-01T00:00:00Z

Objectives: To support policies to tackle socio-economic inequalities in smoking, monitoring systems should include information on smoking according to socio-economic position (SEP). This paper aims to review the methods applied in recent scientific studies on inequalities in smoking, with the aim of drawing lessons for the monitoring of smoking inequalities. Study design: Literature review. Methods: Seventy studies on socio-economic inequalities in smoking, published since 1990, were selected and reviewed, with particular focus on study design, indicators of SEP and smoking outcomes. Results: Most studies had a cross-sectional design and measured smoking prevalence rates among adults in relation to educational level. In addition to educational level, measures of household wealth and occupational class had strong associations with smoking outcomes. In addition to smoking prevalence, other outcome measures such as initiation rates, cessation rates and consumption level are needed to provide in-depth knowledge of the effect of SEP on smoking, especially from a life-course perspective. Conclusions: It is recommended that, as well as educational level, other socio-economic indicators should be used to identify socio-economic groups where smoking rates are highest. Estimates of inequalities in initiation and cessation rates are needed to identify the most important age groups and entry points for policies to tackle inequalities in smoking.

Association between educational level and vegetable use in nine European countries (Article)

2009-02-01T00:00:00Z

Objective: The relationship of socio-economic status and vegetable consumption is examined in nine European countries. The aim is to analyse whether the pattern of socio-economic variation with regard to vegetable consumption is similar in all studied countries with high v. low vegetable availability and affordability, and whether education has an independent effect on vegetable consumption once the effects of other socio-economic factors have been taken into account.Design The data for the study were obtained from national surveys conducted in Finland, Denmark, Germany, Estonia, Latvia, Lithuania, France, Italy and Spain, in 1998 or later. These surveys included data on the frequency of use of vegetables. Food Balance Sheets indicated that the availability of vegetables was best in the Mediterranean countries. The prices of vegetables were lowest in the Mediterranean countries and Germany.Results: Educational level was positively associated with vegetable consumption in the Nordic and Baltic countries. In the Mediterranean countries, education was not directly associated with the use of vegetables but, after adjusting for place of residence and occupation, it was found that those with a lower educational level consumed vegetables slightly more often. Manual workers consumed vegetables less often than non-manual workers, but otherwise there was no systematic association with occupation.Conclusions: The Mediterranean countries did not show a positive association between educational level and vegetable consumption. The positive association found in the Northern European countries is linked to the lower availability and affordability of vegetables there and their everyday cooking habits with no long-standing cultural tradition of using vegetables.

Socioeconomic inequalities in mortality in Europe [Les inégalités sociales de mortalité en Europe] (Article)

2009-01-01T00:00:00Z

In all European countries, the rates of death were higher in groups of lower socioeconomic status, but the magnitude of the inequalities between groups of higher and lower socioeconomic status was much larger in some countries than in others. Inequalities in mortality were small in some Southern European countries and very large in most countries in the eastern and Baltic regions. These variations among countries appeared to be attributable in part to causes of death related to smoking or alcohol use or amenable to medical intervention. These results imply that there is opportunity to reduce inequalities in mortality. Developing policies and interventions that effectively target the structural and immediate determinants of inequalities in health is an urgent priority for public health research.

Trends in socioeconomic inequalities in mortality over a twenty-two-year period in the city of Barcelona (Spain) [Veintidós años de evolución de las desigualdades socioeconómicas en la mortalidad en la ciudad de Barcelona] (Article)

2009-01-01T00:00:00Z

Objective: To analyze the trend in socioeconomic inequalities in all-cause mortality in Barcelona from 1983 to 2004. Methods: We performed an ecological study of trends over 4 cross-sections (1983-1988, 1989-1994, 1995-1999 and 2000-2004), with the basic health area (BHA) as the unit of analysis. The study population consisted of men and women aged 20 years or more living in Barcelona. The information sources were the mortality registry, the municipal census and the census of inhabitants and dwellings. The age- and sex-specific mortality rate (ASMR) for all causes was used as the dependent variable. As the independent variable, a composite index of socioeconomic deprivation of the BHA was calculated; BHAs were grouped in quartiles according to the values on the index. Poisson models were adjusted to estimate the relative risk of mortality from all causes in the 4 groups of BHA, stratified by age groups and sex. Results: In all the study periods, inequalities in mortality were found, depending on the BHA of residence, both for men and for women: the ASMR of the most deprived BHAs were greater than those of less deprived BHA, and were greater among men than among women. Likewise, relative risks in the youngest age groups were higher than in the oldest age groups. However, from the second to fourth study periods, inequalities decreased in absolute and relative terms, especially among men. Conclusions: Inequalities in mortality persist in BHA in Barcelona but have decreased over the last 2 decades. Public policies should take this information into account when tackling inequalities among BHA.

Future disability projections could be improved by connecting to the theory of a dynamic equilibrium (Article)

2009-01-01T00:00:00Z

Objective Projections of future trends in the burden of disability could be guided by models linking disability to life expectancy, such as the dynamic equilibrium theory. This paper tests the key assumption of this theory that severe disability is associated to proximity to death whereas mild disability is not. Study Design and Setting Using data from the GLOBE study, the association of three levels of self-reported ADL disability with age and proximity to death was studied using logistic regression models. These regression estimates were used to estimate the number of life years with disability for life spans of 75 and 85 years. Results The prevalence of disability incrementally increased with approaching death with 12 percent per year for moderate disability to 19 percent for severe disability. However, no association was observed for mild disability. A ten year increase of lifespan was estimated to result in a substantial expansion of mild disability (4.6 years) compared to a small expansion of moderate (0.7 years) and severe (0.9 years) disability. Conclusion These findings support the theory of a dynamic equilibrium. Projections of the future burden of disability could be substantially improved by connecting to this theory and incorporating information on proximity to death.

Socioeconomic inequalities in mortality in Europe [Les inégalités sociales de mortalité en Europe] (Article)

2009-01-01T00:00:00Z

Gender, health inequalities and welfare state regimes: A cross-national study of 13 European countries (Article)

2009-01-01T00:00:00Z

Background: This study is the first to examine the relationship between gender and self-assessed health (SAH), and the extent to which this varies by socioeconomic position in different European welfare state regimes (Liberal, Corporatist, Social Democratic, Southern). Methods: The EUROTHINE harmonised data set (based on representative cross-sectional national health surveys conducted between 1998 and 2004) was used to analyse SAH differences by gender and socioeconomic position (educational rank) in different welfare states. The sample sizes ranged from 7124 (Germany) to 118 245 (Italy) and concerned the adult population (aged ≥16 years). Results: Logistic regression analysis (adjusting for age) identified significant gender differences in SAH in nine European welfare states. In the UK (OR 0.88; 95% CI 0.78 to 0.99) and Finland (OR 0.85; 95% CI 0.77 to 0.95), men were significantly more likely to report "bad" or "very bad" health. In Denmark, Sweden, Norway, Holland, Italy, Spain and Portugal, a significantly higher proportion of women than men reported that their health was "bad" or "very bad". The increased risk of poor SAH experienced by women from these countries ranged from a 23% increase in Denmark (OR 1.23; 95% CI 1.08 to 1.39) to more than a twofold increase in Portugal (OR 2.01; 95% CI 1.87 to 2.15). For some countries (Italy, Portugal, Sweden), women's relatively worse SAH tended to be most prominent in the group with the highest level of education. Discussion: Women in the Social Democratic and Southern welfare states were more likely to report worse SAH than men. In the Corporatist countries, there were no gender differences in SAH. There was no consistent welfare state regime patterning for gender differences in SAH by socioeconomic position. These findings constitute a challenge to regime theory and comparative social epidemiology to engage more with issues of gender.

The diversity in associations between community social capital and health per health outcome, population group and location studied (Article)

2008-12-15T00:00:00Z

Background: Literature on the effect of community social capital on health is inconsistent and could be related to differences in social capital measures, health outcomes, population groups and locations studied. Therefore this study examines the diversity in associations between community social capital and health by investigating different diseases, populations groups and locations. Methods: Mortality records and individual data on sex, age, marital status, ethnic origin and place of residence were available for 6 years (1995-2000). Neighbourhood data, i.e. community social capital, socio-economic level and urbanicity, were linked through postcode information. Community social capital was indicated by measures of community interaction, belongingness, satisfaction and involvement. Variations in all-cause and cause-specific mortality across low and high social capital neighbourhoods were estimated through Poisson regression. In addition, analyses were stratified according to population group and to urbanization level. Results: In the total population, community social capital was not related to all-cause mortality (RR = 1.00; CI: 0.99-1.01). However, residents of high social capital neighbourhoods had lower mortality risks for cancer [especially lung cancer (RR = 0.92; CI: 0.89-0.96)] and for suicide (RR = 0.90; CI: 0.83-0.98). Slightly lower mortality risks were also found for men (RR = 0.98; CI: 0.97-0.99), married individuals (RR = 0.96; CI: 0.94-0.97) and for residents living in socially strong neighbourhoods located in large cities (RR = 0.95; CI: 0.91-0.99). Conclusions: The association between community social capital and health differs per health outcome, study population and location studied. This underlines the need to take such diversity into account when aiming to conceptualize the relation between community social capital and health.

The predictive value of different socio-economic indicators for overweight in nine European countries (Article)

2008-12-01T00:00:00Z

Objectives: To assess which socio-economic indicator best predicts overweight in the European Union: educational attainment, occupational class or household income. Setting: The prevalence of overweight is strongly related to socio-economic position. The relative importance of different socio-economic dimensions is uncertain, and might vary between countries. Design and subjects: Cross-sectional self-report data of the European Community Household Panel were obtained from nine countries (n 52 855; age 25-64 years). Uni- and multivariate regression analyses were employed to predict overweight (BMI ≥ 25 kg/m2) in relationship to socio-economic indicators. Occupational class was measured using the new European Socioeconomic Classification. Results: Large socio-economic differences in overweight were observed in all countries, especially for women. For both sexes, a low educational attainment was the strongest predictor of overweight. After controlling for education, overweight was negatively related to household income in women, but positively in men. Similar patterns were found for occupational class. For women, but not for men, educational inequalities in overweight were generally greater in Southern European countries. A similar pattern of inequalities in overweight was observed for all ages between 25 and 64 years. Conclusions: Across Europe, overweight was more strongly and more consistently related to educational attainment than to occupational class or household income. People with lower educational attainment should be a specific target group for programmes and policies that aim to prevent overweight.

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

2008-11-01T00:00:00Z

Aims/hypothesis: The 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. Methods: We 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. Results: In 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/interpretation: In 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.

Higher mortality in urban neighbourhoods in The Netherlands: who is at risk? (Article)

2008-10-31T00:00:00Z

BACKGROUND: Urban residents have higher mortality risks than rural residents. These urban-rural differences might be more pronounced within certain demographic subpopulations. AIM: To determine urban-rural differences in all-cause and cause-specific mortality within specific demographic subpopulations of the Dutch population. METHOD: Mortality records with information on gender, age, marital status, region of origin and place of residence were available for 1995 through 2000. Neighbourhood data on address density and socioeconomic level were linked through postcode information. Variations in all-cause and cause-specific mortality between urban and rural neighbourhoods were estimated through Poisson regression. Additionally, analyses were stratified according to demographic subpopulation. RESULT: After adjustments for population composition, urban neighbourhoods have higher all-cause mortality risks than rural neighbourhoods (RR = 1.05; CI 1.04 to 1.05), but this pattern reverses after adjustment for neighbourhood socioeconomic level (RR = 0.98; CI 0.97 to 0.99). The beneficial effect of living in an urban environment applies particularly to individuals aged 10-40 years and 80 years and above, people who never married and residents from non-Western ethnic origins. The beneficial effect of urban residence for non-married people is related to their lower cancer and heart disease mortality. The beneficial effect of urban residence for people of non-Western ethnic origin is related to their lower cancer and suicide mortality. CONCLUSION: In The Netherlands, living in an urban environment is not consistently related to higher mortality risks. Young adults, elderly, single and non-Western residents, especially, benefit from living in an urban environment. The urban environment seems to offer these subgroups better opportunities for a

Inequalities in health by social class dimensions in European countries of different political traditions (Article)

2008-10-13T00:00:00Z

Objective: To compare inequalities in self-perceived health in the population older than 50 years, in 2004, using Wright's social class dimensions, in nine European countries grouped in three political traditions (Social democracy, Christian democracy and Late democracies). Methods: Cross-sectional design, including data of the Survey of Health, Ageing and Retirement in Europe (Sweden, Denmark, Austria, France, Germany, The Netherlands, Spain, Italy and Greece). The population aged from 50 to 74 years was included. Absolute and relative social class dimension inequalities in poor self-reported health and long-term illness were determined for each sex and political tradition. Relative inequalities were assessed by fitting Poisson regression models with robust variance estimators. Results: Absolute and relative health inequalities by social class dimensions are found in the three political traditions, but these differences are more marked in Late democracies and mainly among women. For example the prevalence ratio of poor self-perceived health comparing poorly educated women with highly educated women, was 1.75 (95% CI: 1.39-2.21) in Late democracies and 1.36 (95% CI: 1.21-1.52) in Social democracies. The prevalence differences were 24.2 and 13.7%, respectively. Conclusion: This study is one of the first to show the impact of different political traditions on social class inequalities in health. These results emphasize the need to evaluate the impact of the implementation of public policies.

Social inequalities in cancer incidence and cancer survival: Lessons from Danish studies (Article)

2008-09-01T00:00:00Z

Socioeconomic inequalities in health in 22 European countries (Article)

2008-06-05T00:00:00Z

BACKGROUND: Comparisons among countries can help to identify opportunities for the reduction of inequalities in health. We compared the magnitude of inequalities in mortality and self-assessed health among 22 countries in all parts of Europe. METHODS: We obtained data on mortality according to education level and occupational class from census-based mortality studies. Deaths were classified according to cause, including common causes, such as cardiovascular disease and cancer; causes related to smoking; causes related to alcohol use; and causes amenable to medical intervention, such as tuberculosis and hypertension. Data on self-assessed health, smoking, and obesity according to education and income were obtained from health or multipurpose surveys. For each country, the association between socioeconomic status and health outcomes was measured with the use of regression-based inequality indexes. RESULTS: In almost all countries, the rates of death and poorer self-assessments of health were substantially higher in groups of lower socioeconomic status, but the magnitude of the inequalities between groups of higher and lower socioeconomic status was much larger in some countries than in others. Inequalities in mortality were small in some southern European countries and very large in most countries in the eastern and Baltic regions. These variations among countries appeared to be attributable in part to causes of death related to smoking or alcohol use or amenable to medical intervention. The magnitude of inequalities in self-assessed health also varied substantially among countries, but in a different pattern. CONCLUSIONS: We observed variation across Europe in the magnitude of inequalities in health associated with socioeconomic status. These inequalities might be reduced by improving educational opportunities, income distribution, health-related behavior, or access to health care. Copyright

Health inequalities according to educational level in different welfare regimes: A comparison of 23 European countries (Article)

2008-05-01T00:00:00Z

The object of this study was to determine whether the magnitude of educational health inequalities varies between European countries with different welfare regimes. The data source is based on the first and second wave of the European Social Survey. The first health indicator describes people's mental and physical health in general, while the second reports cases of any limiting longstanding illness. Educational inequalities in health were measured as the difference in health between people with an average number of years of education and people whose educational years lay one standard deviation below the national average. Moreover, South European welfare regimes had the largest health inequalities, while countries with Bismarckian welfare regimes tended to demonstrate the smallest. Although the other welfare regimes ranked relatively close to each other, the Scandinavian welfare regimes were placed less favourably than the Anglo-Saxon and East European. Thus, this study shows an evident patterning of magnitudes of health inequalities according to features of European welfare regimes. Although the greater distribution of welfare benefits within the Scandinavian countries are likely to have a protective effect for disadvantaged cities in these countries, other factors such as relative deprivation and class-patterned health behaviours might be acting to widen health inequalities.

Effects of spouses' socioeconomic characteristics on mortality among men and women in a Norwegian longitudinal study (Article)

2008-05-01T00:00:00Z

A partner's socioeconomic characteristics can influence one's own health. Nevertheless, little is known about the relative importance of a partner's education, occupation and income in relation to inequalities in mortality. In this study, we consider the relative contribution of these three spouse characteristics to predicting general and cause-specific mortality in men and women. Data on married persons and their spouses were taken from a Norwegian cross-sectional survey of a total county population (the Nord-Trøndelag Health Study, HUNT 1, 1984-1986). A mortality follow-up was maintained until 2003. Associations of mortality with socioeconomic indicators were assessed computing hazard ratios and Relative Index of Inequality in Cox regression. In women, a clear gradient in age-adjusted mortality rates was observed according to all husband's characteristics. In men, wife's education was most consistently associated with their mortality. After mutual adjustment for all own and spouse's socioeconomic characteristics, the effect of husband's education on women's overall mortality diminished (HR 1.07), whereas the effects of husband's occupation and income remained of similarly moderate size (HR 1.12). Wife's education persisted after adjustment as a significant and strong predictor of men's all-cause mortality (HR 1.35). Effects of partner's characteristics were mostly pronounced in cardiovascular mortality and far less in cancer mortality. In men, wife's education was the strongest and only predictor of mortality across all causes of death examined, except stroke. In women, husband's occupation was mainly related to ischemic heart disease and lung cancer mortality, while husband's income influenced mainly stroke mortality. Wife's education and husband's occupation and income were the most important predictors of mortality across partner relationships. It is suggested that men contribute to their wives' health not only by means of financial security, but also through occupational class. Further research should test our hypothesis that the effect of husband's occupation on their spouses works through occupation-related lifestyle and social prestige.

Educational differences in cancer mortality among women and men: A gender pattern that differs across Europe (Article)

2008-03-11T00:00:00Z

We used longitudinal mortality data sets for the 1990s to compare socioeconomic inequalities in total cancer mortality between women and men aged 30-74 in 12 different European populations (Madrid, Basque region, Barcelona, Slovenia, Turin, Switzerland, France, Belgium, Denmark, Norway, Sweden, Finland) and to investigate which cancer sites explain the differences found. We measured socioeconomic status using educational level and computed relative indices of inequality (RII). We observed large variations within Europe for educational differences in total cancer mortality among men and women. Three patterns were observed: Denmark, Norway and Sweden (significant RII around 1.3-1.4 among both men and women); France, Switzerland, Belgium and Finland (significant RII around 1.7-1.8 among men and around 1.2 among women); Spanish populations, Slovenia and Turin (significant RII from 1.29 to 1.88 among men; no differences among women except in the Basque region, where RII is significantly lower than 1). Lung, upper aerodigestive tract and breast cancers explained most of the variations between gender and populations in the magnitude of inequalities in total cancer mortality. Given time trends in cancer mortality, the gap in the magnitude of socioeconomic inequalities in cancer mortality between gender and between European populations will probably decrease in the future.

Educational inequalities in cancer mortality differ greatly between countries around the Baltic Sea (Article)

2008-02-01T00:00:00Z

Objective: To compare educational inequalities in cancer mortality between Poland, Lithuania, Estonia, Finland and Sweden. Methods: Data are either follow-up or unlinked cross-sectional studies. The relative index of inequality (RII) and the slope index of inequality (SII) are calculated to express the magnitude of mortality differences according to educational level for all cancers and for specific cancers. Results: Large educational inequalities in total cancer mortality were observed, particularly amongst men. Inequalities in upper aero-digestive tract and lung cancer in men and cervix cancer in women were larger in Poland, Lithuania and Estonia, whereas inequalities in lung cancer in women were larger in Finland and Sweden. Conclusions: Countries of the Baltic Sea region differ strongly with regard to the magnitude and pattern of the educational inequalities in cancer mortality.

Identification of socioeconomic groups at increased risk for smoking in European countries: Looking beyond educational level (Article)

2008-02-01T00:00:00Z

Educational level is most often used to identify social groups with increased prevalence of smoking. Other indicators of socioeconomic position (SEP) might, however, be equally or even more discriminatory. This study examined the extent to which smoking behavior is related to other socioeconomic indicators in addition to educational level. Data were derived from the European Household Panel. We selected data for 45,765 respondents aged 25-60 years from nine European countries. The association between six different SEP indicators and smoking prevalence was examined using prevalence rate ratios (RRs) estimated through log linear regression analyses. In univariate analyses, most selected SEP indicators were associated with smoking. In multivariate analyses, educational level, occupational class, accumulated wealth (measured by household assets), and housing tenure retained independent effects on smoking (RRs about 1.20). The effects observed for activity status and household income were small and insignificant in nearly all populations. In northern Europe, educational level had the greatest predictive value in the younger age groups; occupational class and housing tenure predicted most of smoking prevalence in the older age groups. The results showed a less pronounced and more varied pattern in southern Europe. Our results indicate that smoking prevalence is related not only to educational level but also to occupational class and measures of accumulated wealth (other than income). These measures should be used in addition to educational level to identify groups at increased risk for smoking.

High satisfaction rates in women after DIEP flap breast reconstruction (Article)

2008-01-01T00:00:00Z

Background: Breast reconstruction (BR) is aimed at improving quality of life (QoL) after mastectomy. Patient satisfaction is an important indicator to evaluate the success of BR. This study explored patient satisfaction and its determinants in women undergoing deep inferior epigastric artery perforator (DIEP) flap BR as well as the impact of the procedure on body image, sexuality and QoL. Methods: Patient satisfaction and QoL were studied in 72 women who underwent DIEP flap BR using a study-specific questionnaire as well as the Short Form-36 (SF-36). Results: Patient satisfaction was very high. Approximately 90% of the patients reported that they had been sufficiently informed about the procedure and its consequences, that their preoperative expectations had been met, that the reconstructed breast felt like their own and that they would choose the same procedure again and would recommend this procedure to a friend. Patient satisfaction was positively and significantly related to the reconstructed breast(s) feeling like their own. Women with secondary reconstructions were more positive about changes in sexuality and femininity than women with primary BRs. There were no clinically relevant differences in QoL between our study population and a random sample of Dutch females. Conclusions: Women with DIEP flap BRs reported high satisfaction rates. However, to compare these satisfaction rates with other forms of BR, prospective studies in comparable groups are necessary.

Social determinants of ever initiating smoking differ from those of quitting: A cross-sectional study in Estonia (Article)

2007-12-01T00:00:00Z

Background: To study the association of socioeconomic and demographic indicators with ever initiating regular smoking and quitting smoking among ever regular smokers in Estonia in order to identify target groups for equity-oriented tobacco control policies. Methods: Data for 4277 individuals in the 25-64 age group come from three cross-sectional studies conducted in 2000, 2002 and 2004. Age-standardized prevalence rates and odds ratios with 95% confidence intervals were calculated. Results: High rates of ever initiation were observed for lower educated men and women after controlling for other socioeconomic indicators. This association was not observed for women above age 50. Independent, although weaker associations were found among men who were unemployed or with a low occupational status. Low cessation rates were observed among men who were unemployed, who had a lower occupational position or who had a low income. These associations remained after controlling for other socioeconomic variables. The effect of income became stronger in the older age groups among men. Rates of ever initiation and cessation also varied strongly in relationship to some demographic variables. The highest initiation rates were found among divorced women and among women living in the capital city. The lowest cessation rates were found among divorced women, and among Russian men. Conclusions: While educational level was the strongest predictor of ever initiating regular smoking, smoking cessation was related more directly to aspects of social disadvantage originating in adult life. To be effective, tobacco control interventions should not only target lower educated, but also those in material disadvantage.

Using relative and absolute measures for monitoring health inequalities: Experiences from cross-national analyses on maternal and child health (Article)

2007-12-01T00:00:00Z

Background. As reducing socio-economic inequalities in health is an important public health objective, monitoring of these inequalities is an important public health task. The specific inequality measure used can influence the conclusions drawn, and there is no consensus on which measure is most meaningful. The key issue raising most debate is whether to use relative or absolute inequality measures. Our paper aims to inform this debate and develop recommendations for monitoring health inequalities on the basis of empirical analyses for a broad range of developing countries. Methods. Wealth-group specific data on under-5 mortality, immunisation coverage, antenatal and delivery care for 43 countries were obtained from the Demographic and Health Surveys. These data were used to describe the association between the overall level of these outcomes on the one hand, and relative and absolute poor-rich inequalities in these outcomes on the other. Results. We demonstrate that the values that the absolute and relative inequality measures can take are bound by mathematical ceilings. Yet, even where these ceilings do not play a role, the magnitude of inequality is correlated with the overall level of the outcome. The observed tendencies are, however, not necessities. There are countries with low mortality levels and low relative inequalities. Also absolute inequalities showed variation at most overall levels. Conclusion. Our study shows that both absolute and relative inequality measures can be meaningful for monitoring inequalities, provided that the overall level of the outcome is taken into account. Suggestions are given on how to do this. In addition, our paper presents data that can be used for benchmarking of inequalities in the field of maternal and child health in low and middle-income countries.

Higher smoking prevalence in urban compared to non-urban areas: Time trends in six European countries (Article)

2007-09-01T00:00:00Z

We investigated differences in smoking prevalence between urban and non-urban area of residence in six Western European countries (Sweden, Finland, Denmark, Germany, Italy and Spain), and smoking prevalence trends over the period 1985-2000. In most countries, smoking prevalence was highest in urban areas, and increased with urbanization. Urban/non-urban inequalities were most pronounced among individuals with low education levels, and also among females. There were no significant differences in annual rate of change in smoking prevalence between non-urban and urban areas.

Time trends and educational differences in the incidence of quitting smoking in Spain (1965-2000) (Article)

2007-08-09T00:00:00Z

Background: To analyze the pattern in the incidence of quitting smoking in Spain from 1965 to 2000 according to gender, age and educational level. Methods: We used data from 5 Spanish National Health Interview Surveys including 33532 ever smokers ≥ 20 years old. We reconstructed the history of smoking and the age at smoking cessation. We calculated the biannual incidence of quitting smoking according to sex, age and educational level. We fitted joinpoint regression to identify significant changes in trends. Results: The incidence of quitting smoking at ages 20-50 years has increased from 0.5% in 1965-1966 to 4.9% in 1999-2000 for males and from 1.1% in 1965-1966 to 5.0% in 1999-2000 in females. For those aged > 50 years old, the incidence of quitting smoking has increased from 0.4% in 1965-1966 to 8.7% in 1999-2000 for males and from 7.9% in 1973-1974 to 8.8% in 1999-2000 in females. A level-off in cessation rates is observed both in men and women aged 20-50 years old with lower educational level in the last decade, while cessation among those with higher educational level continue to increase. Conclusions: The different pattern of smoking cessation according to gender, age, and level of education suggests that health promotion actions and tobacco control policies might have had a different effect among different population subgroups.

Socioeconomic inequalities in alcohol related cancer mortality among men: To what extent do they differ between Western European populations? (Article)

2007-08-01T00:00:00Z

We aim to study socioeconomic inequalities in alcohol related cancers mortality [upper aerodigestive tract (UADT) (oral cavity, pharynx, larynx, oesophagus and liver)] in men and to investigate whether the contribution of these cancers to socioeconomic inequalities in cancer mortality differs within Western Europe. We used longitudinal mortality datasets, including causes of death. Data were collected during the 1990s among men aged 30-74 years in 13 European populations [Madrid, the Basque region, Barcelona, Turin, Switzerland (German and Latin part), France, Belgium (Walloon and Flemish part, Brussels), Norway, Sweden, Finland]. Socioeconomic status was measured using the educational level declared at the census at the beginning of the follow-up period. We conducted Poisson regression analyses and used both relative [Relative index of inequality (RII)] and absolute (mortality rates difference) measures of inequality. For UADT cancers, the RII's were above 3.5 in France, Switzerland (both parts) and Turin whereas for liver cancer they were the highest (around 2.5) in Madrid, France and Turin. The contribution of alcohol related cancer to socioeconomic inequalities in cancer mortality was 29-36% in France and the Spanish populations, 17-23% in Switzerland and Turin, and 5-15% in Belgium and the Nordic countries. We did not observe any correlation between mortality rates differences for lung and UADT cancers, confirming that the pattern found for UADT cancers is not only due to smoking. This study suggests that alcohol use substantially influences socioeconomic inequalities in male cancer mortality in France, Spain and Switzerland but not in the Nordic countries and nor in Belgium.

The effects of ill health on entering and maintaining paid employment: Evidence in European countries (Article)

2007-07-01T00:00:00Z

Objectives: To examine the effects of ill health on selection into paid employment in European countries. Methods: Five annual waves (1994-8) of the European Community Household Panel were used to select two populations: (1) 4446 subjects unemployed for at least 2 years, of which 1590 (36%) subjects found employment in the next year, and (2) 57 436 subjects employed for at least 2 years, of which 6191 (11%) subjects left the workforce in the next year because of unemployment, (early) retirement or having to take care of household. The influence of a perceived poor health and a chronic health problem on employment transitions was studied using logistic regression analysis. Results: An interaction between health and sex was observed, with women in poor health (odds ratio (OR) 0.4), men in poor health (OR 0.6) and women (OR 0.6) having less chance to enter paid employment than men in good health. Subjects with a poor health and low/intermediate education had the highest risks of unemployment or (early) retirement. Taking care of the household was only influenced by health among unmarried women. In most European countries, a poor health or a chronic health problem predicted staying or becoming unemployed and the effects of health were stronger with a lower national unemployment level. Conclusion: In most European countries, socioeconomic inequalities in ill health were an important determinant for entering and maintaining paid employment. In public health measures for health equity, it is of paramount importance to include people with poor health in the labour market.

Duration of residence was not consistently related to immigrant mortality (Article)

2007-06-01T00:00:00Z

Objective: This paper aimed to examine immigrant mortality according to duration of residence in the Netherlands and to compare duration-specific mortality levels to levels of mortality in the native Dutch population. Study Design and Setting: For the years 1995-2000, we linked the national cause of death register, that contains information on deaths of legal residents, to the municipal population register, that contains information on all legal residents. We studied mortality in relation to period of immigration by means of directly standardized mortality rates and Poisson regression. Results: All cause mortality was not related to year of immigration among Turkish and Moroccan men and women, and among Surinamese women. Among Surinamese men and among Antilleans/Aruban men and women, mortality was higher in more recent immigrants. Part of their excess mortality was due to their relatively low socioeconomic status. For most specific causes of death, no consistent relation with duration of residence was observed. Conclusion: A consistent relation between duration of residence and immigrant mortality was only observed in some immigrant groups. The results suggest that the healthy migrant effect or adaptation of health-related behaviors were no predominant determinants of immigrant mortality in the Netherlands.

Educational inequalities in initiation, cessation, and prevalence of smoking among 3 Italian birth cohorts (Article)

2007-05-01T00:00:00Z

Objectives. We examined socioeconomic inequalities in initiation and cessation rates of smoking and the resultant inequality in smoking prevalence among 3 consecutive Italian birth cohorts. Methods. We used data from the 1999-2000 Italian National Health Interview Survey, which included 28958 men and 29769 women who were born between 1940 and 1969. The association between smoking variables and level of education was assessed with logistic regression and life table analyses. Results. Inequalities in the lifetime prevalence of smoking increased across the 3 birth cohorts in Italy. At age 40, lower-educated persons in the youngest cohort reported on average 1 to 5 years of additional exposure to regular smoking compared with higher-educated persons. Inequalities in smoking prevalence increased among both men and women because of widening inequalities in initiation rates. Among women, growing inequalities in cessation rates also played a role. Conclusions. The relative contribution of initiation and cessation to socioeconomic inequalities in smoking rates varied by both gender and birth cohort. For the youngest birth cohort, policies that address inequalities in smoking should focus on both initiation and cessation.

The reversed social gradient: Higher breast cancer mortality in the higher educated compared to lower educated. A comparison of 11 European populations during the 1990s (Article)

2007-05-01T00:00:00Z

Higher socioeconomic position has been reported to be associated with increased risk of breast cancer mortality. Our aim was to see if this is consistently observed within 11 European populations in the 1990s. Longitudinal data on breast cancer mortality by educational level and marital status were obtained for Finland, Norway, Denmark, England and Wales, Belgium, France, Switzerland, Austria, Turin, Barcelona and Madrid. The relationship between breast cancer mortality and education was summarised by means of the relative index of inequality. A positive association was found in all populations, except for Finland, France and Barcelona. Overall, women with a higher educational level had approximately 15% greater risk of dying from breast cancer than those with lower education. This was observed both among never- and ever-married women. The greater risk of breast cancer mortality among women with a higher level of education was a persistent and generalised phenomenon in Europe in the 1990s.

The effect of age at immigration and generational status of the mother on infant mortality in ethnic minority populations in The Netherlands (Article)

2007-04-01T00:00:00Z

Background: Migrant populations consist of migrants with differences in generational status and length of residence. Several studies suggest that health outcomes differ by generational status and duration of residence. We examined the association of generational status and age at immigration of the mother with infant mortality in migrant populations in The Netherlands. Methods: Data from Statistics Netherlands were obtained from 1995 through 2000 for infants of mothers with Dutch, Turkish and Surinamese ethnicity. Mothers were categorized by generational status (Dutch-born and foreign-born) and by age at immigration (0-16 and >16 years). The associations of generational status and age at immigration of the mother with total and cause-specific infant mortality were examined. Results: The infant mortality rate in Turkish mothers rose with lower age at immigration (from 5.5 to 6.4 per 1000) and was highest for Dutch-born Turkish mothers (6.8 per 1000). Infant death from perinatal and congenital causes increased with lower age at immigration and was highest in the Dutch-born Turkish women. In contrast, in Surinamese mothers infant mortality declined with lower age at immigration (from 8.0 to 6.3 per 1000) and was lowest for Dutch-born Surinamese mothers (5.5 per 1000). Generational status and lower age at immigration of Surinamese women were associated with declining mortality of congenital causes. Conclusions: Total and cause-specific infant mortality seem to differ according to generational status and age at immigration of the mother. The direction of these trends however differs between ethnic populations. This may be related to acculturation and selective migration.

Exceptions to the rule: Healthy deprived areas and unhealthy wealthy areas (Article)

2007-03-01T00:00:00Z

In general, inhabitants of low socio-economic areas are unhealthier than inhabitants of high socio-economic areas, but some areas are an exception to this rule. These exceptions imply that other factors besides the socio-economic level of an area contribute to the health of the inhabitants of an area, e.g. environmental factors. In our study we concentrate on areas within the Netherlands that are healthier or unhealthier than could be expected based on their socio-economic level. This study first identifies these areas and secondly determines which area characteristics distinguish these areas from those areas where the level of health is in agreement with their socio-economic level. We used nation-wide data on neighbourhood differences in population composition (gender, age, marital status and ethnicity), urbanisation and two health indicators: mortality and hospitalisation rates. In the Netherlands, many areas are healthier or unhealthier than could be expected based on their income level alone. Areas with higher mortality rates than expected are mainly urban areas with high percentages of elderly people and persons living alone. Similar but opposite associations are observed for areas with lower mortality rates than expected, which are further characterised by a low percentage of non-western immigrants. Areas with lower hospitalisation rates than expected are mainly rural areas with few non-western immigrants. From these results, we conclude that urbanisation and residential segregation based on age, ethnicity and marital status might be important contributors to geographical health inequalities.

Differences in cause-of-death patterns between the native Dutch and persons of Indonesian descent in the Netherlands (Article)

2007-01-09T00:00:00Z

We studied differences in causespecific mortality between highly integrated first- and second-generation Indonesians and native Dutch. We used the municipal population registers and cause-of-death registry to estimate rate ratios via Poisson regression analyses. Although overall mortality levels were similar, cause-of-death patterns varied between Indonesian migrants and native Dutch; the similar levels in overall mortality coincided with the high degree of integration of Indonesians within Dutch society. The differences in cause-of-death patterns may reflect persistent influences of country of origin and migration history.

Childhood socioeconomic position and cause-specific mortality in early adulthood (Article)

2007-01-01T00:00:00Z

There is growing evidence that childhood socioeconomic position (SEP) influences adult health. The authors' aim was to describe the association between childhood SEP measures (parents' education, occupation, and income) and mortality, for both genders, and to assess to what extent this association was mediated by adult SEP. Registry data for all Norwegians born in 1955-1965 were used. Death records were linked to the cohort, and 6,589 persons died during 1990-2001. Cox's regression was used to calculate relative rates and the relative index of inequality. Low childhood SEP was associated with increased mortality for most causes of death, except for breast cancer, where no association was found. For suicide in women, low childhood SEP was protective. Adult SEP accounted for the associations for total mortality and most causes of death. However, adult SEP accounted for only one half of the association of father's educational level with ischemic heart disease mortality among men. The increased suicide risk among women with high childhood SEP persisted, regardless of adult SEP. In summary, childhood SEP had a direct association with early adult cardiovascular mortality in men and with suicide in women. For other causes of death, childhood SEP was only indirectly associated, mostly through persons' own educational level. Copyright

Cohort-specific trends in stroke mortality in seven European countries were related to infant mortality rates (Article)

2006-12-01T00:00:00Z

Objectives To assess, in a population-based study, whether secular trends in cardiovascular disease mortality in seven European countries were correlated with past trends in infant mortality rate (IMR) in these countries. Study Design and Setting Data on ischemic heart disease (IHD) and stroke mortality in 1950–1999 in the Netherlands, England & Wales, France, and four Nordic countries were analyzed. We used Poisson regression to describe trends in mortality according to birth cohort, for the cohorts born between 1860 and 1939. Pearson correlation coefficients were calculated to determine associations between IMR and IHD, or stroke mortality. Results IHD mortality increased for successive cohorts up to 1900, and then started to decline. Stroke mortality levels were virtually stable among birth cohorts up to 1880, but declined rapidly among later cohorts. A strong positive association was found between cohort-specific IMR levels and stroke mortality rates. There were no strong cohort-wise associations between IMR and IHD mortality. Conclusion These results support other studies in suggesting that living conditions in early childhood may influence population levels of stroke mortality. Future studies should determine the contribution of specific early life factors to the mortality decline in IHD and especially stroke.

Trends in stomach cancer mortality in relation to living conditions in childhood. A study among cohorts born between 1860 and 1939 in seven European countries (Article)

2006-09-01T00:00:00Z

Aim: To assess whether secular trends in stomach cancer mortality were correlated with trends in infant mortality rate (IMR) or gross domestic product (GDP). Methods: Data from seven European countries were analyzed. We used Poisson regression to describe mortality trends among birth cohorts of 1865-1939 and correlation coefficients to determine associations with IMR/GDP. Results: Large differences were observed between birth cohorts in mortality from stomach cancer. In each country, these cohort differences were closely related to IMR/GDP levels at birth time. However, stronger associations were observed with measures of living conditions during later life. In comparisons between countries, stomach cancer mortality rates were not consistently related to national levels of IMR/GDP. Conclusion: General living conditions in childhood don’t seem to have had a predominant effect on secular trends in stomach cancer mortality. The mortality decline is likely to be related to more specific factors, such as declining H. pylori prevalence.

Differences in avoidable mortality between migrants and the native Dutch in The Netherlands. (Article)

2006-03-27T00:00:00Z

BACKGROUND: The quality of the healthcare system and its role in influencing mortality of migrant groups can be explored by examining ethnic variations in 'avoidable' mortality. This study investigates the association between the level of mortality from 'avoidable' causes and ethnic origin in the Netherlands and identifies social factors that contribute to this association. METHODS: Data were obtained from cause of death and population registries in the period 1995-2000. We compared mortality rates for selected 'avoidable' conditions for Turkish, Moroccan, Surinamese and Antillean/Aruban groups to native Dutch. RESULTS: We found slightly elevated risk in total 'avoidable' mortality for migrant populations (RR = 1.13). Higher risks of death among migrants were observed from almost all infectious diseases (most RR > 3.00) and several chronic conditions including asthma, diabetes and cerebro-vascular disorders (most RR > 1.70). Migrant women experienced a higher risk of death from maternity-related conditions (RR = 3.37). Surinamese and Antillean/Aruban population had a higher mortality risk (RR = 1.65 and 1.31 respectively), while Turkish and Moroccans experienced a lower risk of death (RR = 0.93 and 0.77 respectively) from all 'avoidable' conditions compared to native Dutch. Control for demographic and socioeconomic factors explained a substantial part of ethnic differences in 'avoidable' mortality. CONCLUSION: Compared to the native Dutch population, total 'avoidable' mortality was slightly elevated for all migrants combined. Mortality risks varied greatly by cause of death and ethnic origin. The substantial differences in mortality for a few 'avoidable' conditions suggest opportunities for quality improvement within specific areas of the healthcare system targeted to disadvantaged groups.

Educational inequalities in smoking among men and women aged 16 years and older in 11 European countries. (Article)

2005-04-01T00:00:00Z

OBJECTIVE: To determine those groups who are at increased risk of smoking related diseases, we assessed in which male and female generations smoking was more prevalent among lower educated groups than among the higher educated, in 11 European countries. DESIGN: Cross sectional analysis of data on smoking, covering the year 1998, from a social survey designed for all member states of the European Union. SUBJECTS: Higher and lower educated men and women aged 16 years and older from 11 member states of the European Union. OUTCOME MEASURES: Age standardised prevalence rates by education and prevalence odds ratios of current and ever daily smoking comparing lower educated groups with higher educated groups. RESULTS: A north-south gradient in educational inequalities in current and ever daily smoking was observed for women older than 24 years, showing larger inequalities in the northern countries. Such a gradient was not observed for men. A disadvantage for the lower educated in terms of smoking generally occurred later among women than among men. Indications of inequalities in smoking in the age group 16-24 years were observed for all countries, with the exception of women from Greece and Portugal. CONCLUSIONS: Preventing and reducing smoking among lower educated subgroups should be a priority of policies aiming to reduce inequalities in health in Europe. If steps are not taken to control tobacco use among the lower educated groups specifically, inequalities in lung cancer and other smoking related diseases should be anticipated in all populations of the European Union, and both sexes.

Relation between trends in late middle age mortality and trends in old age mortality--is there evidence for mortality selection? (Article)

2005-01-01T00:00:00Z

STUDY OBJECTIVE: To test whether mortality selection was a dominant factor in determining trends in old age mortality, by empirically studying the existence of a negative correlation between trends in late middle age mortality and trends in old age mortality among the same cohorts. DESIGN AND METHODS: A cohort approach was applied to period data on total and cause specific mortality for Denmark, England and Wales, Finland, France, the Netherlands, Norway, and Sweden, in 1950-1999. The study described and correlated mortality trends for five year centralised cohorts from 1895 to 1910 at ages 55-69, with the trends for the same cohorts at ages 80-89. The research distinguished between circulatory diseases, cancers, and diseases specifically related to old age. MAIN RESULTS: All cause mortality changes at ages 80-89 were strongly positively correlated with all cause mortality changes at ages 55-69, especially among men, and in all countries. Virtually the same correlations were seen between all cause mortality changes at ages 80-89 and changes in circulatory disease mortality at ages 55-69. Trends in mortality at ages 80-89 from infectious diseases, pneumonia, diabetes mellitus, symptoms, or external causes showed no clear negative correlations with all cause mortality trends at ages 55-69. CONCLUSIONS: The consistently positive correlations seen in this study suggest that trends in old age mortality in north western Europe in the late 20th century were determined predominantly by the prolonged effects of exposures carried throughout life, and not by mortality selection.

Trends in smoking behaviour between 1985 and 2000 in nine European countries by education (Article)

2005-01-01T00:00:00Z

OBJECTIVE: To examine whether trends in smoking behaviour in Western Europe between 1985 and 2000 differed by education group. DESIGN: Data of smoking behaviour and education level were obtained from national cross sectional surveys conducted between 1985 and 2000 (a period characterised by intense tobacco control policies) and analysed for countries combined and each country separately. Annual trends in smoking prevalence and the quantity of cigarettes consumed by smokers were summarised for each education level. Education inequalities in smoking were examined at four time points. SETTING: Data were obtained from nine European countries: Norway, Sweden, Denmark, Finland, the United Kingdom, the Netherlands, Germany, Italy, and Spain. PARTICIPANTS: 451 386 non-institutionalised men and women 25-79 years old. MAIN OUTCOME MEASURES: Smoking status, daily quantity of cigarettes consumed by smokers. RESULTS: Combined country analyses showed greater declines in smoking and tobacco consumption among tertiary educated men and women compared with their less educated counterparts. In country specific analyses, elementary educated British men and women, and elementary educated Italian men showed greater declines in smoking than their more educated counterparts. Among Swedish, Finnish, Danish, German, Italian, and Spanish women, greater declines were seen among more educated groups. CONCLUSIONS: Widening education inequalities in smoking related diseases may be seen in several European countries in the future. More insight into effective strategies specifically targeting the smoking behaviour of low educated groups may be gained from examining the tobacco control policies of the UK and Italy over this period.

Socioeconomic inequalities in mortality within ethnic groups in the Netherlands, 1995-2000 (Article)

2005-01-01T00:00:00Z

STUDY OBJECTIVE: To analyse socioeconomic inequalities in mortality in Dutch, Turkish, Moroccans, Surinamese, and Antillean/Aruban men and women living in the Netherlands and to assess the contribution of specific causes of death to these inequalities. DESIGN: Open cohort design using data from the Municipal Population Registers and cause of death registry. SETTING: the Netherlands from 1995 through 2000. PARTICIPANTS: All inhabitants of the Netherlands. MAIN OUTCOME MEASURES: This study calculated directly standardised mortality rates by mean neighbourhood income and estimated relative mortality ratios comparing the two lowest socioeconomic groups with the two highest socioeconomic groups for all and cause specific mortality by country of origin and sex. MAIN RESULTS: Socioeconomic differences in total mortality were comparatively large in Dutch, (RR = 1.49, CI = 1.46 to 1.52), Surinamese (1.32, 1.19 to 1.46), and Antillean/Aruban men (1.56, 1.29 to 1.89) and in Dutch (1.39, 135 to 1.42) and Surinamese women (1.27, 1.11 to 1.46). They were comparatively small among Turkish (1.10, 0.99 to 1.23) and Moroccan men (1.10, 0.97 to 1.26) and among Turkish (1.13, 0.97 to 1.33), Moroccan (1.12, 0.93 to 1.35) and Antillean/Aruban women (1.03, 0.80 to 1.33). The mortality differences among the Dutch were partly attributable to inequalities in mortality from cardiovascular diseases, whereas among Antillean/Aruban men external causes strongly contributed to the mortality differences. The small differences among Turkish and Moroccan men were due to a lack of inequalities for cardiovascular diseases and small inequalities for the other causes. CONCLUSIONS: The impact of socioeconomic status on mortality differed between ethnic groups living in the Netherlands. Maintaining small socioeconomic inequalities in mortality among Turkish and Moroccans men and women and among Antillean/Aruban women could prevent future increases in overall mortality in these groups.

Ethnic inequalities in age- and cause-specific mortality in The Netherlands. (Article)

2004-10-01T00:00:00Z

BACKGROUND: By describing ethnic differences in age- and cause-specific mortality in The Netherlands we aim to identify factors that determine whether ethnic minority groups have higher or lower mortality than the native population of the host country. METHODS: We used data for 1995-2000 from the municipal population registers and cause of death registry. All inhabitants of The Netherlands were included in the study. The mortality of people who themselves or whose parent(s) were born in Turkey, Morocco, Surinam, or the Dutch Antilles/Aruba was compared with that of the native Dutch population. Mortality differences were estimated by Poisson regression analyses and by directly standardized mortality rates. RESULTS: Compared with native Dutch men, mortality was higher among Turkish (relative risk [RR] = 1.21, 95% CI: 1.16, 1.26), Surinamese (RR = 1.24, 95% CI: 1.19, 1.29), and Antillean/Aruban (RR = 1.25, 95% CI: 1.15, 1.36) males, and lower among Moroccan males (RR = 0.85, 95% CI: 0.81, 0.90). Among females, inequalities in mortality were small. In general, mortality differences were influenced by socio-economic and marital status. Most minority groups had a high mortality at young ages and low mortality at older ages, a high mortality from ill-defined conditions (which is related to mortality abroad) and external causes, and a low mortality from neoplasms. Cardiovascular disease mortality was low among Moroccan males (RR = 0.51, 95% CI: 0.44, 0.59) and high among Surinamese males (RR = 1.13, 95% CI: 1.05, 1.21) and females (RR = 1.14, 95% CI: 1.06, 1.23). Homicide mortality was elevated in all groups. CONCLUSION: Socio-economic factors and marital status were important determinants of ethnic inequalities in mortality in The Netherlands. Mortality from cardiovascular diseases, homicide, and mortality abroad were of particular importance for shifting the balance from high towards low all-cause mortality.

Educational level and stroke mortality: a comparison of 10 European populations during the 1990s. (Article)

2004-02-01T00:00:00Z

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 >or=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

Socioeconomic inequalities in mortality among elderly people in 11 European populations (Article)

2004-01-01T00:00:00Z

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.

Widening socioeconomic inequalities in mortality in six Western European countries (Article)

2003-01-01T00:00:00Z

OBJECTIVES: During the past decades a widening of the relative gap in death rates between upper and lower socioeconomic groups has been reported for several European countries. Although differential mortality decline for cardiovascular diseases has been suggested as an important contributory factor, it is not known what its quantitative contribution was, and to what extent other causes of death have contributed to the widening gap in total mortality. METHODS: We collected data on mortality by educational level and occupational class among men and women from national longitudinal studies in Finland, Sweden, Norway, Denmark, England/Wales, and Italy (Turin), and analysed age-standardized death rates in two recent time periods (1981-1985 and 1991-1995), both total mortality and by cause of death. For simplicity, we report on inequalities in mortality between two broad socioeconomic groups (high and low educational level, non-manual and manual occupations). RESULTS: Relative inequalities in total mortality have increased in all six countries, but absolute differences in total mortality were fairly stable, with the exception of Finland where an increase occurred. In most countries, mortality from cardiovascular diseases declined proportionally faster in the upper socioeconomic groups. The exception is Italy (Turin) where the reverse occurred. In all countries with the exception of Italy (Turin), changes in cardiovascular disease mortality contributed about half of the widening relative gap for total mortality. Other causes also made important contributions to the widening gap in total mortality. For these causes, widening inequalities were sometimes due to increasing mortality rates in the lower socioeconomic groups. We found rising rates of mortality from lung cancer, breast cancer, respiratory disease, gastrointestinal disease, and injuries among men and/or women in lower socioeconomic groups in several countries. CONCLUSIONS: Reducing socioeconomic inequalities in mortality in Western Europe critically depends upon speeding up mortality declines from cardiovascular diseases in lower socioeconomic groups, and countering mortality increases from several other causes of death in lower socioeconomic groups.

Measuring health inequality among children in developing countries: does the choice of the indicator of economic status matter? (Article)

2003-01-01T00:00:00Z

BACKGROUND: Currently, poor-rich inequalities in health in developing countries receive a lot of attention from both researchers and policy makers. Since measuring economic status in developing countries is often problematic, different indicators of wealth are used in different studies. Until now, there is a lack of evidence on the extent to which the use of different measures of economic status affects the observed magnitude of health inequalities. METHODS: This paper provides this empirical evidence for 10 developing countries, using the Demographic and Health Surveys data-set. We compared the World Bank asset index to three alternative wealth indices, all based on household assets. Under-5 mortality and measles immunisation coverage were the health outcomes studied. Poor-rich inequalities in under-5 mortality and measles immunisation coverage were measured using the Relative Index of Inequality. RESULTS: Comparing the World Bank index to the alternative indices, we found that (1) the relative position of households in the national wealth hierarchy varied to an important extent with the asset index used, (2) observed poor-rich inequalities in under-5 mortality and immunisation coverage often changed, in some cases to an important extent, and that (3) the size and direction of this change varied per country, index, and health indicator. CONCLUSION: Researchers and policy makers should be aware that the choice of the measure of economic status influences the observed magnitude of health inequalities, and that differences in health inequalities between countries or time periods, may be an artefact of different wealth measures used.

Trends in socioeconomic health inequalities in the Netherlands, 1981-1999 (Article)

2002-01-01T00:00:00Z

STUDY OBJECTIVE: To determine changes in socioeconomic inequalities in self reported health in both the 1980s and the 1990s in the Netherlands. DESIGN: Analysis of trends in socioeconomic health inequalities during the last decades of the 20th century were made using data from the Health Interview Survey (Nethhis) and the subsequent Permanent Survey on Living Conditions (POLS) from Statistics Netherlands. Socioeconomic inequalities in self assessed health, short-term disabilities during the past 14 days, long term health problems and chronic diseases were studied in relation to both educational level and household income. Trends from 1981 to 1999 were studied using summary indices for both the relative and absolute size of socioeconomic inequalities in health. SETTING: The Netherlands. PARTICIPANTS: For the period 1981-1999 per year a random sample of about 7000 respondents of 18 years and older from the non-institutionalised population. MAIN RESULTS: Socioeconomic inequalities in self assessed health showed a fairly consistent increase over time. Socioeconomic inequalities in the other health indicators were more or less stable over time. In no case did socioeconomic inequalities in health seemed to have decreased over time. Socioeconomic inequalities in self assessed health increased both in the 1980s and the 1990s. This increase was more pronounced for income (as compared with education) and for women (as compared with men). CONCLUSION: There are several possible explanations for the fact that, in addition to stable health inequalities in general, income related inequalities in some health indicators increased in the Netherlands, especially in the early 1990s. Most influential were perhaps selection effects, related to changing labour market policies in the Netherlands. The fact that the health inequalities did not decrease over recent years underscores the necessity of policies that explicitly aim to tackle these inequalities.

Socioeconomic differences in children's use of physician services in the Nordic countries (Article)

2002-01-01T00:00:00Z

OBJECTIVE: To assess the relation between socioeconomic factors and the use of physician services among children and whether variations of the level of co-payment are correlated with different levels of inequalities in health services use. DESIGN: Description of the socioeconomic differences in the use of health care using data from countrywide postal surveys to parents. SETTING: The five Nordic countries in 1996. SUBJECTS: Samples of 15 000 children aged 2-17 years: 3000 children at random, from the national registry in each country. MAIN OUTCOME MEASURE: Odds ratios of use of GP, specialist, and hospital services between children according to the educational level of both parents and the disposable income of the family, for all countries together and for each country separately. Odds ratios were adjusted for age, sex, urbanisation grade, and health status. RESULTS: There was little difference in the use of GP services according to socioeconomic factors. Parents from lower socioeconomic groups used telephone services of physicians less than parents from the higher groups and children of lower socioeconomic groups were seen less often by specialists. The reverse was true for hospitalisation of the children. The differential use of those three types of services was more marked in Denmark, Finland and Norway than in Iceland and Sweden. When controlled for other socioeconomic factors, the largest differences were observed according to the education of the mother. CONCLUSION: The specialist services and use of telephone services for children in the Nordic countries do not meet the criteria of equal use for equal need whereas the GP services and hospital services do to some extent. The education of the mother is a more important determinant than income for the use of each service.

Black-white differences in infectious disease mortality in the United States (Article)

2001-01-01T00:00:00Z

OBJECTIVES: This study determined the degree to which Black-White differences in infectious disease mortality are explained by income and education and the extent to which infectious diseases contribute to Black-White differences in all-cause mortality. METHODS: A sample population of the National Longitudinal Mortality Study from 1979 through 1981 was analyzed and followed up through 1989. RESULTS: Infectious disease mortality among Blacks was higher than among Whites, with a relative risk of 1.53 after adjustment for age and sex and 1.34 after further adjustment for income and education. Death from infectious diseases contributed to 9.3% of the difference in all-cause mortality. CONCLUSIONS: In the United States, infectious diseases account for nearly 10% of the excess all-cause mortality rates in Blacks compared with Whites.

Socioeconomic inequalities in cardiovascular disease mortality; an international study. (Article)

2000-07-15T00:00:00Z

BACKGROUND: Differences between socioeconomic groups in mortality from and risk factors for cardiovascular diseases have been reported in many countries. We have made a comparative analysis of these inequalities in the United States and 11 western European countries. The aims of the analysis were (1) to compare the size of inequalities in cardiovascular disease mortality between countries, and (2) to explore the possible contribution of cardiovascular risk factors to the explanation of between-country differences in inequalities in cardiovascular disease mortality. DATA AND METHODS: Data on ischaemic heart disease, cerebrovascular disease and total cardiovascular disease mortality by occupational class and/or educational level were obtained from national longitudinal or unlinked cross-sectional studies. Data on smoking, alcohol consumption, overweight and infrequent consumption of fresh vegetables by occupational class and/or educational level were obtained from national health interview or multipurpose surveys and from the European Union's Eurobarometer survey. Age-adjusted rate ratios for mortality were correlated with age-adjusted odds ratios for the behavioural risk factors. RESULTS: In all countries mortality from cardiovascular diseases is higher among persons with lower occupational class or lower educational level. Within western Europe, a north-south gradient is apparent, with relative and absolute inequalities being larger in the north than in the south. For ischaemic heart disease, but not for cerebrovascular disease, an even more striking north-south gradient is seen, with some 'reverse' inequalities in southern Europe. The United States occupy intermediate positions on most indicators. Inequalities in cardiovascular disease mortality are associated with inequalities in some risk factors, especially cigarette smoking and excessive alcohol consumption. CONCLUSIONS: Socioeconomic inequalities in cardiovascular disease mortality are a major public health problem in most industrialized countries. Closing the gap between low and high socioeconomic groups offers great potential for reducing cardiovascular disease mortality. Developing effective methods of behavioural risk factor reduction in the lower socioeconomic groups should be a top priority in cardiovascular disease prevention.

Educational differences in smoking: international comparison (Article)

2000-01-01T00:00:00Z

OBJECTIVE: To investigate international variations in smoking associated with educational level. DESIGN: International comparison of national health, or similar, surveys. SUBJECTS: Men and women aged 20 to 44 years and 45 to 74 years. SETTING: 12 European countries, around 1990. MAIN OUTCOME MEASURES: Relative differences (odds ratios) and absolute differences in the prevalence of ever smoking and current smoking for men and women in each age group by educational level. RESULTS: In the 45 to 74 year age group, higher rates of current and ever smoking among lower educated subjects were found in some countries only. Among women this was found in Great Britain, Norway, and Sweden, whereas an opposite pattern, with higher educated women smoking more, was found in southern Europe. Among men a similar north-south pattern was found but it was less noticeable than among women. In the 20 to 44 year age group, educational differences in smoking were generally greater than in the older age group, and smoking rates were higher among lower educated people in most countries. Among younger women, a similar north-south pattern was found as among older women. Among younger men, large educational differences in smoking were found for northern European as well as for southern European countries, except for Portugal. CONCLUSIONS: These international variations in social gradients in smoking, which are likely to be related to differences between countries in their stage of the smoking epidemic, may have contributed to the socioeconomic differences in mortality from ischaemic heart disease being greater in northern European countries. The observed age patterns suggest that socioeconomic differences in diseases related to smoking will increase in the coming decades in many European countries.

Postneonatal and child mortality among twins in Southern and Eastern Africa (Article)

2000-01-01T00:00:00Z

BACKGROUND: Few studies have evaluated the difference in mortality between twins and singleton children during the postneonatal and childhood period in sub-Saharan Africa. The aim of this study was to quantify the excess mortality of twins during the postneonatal and childhood period and to identify factors that contribute to the excess mortality among twins. The different use made of health care services was hypothesized to contribute to the increased mortality. METHODS: The Demographic and Health Survey data on Malawi, Tanzania and Zambia were pooled. Logistic regression was used to estimate twin/singleton differences for the combined postneonatal and child mortality and to study the role of intermediate factors and effect modifiers. RESULTS: The study was based on 18 214 singleton children and 706 twins. The twin/ singleton odds ratio (OR) of the combined postneonatal and child mortality was 2.33 (95% CI : 1.85-2.93). This excess mortality was largest during the first year of life. Control for intermediate factors (preventive health care and breastfeeding) did not sizeably diminish the mortality difference. Effect modifiers that were associated with increased twin/singleton OR were male sex, unwanted child, short birth interval and low socioeconomic status. CONCLUSIONS: The excess mortality of twins compared to singletons is considerable. A difference in use of preventive health care or in breastfeeding cannot explain the increased mortality. Males, unwanted children, those born after a short birth interval and the socioeconomically disadvantaged are at special risk. The generally good attendance at under-5 clinics gives health care providers the opportunity for increased surveillance of these high-risk groups.

Occupational class and ischemic heart disease mortality in the United States and 11 European countries (Article)

1999-01-01T00:00:00Z

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.

Gains in life expectancy after elimination of major causes of death: revised estimates taking into account the effect of competing causes (Article)

1999-01-01T00:00:00Z

BACKGROUND: It is generally acknowledged that conventional estimates of the potential number of life years to be gained by elimination of causes of death are too generous. This is because these estimates fail to take into account the fact that those who are saved from the cause are likely to have one or more other conditions ("competing" causes of death), which may increase their risks of dying. It is unknown to what extent this introduces bias in comparisons of life years to be gained between underlying causes of death. The purpose of the study was to assess this bias. DATA AND METHODS: A sample of 5975 death certificates from the Netherlands, 1990, was coded for the presence of diseases that, according to a set of explicit rules, could be regarded as potential causes of death "competing" with the underlying cause. Logistic regression analysis was used to quantify age and sex adjusted differences between four main underlying causes of death (neoplasms, cardiovascular diseases, respiratory diseases, all other diseases) in prevalence of the six most frequent competing causes of death (neoplasms, ischaemic heart disease, cerebrovascular disease, other cardiovascular diseases, chronic obstructive lung disease, all other diseases). These prevalence differences were then used to revise conventional calculations of gains in life expectancy, by taking them to indicate differences in risk of dying from these competing causes after the underlying cause has been eliminated. RESULTS: The prevalence of competing causes of death is relatively low among persons dying from neoplasms as the underlying cause, about average among persons dying from cardiovascular diseases, and relatively high among persons dying from respiratory diseases. Taking this into account results in substantial decreases of potential life years to be gained by elimination of cardiovascular diseases and respiratory diseases, relative to the number of years to be gained by elimination of neoplasms. Specifically, while according to the conventional calculations the gain in life expectancy by elimination of cardiovascular diseases exceeds that for neoplasms by more than one year, in the revised calculations the number of life years to be gained is approximately equal. CONCLUSIONS: Despite its limitations, mainly relating to reliance on death certificate data, this study suggests that conventional estimates of differences between underlying causes of death in life years to be gained by elimination are seriously biased by ignoring the effects of competing causes. Specifically, the relative impacts of eliminating cardiovascular diseases and respiratory diseases, as compared with eliminating neoplasms, seem to be overestimated. The implications are discussed.

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

1999-01-01T00:00:00Z

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.

Morbidity differences by occupational class among men in seven European countries: an application of the Erikson-Goldthorpe social class scheme (Article)

1998-01-01T00:00:00Z

BACKGROUND: This paper describes morbidity differences according to occupational class among men from France, Switzerland, (West) Germany, Great Britain, the Netherlands, Denmark, and Sweden. METHODS: Data were obtained from national health interview surveys or similar surveys between 1986 and 1992. Four morbidity indicators were included. For each country, individual-level data on occupation were recorded according to one standard occupational class scheme: the Erikson-Goldthorpe social class scheme. To describe the pattern of morbidity by occupational class, odds ratios (OR) were calculated for each class using the average of the population as a reference. The size of morbidity differences was summarized by the OR of two broad hierarchical classes. All OR were age-adjusted. RESULTS: For all countries, a lower than average prevalence of morbidity was found for higher and lower administrators and professionals as well as for routine nonmanual workers, whereas a higher than average prevalence was found for skilled and unskilled manual workers and agricultural workers. Self-employed men were in general healthier than the average population. The relative health of farmers differed between countries. The morbidity difference between manual workers and the class of administrators and professionals was approximately equally large in all countries. Consistently larger inequality estimates, with no or slightly overlapping confidence intervals, were only found for Sweden in comparison with Germany. CONCLUSIONS: Thanks to the use of a common social class scheme in each country, a high degree of comparability was achieved. The results suggest that morbidity differences according to occupational class among men are very similar between different European countries.

Occupational class and cause specific mortality in middle aged men in 11 European countries: comparison of population based studies. EU Working Group on Socioeconomic Inequalities in Health (Article)

1998-01-01T00:00:00Z

OBJECTIVES: To compare countries in western Europe with respect to class differences in mortality from specific causes of death and to assess the contributions these causes make to class differences in total mortality. DESIGN: Comparison of cause of death in manual and non-manual classes, using data on mortality from national studies. SETTING: Eleven western European countries in the period 1980-9. SUBJECTS: Men aged 45-59 years at death. RESULTS: A north-south gradient was observed: mortality from ischaemic heart disease was strongly related to occupational class in England and Wales, Ireland, Finland, Sweden, Norway, and Denmark, but not in France, Switzerland, and Mediterranean countries. In the latter countries, cancers other than lung cancer and gastrointestinal diseases made a large contribution to class differences in total mortality. Inequalities in lung cancer, cerebrovascular disease, and external causes of death also varied greatly between countries. CONCLUSIONS: These variations in cause specific mortality indicate large differences between countries in the contribution that disease specific risk factors like smoking and alcohol consumption make to socioeconomic inequalities in mortality. The mortality advantage of people in higher occupational classes is independent of the precise diseases and risk factors involved.

Differences in self reported morbidity by educational level: a comparison of 11 western European countries (Article)

1998-01-01T00:00:00Z

STUDY OBJECTIVE: To assess whether there are variations between 11 Western European countries with respect to the size of differences in self reported morbidity between people with high and low educational levels. DESIGN AND METHODS: National representative data on morbidity by educational level were obtained from health interview surveys, level of living surveys or other similar surveys carried out between 1985 and 1993. Four morbidity indicators were included and a considerable effort was made to maximise the comparability of these indicators. A standardised scheme of educational levels was applied to each survey. The study included men and women aged 25 to 69 years. The size of morbidity differences was measured by means of the regression based Relative Index of Inequality. MAIN RESULTS: The size of inequalities in health was found to vary between countries. In general, there was a tendency for inequalities to be relatively large in Sweden, Norway, and Denmark and to be relatively small in Spain, Switzerland, and West Germany. Intermediate positions were observed for Finland, Great Britain, France, and Italy. The position of the Netherlands strongly varied according to sex: relatively large inequalities were found for men whereas relatively small inequalities were found for women. The relative position of some countries, for example, West Germany, varied according to the morbidity indicator. CONCLUSIONS: Because of a number of unresolved problems with the precision and the international comparability of the data, the margins of uncertainty for the inequality estimates are somewhat wide. However, these problems are unlikely to explain the overall pattern. It is remarkable that health inequalities are not necessarily smaller in countries with more egalitarian policies such as the Netherlands and the Scandinavian countries. Possible explanations are discussed.

Socioeconomic inequalities in stroke mortality among middle-aged men: an international overview. European Union Working Group on Socioeconomic Inequalities in Health (Article)

1998-01-01T00:00:00Z

BACKGROUND AND PURPOSE: Several studies observed that people from lower socioeconomic groups have higher chances of dying of stroke. There are reasons to expect that these differences are relatively small in southern European countries or in Nordic welfare states. This report therefore presents an international overview of socioeconomic differences in stroke mortality. METHODS: Unpublished data on mortality by occupational class were obtained from national longitudinal studies or cross-sectional studies. The data refer to deaths among men aged 30 to 64 years in the 1980s. A common occupational class scheme was applied to most countries. The mortality difference between manual classes and nonmanual classes was measured in relative terms (by rate ratios) and in absolute terms (by rate differences). RESULTS: In all countries, manual classes had higher stroke mortality rates than nonmanual classes. This difference was relatively large in England and Wales, Ireland, and Finland and relatively small in Sweden, Norway, Denmark, Italy, and Spain. Differences were intermediate in the United States, France, and Switzerland. In Portugal, mortality differences were intermediate in relative terms but large in absolute terms. In most countries, inequalities were much larger for stroke mortality than for ischemic heart disease mortality. CONCLUSIONS: Socioeconomic differences in stroke mortality are a problem common to all countries studied. There are probably large variations, however, in the contribution that different risk factors, such as tobacco and alcohol consumption, make to the stroke mortality excess of lower socioeconomic groups. Medical services can contribute to reducing socioeconomic differences in stroke mortality.

Cross-national comparisons of socio-economic differences in mortality (Doctoral Thesis)

1997-09-17T00:00:00Z

The association between two windchill indices and daily mortality variation in The Netherlands (Article)

1994-01-01T00:00:00Z

OBJECTIVES. The purpose of this study was to compare temperature and two windchill indices with respect to the strength of their association with daily variation in mortality in the Netherlands during 1979 to 1987. The two windchill indices were those developed by Siple and Passel and by Steadman. METHODS. Daily numbers of cause-specific deaths were related to the meteorological variables by means of Poisson regression with control for influenza incidence. Lag times were taken into account. RESULTS. Daily variation in mortality, especially mortality from heart disease, was more strongly related to the Steadman windchill index than to temperature or the Siple and Passel index (34.9%, 31.2%, and 31.5%, respectively, of mortality variation explained). The strongest relation was found with daytime values of the Steadman index. CONCLUSIONS. In areas where spells of cold are frequently accompanied by strong wind, the use of the Steadman index probably adds much to the identification of weather conditions involving an increased risk of death. The results of this study provide no justification for the wide-spread use (e.g., in the United States) of the Siple and Passel index.

The size of mortality differences associated with educational level in nine industrialized countries (Article)

1994-01-01T00:00:00Z

OBJECTIVES. This study addresses the question of whether inequalities in premature mortality related to educational level differ among countries. METHODS. Data on mortality by educational level were obtained from longitudinal studies from nine industrialized countries. The data referred to men between 35 and 64 years of age. The follow-up periods occurred between 1970 and 1982. The size of mortality differences associated with educational level was measured by means of two inequality indices, both based on Poisson regression analysis. RESULTS. Inequalities in mortality are relatively small in the Netherlands, Sweden, Denmark, and Norway and about two times as large in the United States, France, and Italy. Finland and England and Wales occupy intermediate positions. The large inequalities in mortality in the United States and France can be attributed in part to large inequalities in education in these countries. CONCLUSIONS. The international pattern found in this study was also observed in a comparison that used occupation as the socioeconomic indicator. Differences between countries in levels of inequality in mortality may be partially explained by the countries' different levels of egalitarian social and economic policies.