Educational differentials in mortality from cardiovascular disease among men and women: the Israel Longitudinal Mortality Study

PURPOSE: While socioeconomic inequalities in cardiovascular disease have been observed in most industrialized countries, available information in Israel centers on ethnic variations and the role of education has yet to be investigated. This study examines educational differentials in cardiovascular mortality in Israel for both men and women aged 45 to 69 and 70 to 89 years. METHODS: Data are based on a linkage of records from a 20% sample of the 1983 census with the records of deaths occurring until the end of 1992. The study population includes 152,150 individuals and the number of cardiovascular deaths was 14,651. Educational differentials were assessed for mortality of diseases of the circulatory system, ischemic heart diseases, cerebrovascular diseases, hypertensive diseases, and sudden death. RESULTS: Substantial mortality differentials were found among individuals aged 45 to 69 years, with larger inequalities among women. The age-adjusted relative risk for mortality of cardiovascular diseases among those with elementary education (< or =8 years) compared with those with high education (> or=13 years) was 1.46 (95% CI: 1.32-1.61) for men and 2.06 (95% CI: 1.76-2.41) for women. Differentials among the elderly were markedly narrower than those for younger adults. Similar trends were observed for mortality of subgroups of causes including cerebrovascular diseases and ischemic heart diseases. Educational differentials were not affected by adjustment for ethnic origin and car ownership. CONCLUSIONS: Those with 8 years of education or less suffer higher risk of cardiovascular mortality compared with adults with 13 or more years of education. Young, less educated women are more vulnerable, and health and social policies oriented towards this group are needed.     

Childhood cognitive ability and deaths up until middle age: a post-war birth cohort study

BACKGROUND: Childhood IQ has been related to mortality in later life in four studies. Cognitive ability may be a mediator between early disadvantage and mortality, a marker of the efficiency of information processing in the central nervous system, or predict entry to safe adult environments or healthy behaviours. We examined mortality in relation to cognitive ability at age 8 years in a birth cohort and investigated these possible reasons. METHODS: Cox's proportional hazards models were used to investigate the effect of early cognitive ability on all-cause mortality in 2057 women and 2192 men born in England, Scotland, and Wales in March 1946 and followed until age 54 years. We tested whether the relationship was accounted for by childhood socioeconomic conditions or serious illness, education, adult socioeconomic conditions, or smoking. RESULTS: Cognitive ability was related to mortality in men but not women. The excess mortality rate in men was concentrated in the bottom quarter of the cognitive score (hazard ratio [HR] for bottom versus top quarter 1.8, 95% CI: 1.0, 3.0) and there was no gradient across the range of ability. Adjustment for childhood socioeconomic conditions and serious illness had a small effect on the HR for deaths between 9 and 54 years while adjustment for education or early adult socioeconomic conditions halved the HR for deaths from age 26 years. Smoking was not a mediator of the effect of early ability on adult mortality. CONCLUSIONS: Greater cumulative exposure to poor lifetime socioeconomic conditions is the most likely explanation for the observed relationship between low cognitive ability in childhood and mortality. This relationship may therefore be elucidated further by studying the causes of lifelong socioeconomic inequalities in health.     

Effects of education and other socioeconomic factors on middle age mortality in rural Bangladesh

STUDY OBJECTIVE: To examine socioeconomic gradients in mortality in adult women and their husbands in Bangladesh, paying particular attention to the independent effects of the educational status of each spouse. DESIGN: Historical cohort study. SETTING: Matlab, a rural area 60 km south east of Dhaka, the capital of Bangladesh. PARTICIPANTS: 14803 married women aged 45 or over and their husbands who were resident in the Matlab Demographic Surveillance area between 30 June 1982 and 31 December 1998. MAIN RESULTS: Mortality was lower in women with formal or Koranic education compared with those with none (adjusted rate ratio for formal education = 0.68, 95% CI 0.53 to 0.86; adjusted rate ratio for Koranic schooling = 0.82, 95% CI 0.66 to 1.00). After adjusting for her own education, the husband's level of education or occupation did not have an independent effect on a woman's survival. Men who had attended formal education had lower mortality than those without any education (adjusted rate ratio = 0.84, 95% CI 0.75 to 0.93), but men whose wives had been educated had an additional survival advantage independent of their own education and occupation (adjusted rate ratio = 0.76, 95% CI 0.67 to 0.87). Mortality in both sexes was also significantly associated with marital status and the percentage of surviving children, and in men was associated with the man's occupation, religion, area of residence. CONCLUSIONS: The data suggest that socioeconomic status has a strong influence on mortality in adults in Bangladesh. They also illustrate how important the continued promotion of education, particularly for women, may be for the survival of both women and men in rural Bangladesh.     

Child mortality,socioeconomic position,and one-parent families: independent associations and variation by age and cause of death

BACKGROUND: Although the association between child mortality and socioeconomic status is well established, it is unclear whether child mortality differences by socioeconomic position are present at all ages. The association of one-parent families with mortality, and whether any such association is due to associated low socioeconomic position, is also not clear. METHODS: In all, 480 of 693 (69%) 0-14 year old deaths during 1991-1994 were linked to 1991 census records. Analyses were weighted to adjust for potential linkage bias. RESULTS: There was approximately twofold higher mortality among the lowest compared with the highest socioeconomic categories of education, income, car access, and neighbourhood deprivation. Occupational class differences were weaker. These socioeconomic differences in mortality were strongest among infants (particularly sudden infant death syndrome [SIDS] mortality), but similar across other age groups (1-4, 5-9, and 10-14 years). The socioeconomic differences were of a similar magnitude for unintentional injury, cancer, congenital, and other deaths. Multivariable analyses demonstrated persistent independent associations of education, income, car access, and neighbourhood deprivation with mortality. Rate ratios (adjusted for age and ethnicity) for one-parent families compared with two-parent or other families were 1.2 (95% CI: 1.0, 1.5) and 1.8 (95% CI: 1.2, 2.5) for all-cause and unintentional injury mortality, respectively. Further adjustment for socioeconomic factors reduced these associations to 0.8 (95% CI: 0.6, 1.2) and 1.2 (95% CI: 0.7, 2.2), respectively. CONCLUSIONS: There does not appear to be notable variation in relative risk terms of socioeconomic differences in child mortality by age or cause of death. Any association of one-parent families with child mortality is due to associated low socioeconomic position.     

Income differences in mortality: a register-based follow-up study of three million men and women

OBJECTIVES: We analyse whether the relationship between net household income and mortality form a continuous linear gradient or is curvilinear, assess the attenuation of this association after adjusting for confounding and reverse causality, and assess the strength of the association by age and cause of death. DESIGN AND SETTING: Prospective study of mortality in Finland among all men and women over 30 years old. Information on household income and sociodemographic factors was from the records of the Finnish tax authorities and the 1990 census. Income data were available for more than 95% of the cohort. Follow-up was by record linkage to death certificates in 1991-1996; altogether about 261 000 deaths. RESULTS: The all-cause mortality ratio between the lowest and the highest household income decile is 2.37 (95% CI : 2.30-2.44) among men and 1.73 (95% CI : 1.67-1.80) among women. Adjusting for household structure, spouse's economic activity, social class, education and own economic activity attenuates the relationship by 61% among men and 52% among women. The association between income and mortality is mainly linear before and after adjusting for confounding, and the association is strong for all 5-year age groups below 60-64 years, after which it declines rapidly in strength. CONCLUSIONS: The mainly linear nature of the relationship and the strong attenuation after adjustment for other socioeconomic factors and economic activity status, and the age pattern of the relationship indicate that a large part of the relationship is unlikely to be due to direct causal effects of poverty and material hardship. Rather, income seems to be related to accumulation of factors that increase mortality over the whole range of incomes.     

Childhood and adult socioeconomic conditions and 31-year mortality risk in women

Links between low socioeconomic position and poor health are well established. Most previous research, however, has focused on middle-aged males and has relied on limited socioeconomic data, usually measured at one point over the life course. This paper examines all-cause, cardiovascular, and noncardiovascular mortality in women in relation to socioeconomic position at different stages of the life course. Information was collected in 1965, 1974, 1983, and 1994 and included recalled father's occupation and education as a measure of childhood socioeconomic position and the respondent's household income, education and occupation, and spouse's occupation from a sample of 3,087 women participating in the Alameda County Study. Cox regression models were used to estimate hazard ratios for risk of death. Lower childhood socioeconomic position was associated with an increased mortality due to cardiovascular disease (hazard ratio (HR) = 1.29, 95% confidence interval (CI): 1.09, 1.54) but was unrelated to death due to other causes (HR = 0.97, 95% CI: 0.82, 1.15). Overall mortality was higher among women reporting the lowest level of education (HR = 1.17, 95% CI: 0.99, 1.39), but education was most strongly related to noncardiovascular disease-related deaths (HR = 1.41, 95% CI: 1.10, 1.81). Low household income was also associated with higher mortality, for both cardiovascular disease-related (HR = 1.47, 95% CI: 1.14, 1.91) and noncardiovascular disease-related (HR = 1.30, 95% CI: 1.03, 1.63) deaths. Both early and later life indicators of socioeconomic position contribute to increased mortality risk among socioeconomically disadvantaged women, but these effects appear stronger for cardiovascular mortality.     

Does one's own and one's spouse's education affect overall and cause-specific mortality in the elderly?

OBJECTIVES: To examine educational gradients in overall and cause-specific mortality among elderly married men and women and their spouses. METHODS: Using the census-based Israel Longitudinal Mortality Study (1983-92), 13 573 married men and 6563 married women were identified who were aged 70-89 years at baseline. Cox proportional hazard models were used to assess the strength of the association between education and overall and cause-specific mortality. RESULTS: Educational gradients for own and spouse's mortality varied by gender and cause of death. In particular, in relation to cardiovascular disease, men married to uneducated wives experienced elevated mortality risks [hazard ratio (HR) = 1.30; 95% confidence interval (95% CI) 1.11-1.52]. Women were generally unaffected by their husband's education, except for those who died from non-breast cancer, for whom husband's low education had a harmful effect (HR = 1.98; 95% CI 1.26-3.11). CONCLUSIONS: Mortality among elderly married persons is associated with one's own and one's spouse's educational achievement. Research using partner's education as a proxy for one's own attainment may be omitting valuable information regarding these and other health risks.     

Alcohol-related deaths contribute to socioeconomic differentials in mortality in Sweden

BACKGROUND: This study aims at estimating the contribution of alcohol to socioeconomic mortality differentials in Sweden. METHODS: Data were obtained from a Census-linked Deaths Registry. Participants in the 1980 and 1990 censuses were included with a follow-up of mortality 1990-1995. Socioeconomic status was assigned from occupation in 1990 or 1980. Alcohol-related deaths were defined from underlying or contributory causes. Poison regressions were applied to compute age-adjusted mortality rate ratios for all-causes, alcohol-related and other causes among 30-79-year-olds. The contribution of alcohol to mortality differentials was calculated from absolute differences. RESULTS: Around 5% (9,547) of all deaths were alcohol-related (30-79 years). For both sexes, manual workers, lower nonmanuals, entrepreneurs and unclassifiable groups had significantly higher alcohol-related mortality than did upper nonmanuals. Male farmers had significantly lower such mortality. The contribution of alcohol to excess mortality over that of upper nonmanuals was greatest among middle-aged (40-59 years) men who were manual workers or who belonged to a group of 'unclassifiable & others' (25-35%). It was of considerable size also for middle-aged lower nonmanuals (both sexes), male entrepreneurs, female manual workers and 'unclassifiable & others'. Among men, the total contribution of alcohol (30-79 years) was estimated at 16% for manual workers, 10% for lower nonmanuals and 7% for entrepreneurs; and among women, 6% (manual workers, lower nonmanuals) and 3% (entrepreneurs). CONCLUSION: Although deaths related to alcohol were probably underreported (e.g. accidents), alcohol clearly contributes to socioeconomic mortality differentials in Sweden. The size of this contribution depends strongly on age (peak among the middle-aged) and gender (greatest among men).     

Social class differences in lung cancer mortality: risk factor explanations using two Scottish cohort studies

BACKGROUND: The study investigated differences in lung cancer mortality risk between social classes. METHODS: Twenty years of mortality follow-up were analysed in 7052 men and 8354 women from the Renfrew/Paisley general population study and 4021 working men from the Collaborative study. RESULTS: More manual than non-manual men and women smoked, reported morning phlegm, had worse lung function and lived in more deprived areas. Lung cancer mortality rates were higher in manual than non-manual men and women. Significantly higher lung cancer mortality risks were seen for manual compared to non-manual workers when adjusting for age only and adjustment for smoking reduced these risks to 1.41 (95% CI : 1.12-1.77) for men in the Renfrew/Paisley study, 1.28 (95% CI : 0.94-1.75) for women in the Renfrew/Paisley study and 1.43 (95% CI : 1.02-2.01) for men in the Collaborative study. Adjustment for lung function, phlegm and deprivation category attenuated the risks which were of borderline significance for men in the Renfrew/Paisley study and non significant for women in the Renfrew/Paisley study and men in the Collaborative study. Adding extra socioeconomic variables, available in the Collaborative study only, reduced the difference between the manual and non-manual social classes completely. CONCLUSIONS: There is a difference in lung cancer risk between social classes, in addition to the effect of smoking. This can be explained by poor lung health, deprivation and poor socioeconomic conditions throughout life. As well as anti-smoking measures, reducing socioeconomic inequalities and targeting individuals with poor lung function for help with smoking cessation could help reduce future lung cancer incidence and mortality.     

The Effect of Parity on Cause-Specific Mortality Among Married Men and Women

The objective of this study was to examine mortality differentials among men and women by parity for deaths from cardio-vascular disease (CVD), cancer and other causes. The census-based Israel Longitudinal Mortality Study II (1995–2004) was used to identify 71,733 married men and 62,822 married women (45–89 years). During the 9-year follow-up period, 19,347 deaths were reported. Cox proportional hazard models adjusted for age, origin, and social class were used. A non-linear association between parity and CVD mortality was detected for men and women. Excess CVD mortality risks were observed among middle-aged women with no children (hazard ratio [HR] 2.43, 95% confidence interval [CI] 1.49, 3.96) and among middle-aged women and men with 8+ children (HR_women 1.64, CI 1.02, 2.65; HR_men 1.40, CI 1.01, 1.93) compared to those with two children. No clear pattern of association between cancer mortality and parity was apparent for men. Elderly women with 8+ children showed reduced mortality risks from reproductive cancers (HR 0.22, CI 0.05, 0.91). Similar parity-related mortality patterns were observed for men and women for deaths from CVD and other causes indicating biosocial pathways. The association between parity and cancer mortality differed by gender, age and type of cancer.     

Socioeconomic differentials in cause-specific mortality among South Korean adolescents

BACKGROUND: There is inconsistent evidence regarding the presence of a socioeconomic differential in adolescent all-cause and cause-specific mortality. This study examines possible socioeconomic mortality differentials in Korean adolescents. Method A total of 330 321 boys and 311 830 girls aged 10-19, who are health insurance beneficiaries for civil servants and private school teachers of Korean Health Insurance Cooperation, were followed for 9 years (1995-2003). Parental income information was linked to national death certificate data. RESULTS: For boys, all-cause mortality showed a graded inverse relationship with income level in both 10-14 year olds (RR = 1.64, 95% CI: 1.40-1.91) and 15-19 year olds (RR = 1.68, 95% CI: 1.40-1.91). The major contributor was mortality differentials from external causes, with differentials of transport accident death the most important. Mortality from circulatory disease was higher in the lowest income groups in 15-19 year olds (RR = 2.21, 95% CI: 1.09-4.50). A significant socioeconomic gradient of non-external cause mortality was found in 15-19 year olds. For girls, socioeconomic differentials were less evident than boys. The all-cause mortality gradient for girls was smaller than for boys and only significant between the lowest and the highest tertile in both 10-14 year olds and 15-19 year olds (RR = 1.33, 95% CI: 1.02-1.72, RR = 1.38, 95% CI: 1.11-1.72, respectively). There were significant socioeconomic mortality differentials in all external causes and transport accidents and a marginally significant difference in suicide mortality for 10-19 year olds. Mortality from non-external causes showed no social gradient in girls. CONCLUSIONS: Socioeconomic differentials in all-cause mortality were observed in adolescents, even in early youth. This pattern might also apply to mortality from non-external causes, especially cardiovascular disease in 15-19 year old males.     

Inequality in health: socioeconomic differentials in mortality in Rome, 1990-95

STUDY OBJECTIVE: Population groups with a lower socioeconomic status (SES) have a greater risk of disease and mortality. The aim of this study was to investigate the relation between SES and mortality in the metropolitan area of Rome during the six year period 1990-1995, and to examine variations in mortality differentials between 1990-92 and 1993-95. DESIGN: Rome has a population of approximately 2,800,000, with 6100 census tracts (CTs). During the study period, 149,002 deaths occurred among residents. The cause-specific mortality rates were compared among four socioeconomic categories defined by a socioeconomic index, derived from characteristics of the CT of residence. MAIN RESULTS: Among men, total mortality and mortality for the major causes of death showed an inverse association with SES. Among 15-44 year old men, the strong positive association between total mortality and low SES was attributable to AIDS and overdose mortality. Among women, a positive association with lower SES was observed for stomach cancer, uterus cancer and cardiovascular disease, whereas mortality for lung and breast cancers was higher in the groups with higher SES. Comparing the periods 1990-92 and 1993-95, differences in total mortality between socioeconomic groups widened in both sexes. Increasing differences were observed for tuberculosis and lung cancer among men, and for uterus cancer, traffic accidents, and overdose mortality among women. CONCLUSIONS: The use of an area-based indicator of SES limits the interpretations of the findings. However, despite the possible limitations, these results suggest that social class differences in mortality in Rome are increasing. Time changes in lifestyle and in the prevalence of risk behaviours may produce differences in disease incidence. Moreover, inequalities in the access to medical care and in the quality of care may contribute to an increasing differentials in mortality.     

Does living in a religiously affiliated neighborhood lower mortality?

PURPOSE: To examine the effects of living in religiously affiliated and unaffiliated neighborhoods on mortality risks above that of individual risk factors, to determine if this effect behaves in a dose-response manner, and to examine the interaction between community wealth and religious affiliation. METHODS: Multilevel modeling of data from the Israel Longitudinal Mortality Study was used to assess mortality differentials based on neighborhood religious affiliation. Data were analyzed for 141,683 individuals aged 45 to 89 years and living in 882 statistical areas. Overall, 29,709 deaths were reported during the 9.5-year follow-up period. RESULTS: After accounting for individual demographic and socioeconomic (SES) characteristics as well as area-SES, men and women living in religiously affiliated neighborhoods had lower mortality rates than those living in unaffiliated areas (odds ratio(men) = 0.75; 95% CI, 0.67-0.84; odds ratio(women) = 0.86; 95% CI, 0.67-0.96). For men, this relationship behaved in a dose-response manner. Furthermore, the beneficial effects on mortality of living in a religiously affiliated area were consistent across age groups, middle-aged and elderly. Lastly, effect modification of area-SES on area-religion was observed for women only, whereby for women living in higher-SES areas, religiosity had no effect on mortality. CONCLUSIONS: The characteristics of one's immediate neighborhood, namely, community wealth and religious affiliation, have valuable health implications that should be included when assessing mortality risks.     

The association between self-rated health and mortality in different socioeconomic groups in the GAZEL cohort study

OBJECTIVES: Self-rated health (SRH) is considered a valid measure of health status as it has been shown to predict mortality in several studies. We examine whether SRH predicts mortality equally well in different socioeconomic groups. METHODS: Data (14 879 men and 5525 women) are drawn from GAZEL, a prospective cohort study of French public utility workers. Data on SRH and the socioeconomic measures (education, occupational position and income) were taken from the baseline questionnaire (1989), when the average age of individuals was 44.2 years (SD = 3.5). Mortality follow-up was available for a mean of 17.2 years and analysed over the first 10 years and over the entire follow-up period. Associations between SRH and mortality were assessed using Cox regression models using the relative index of inequality (RII) to summarize associations. RESULTS: The RII for the association between SRH and mortality over the first 10 years was 6.78 [95% confidence interval (CI) = 3.33-13.81] in the lowest occupational group and 2.10 (95% CI = 0.97-4.54) in the highest. For income, the RIIs were 8.82 (95% CI = 4.70-16.54) for the lowest and 1.80 (95% CI = 0.86-3.80) for the highest groups respectively. Findings over the full follow-up period were similar. The association between SRH and mortality was weaker in the high occupation and income groups, both in the short and the long term. The results for education were similar but generally weaker than for the other socioeconomic measures. CONCLUSIONS: The predictive ability of SRH for mortality weakens with increasing socioeconomic advantage among middle-aged individuals. Thus SRH appears not to measure 'true' health status in a similar way across socioeconomic categories.     

Parity-related mortality: shape of association among middle-aged and elderly men and women

Parity is associated with mortality among middle-aged women, while substantially less is known about this relationship for men and the elderly. Using the census-based Israel Longitudinal Mortality Study (ILMS) II (1995–2004) we sought to examine the parity–mortality relationship among men and women, middle-aged and elderly. In our study cohort of 71,733 married men and 62,822 married women ages 45–89 years at baseline, 19,437 deaths were reported. Mortality differentials by parity were assessed using Cox proportional hazard regression models adjusted stepwise for age, origin, education and number of rooms. Analyzes were carried out for middle-aged (45–64 years) and elderly (65–89 years) men and women separately. We observed a non-linear relationship between parity and mortality for all individuals even after adjustment for demographic and socio-economic variables. In fully adjusted models, for example, nulliparous middle-aged women experienced the highest mortality risks (hazard ratios [HR] = 1.57, 95% confidence intervals [CI] 1.24, 1.98) followed by those with one child (HR = 1.29, 95% CI 1.10, 1.51). These results were attenuated somewhat for nulliparous older women (HR = 1.25, 95% CI 1.11, 1.41). The detrimental effects of low and high parity on mortality among both men and women suggest a non pregnancy-related pathway that is likely mediated by biological and psychosocial factors and other lifestyle characteristics that have long-term consequences into older ages. Further research is warranted to examine the effects of parity by specific cause of death.     

Ozone, area social conditions, and mortality in Mexico City

We investigated whether the association of daily mortality and ambient ozone differs by age and area social conditions of the region of residence using a time-series analysis. The study setting was metropolitan Mexico City, a high altitude city situated in a valley, with an estimated 20 million inhabitants, large socioeconomic gradients, and ozone levels frequently exceeding international standards. We stratified daily deaths by six census-derived socioeconomic indicators, based on characteristics of the county where decedents lived. We used Poisson regression to model the association between daily mortality and ozone levels (on the day of death and the previous day) in separate models, stratified by area socioeconomic level and age, and controlling for time trends and temperature. Ozone was positively associated with total mortality [0.65% increase per 10 ppb increment, 95% confidence interval (CI): 0.02%, 1.28%] and for mortality among those over age 65 [1.39% increase per 10 ppb increment, 95% CI: 0.51%, 2.28%]. Associations between ozone and all-age mortality did not show any consistent patterns according to socioeconomic gradients. We conclude that elderly people are at higher risk for ozone-associated mortality. Though county-level social indicators in Mexico City were not strong markers of vulnerability to ozone-associated acute mortality in this analysis, complex associations between individual and area-level factors may exist that would require additional data and further analyses to elucidate.     

Infant mortality at time of birth and cause-specific adult mortality among residents of the Region of Madrid born elsewhere in Spain

BACKGROUND: To investigate the association between infant mortality at time of birth and mortality from various causes of death in adulthood in men and women. METHODS: Linked mortality study based on mortality records for 1996 and 1997 and on 1996 population census data of the Region of Madrid (Spain). Deaths from five cancer sites and from five chronic diseases were estimated for 1 224 894 people aged 35-74 years residing in the Region of Madrid who were born elsewhere in Spain. RESULTS: A gradient in mortality by infant mortality quartile was seen for mortality from stomach cancer, colon cancer, diabetes mellitus and chronic liver disease in men, and for stomach cancer, ischaemic heart disease and chronic liver disease in women. The association was positive for stomach cancer and negative for all other causes. The relative mortality rates adjusted for age and adult socioeconomic factors for men belonging to infant mortality quartiles 3 and 4 (highest) versus those belonging to quartiles 1 and 2 as baseline were 1.06 (95% CI : 0.75-1.56) for stomach cancer, 0.67 (95% CI : 0.47-0.95) for colon cancer, 0.59 (95% CI : 0.35- 1.00) for diabetes mellitus, and 0.70 (95% CI : 0.49-0.99) for chronic heart disease. The relative mortality rates for women were 2.06 (95% CI : 1.09-3.88) for stomach cancer, 0.58 (95% CI : 0.41-0.80) for ischaemic heart disease, and 0.44 (95% CI : 0.27-0.70) for chronic liver disease. CONCLUSION: Higher infant mortality at time of birth is associated with adult mortality from diabetes mellitus and colon cancer in men, from ischaemic heart disease in women, and from stomach cancer and chronic liver disease in both sexes. These results most likely reflect adverse living conditions and/or nutritional deprivation in childhood.     

Lifelong socioeconomic trajectory and premature mortality (35-65 years) in France: findings from the GAZEL Cohort Study

BACKGROUND: Studies conducted in the UK and Scandinavia show an inverse association between lifetime socioeconomic position and adult mortality. However, there are virtually no data from other countries and few investigations have examined non-cardiovascular mortality in men and women. METHODS: Lifelong socioeconomic trajectories (father's occupation, own occupation in young adulthood and in mid-life) and premature (< or = 65 years) mortality (all-cause, smoking-related cancer, diseases of the circulatory system and external causes) in the French GAZEL Cohort Study (14,972 men and 5,598 women, followed up between 1990 and 2004) were studied. Hazard ratios (HRs) were estimated using Cox's regression models adjusted for age, marital status, tobacco smoking, alcohol consumption, body mass index, and fruit and vegetable consumption. RESULTS: Men and women who experienced lifelong disadvantage or downward intergenerational mobility were at high risk of dying prematurely compared with those with a favourable trajectory (age-adjusted HRs for all-cause mortality: cumulative disadvantage: HR 1.61, 95% confidence interval (CI) 1.26 to 2.06 in men and HR 1.95, 95% CI 1.10 to 3.47 in women; downward mobility: HR 1.87, 95% CI 1.35 to 2.58 in men and HR 2.05, 95% CI 1.12 to 3.75 in women). Associations were strongest for mortality due to chronic diseases (smoking-related cancers and diseases of the circulatory system). These associations were partly explained by marital status, body mass index, alcohol consumption, cigarette smoking, and fruit and vegetable consumption. CONCLUSIONS: In France, where the leading cause of premature death is cancer, lifelong socioeconomic position is associated with the risk of dying before the age of 65 years. Adult factors seem more relevant than childhood socioeconomic circumstances.     

Individual and community-level effects in the socioeconomic inequalities of AIDS-related mortality in an urban area of southern Europe

OBJECTIVE: To study socioeconomic inequalities in AIDS mortality in Barcelona, Spain, during the periods 1991-6 (before highly active antiretroviral therapy (HAART)) and 1997-2001 (post-HAART) taking into account individual as well as community effects of socioeconomic level. DESIGN: Cross-sectional design. SETTING: Barcelona, Spain. PARTICIPANTS: All residents aged > or =20 years. All AIDS-related deaths occurring between 1991 and 2001 were studied. The individual variables analysed were age, sex, educational level, neighbourhood of residence and HIV transmission group. Male unemployment was used as the community-level indicator of neighbourhood deprivation. Multilevel Poisson regression models were fitted to estimate the relationship between AIDS mortality and the individual- and community-level variables. RESULTS: At the individual level, AIDS mortality relative risks (RR) were higher among intravenous drug users (IDUs) with lower educational level in both periods. For the younger population, the RR of AIDS-related mortality associated with having little education compared with having a primary education or more was 4.7 (95% CI 3.6 to 6.1) in men and 5.2 (95%CI 3.6 to 7.7) in women in the pre-HAART period, and 4.7 (95% CI 2.7 to 8.1) in men and 4.5 (95% CI 1.4 to 14.1) in women in the post-HAART period. At the community level, an area effect in AIDS mortality was found, which was more important in neighbourhoods having high deprivation in both periods, although the effect was most important in the post-HAART period. CONCLUSIONS: This study has shown inequalities in AIDS mortality in terms of both individual variables and a community-level variable in the pre-HAART as well as in the post-HAART period. These socioeconomic inequalities of AIDS mortality must be considered when prevention and treatment strategies are implemented.     

Gender differences in the healthy worker effect among synthetic vitreous fiber workers

The aim of this study was to determine whether the healthy worker effect and its component parts operate similarly for women and men. A cohort of workers from 14 synthetic vitreous fiber factories in seven countries, employed for at least 1 year between 1933 and 1977 and followed up to the early 1990s, included 375 deaths and 53,608 person-years among females and 2,568 deaths and 210,073 person-years among males. Standardized mortality ratios for all-cause and circulatory diseases were adjusted for country, age, calendar time, and gender. In addition, internal comparisons were adjusted for time since hire and employment status. The analyses addressed the following: 1) the healthy hire effect, 2) the time since hire effect, and 3) the healthy worker survivor effect. In this cohort, an overall healthy worker effect was not present in either gender. The healthy hire effect, based on standardized mortality ratios for years 1-4 since hire, was observed in males (standardized mortality ratio (SMR) = 0.8; 95% confidence interval (CI): 0.7, 1.0) but was less in females (SMR = 0.9; 95% CI: 0.5, 1.6). The relative risks increased slightly with time since hire in males but not in females. Higher mortality ratios were seen among those leaving employment than among those who remained actively employed; however, this effect was substantially greater for women (relative risk (RR) = 3.4; 95% CI: 1.8, 6.3) than men (RR = 1.8; 95% CI: 1.5, 2.1). The gender difference for active versus inactive status was stronger up to age 60 (men: RR = 1.7; 95% CI: 1.4, 2.0; women: RR = 3.6; 95% CI: 1.8, 7.1) than above that age. In conclusion, it appears that there is a stronger selection of healthy men than women into the workforce, while health-related selection out of the workforce is stronger for women than men.