Democratization and life expectancy in Europe, 1960–2008

Over the past five decades, two successive waves of political reform have brought democracy to, first, Spain, Portugal and Greece, and, more recently, Central and Eastern European countries. We assessed whether democratization was associated with improvements in population health, as indicated by life expectancy and cause-specific mortality rates.Data on life expectancy at birth, age-standardized total and cause-specific mortality rates, levels of democracy and potential time-variant confounding variables were collected from harmonized international databanks. In two pooled cross-sectional time-series analyses with country-fixed effects, life expectancy and cause-specific mortality were regressed on measures of current and cumulative democracy, controlling for confounders. A first analysis covered the 1960–1990 period, a second covered the 1987–2008 period.In the 1960–1990 period, current democracy was more strongly associated with higher life expectancy than cumulative democracy. The positive effects of current democracy on total mortality were mediated mainly by lower mortality from heart disease, pneumonia, liver cirrhosis, and suicide. In the 1987–2008 period, however, current democracy was associated with lower, and cumulative democracy with higher life expectancy, particularly among men. The positive effects of cumulative democracy on total mortality were mediated mainly by lower mortality from circulatory diseases, cancer of the breast, and external causes. Current democracy was associated with higher mortality from motor vehicle accidents in both periods, and also with higher mortality from cancer and all external causes in the second.Our results suggest that in Europe during these two periods democratization has had mixed effects. That short-term changes in levels of democracy had positive effects in the first but not in the second period is probably due to the fact that democratization in Central and Eastern Europe was part of a complete system change which caused major societal disruptions.     

The weaker sex? Exploring lay understandings of gender differences in life expectancy: A qualitative study

Despite increasing interest in gender and health, 'lay' perceptions of gender differences in mortality have been neglected. Drawing on semi-structured interview data from 45 men and women in two age cohorts (born in the early 1950s and 1970s) in the UK, we investigated lay explanations for women's longer life expectancy. Our data suggest that respondents were aware of women's increased longevity, but found this difficult to explain. While many accounts were multifactorial, socio-cultural explanations were more common, more detailed and less tentative than biological explanations. Different socio-cultural explanations (i.e. gendered social roles, 'macho' constraints on men and gender differences in health-related behaviours) were linked by the perception that life expectancy would converge as men and women's lives became more similar. Health behaviours such as going to the doctor or drinking alcohol were often located within wider structural contexts. Female respondents were more likely to focus on women's reproductive and caring roles, while male respondents were more likely to focus on how men were disadvantaged by their 'provider' role. We locate these narratives within academic debates about conceptualising gender: e.g. 'gender as structure' versus 'gender as performance', 'gender as difference' versus 'gender as diversity'.     

Political conditions and life expectancy in Europe, 1900–2008

The rise of life expectancy in Europe has been a very uneven process, both in time and space. This paper aims to identify instances in which major political conditions are likely to have influenced the rise of life expectancy, focusing on formation and dissolution of states and supranational blocs and on differences between political regimes (democratic vs. authoritarian non-communist and communist rule). Data on life expectancy, cause-specific mortality and political conditions were compiled from existing data sources. Possible relations between political conditions and life expectancy were studied by direct comparisons of changes in life expectancy in countries with different political conditions but similar starting levels of life expectancy. We found that formation and dissolution of states often went together with convergence and divergence of life expectancy, respectively, and that otherwise similar countries that did or did not become part of the Soviet bloc had distinctly different life expectancy trajectories. Democratically governed states had higher life expectancies than authoritarian states throughout the 20th century. The gap narrowed between 1920 and 1960 due to rapid catching up of infectious disease control in both non-communist and communist authoritarian states. It widened again after 1960 due to earlier and more rapid progress in democratic states against cardiovascular disease, breast cancer, motor vehicle accidents and other causes of death that have become amenable to intervention. We conclude that the history of life expectancy in Europe contains many instances in which political conditions are likely to have had a temporary or more lasting impact on population health. This suggests that there is scope for further in-depth studies of the impact of specific political determinants on the development of population health in Europe.     

Stroke and active life expectancy in the United States, 1999–2009

BackgroundStroke reduces active life expectancy, both years lived and their proportion without disability. However, active life expectancy studies have provided limited information about strokes in the United States, those occurring throughout older life, or those affecting African Americans.ObjectiveTo measure associations between strokes throughout older life and active life expectancy for African American and White women and men.MethodsUsing data from the Panel Study of Income Dynamics, 1999–2009 (n = 1862, 13,603 person-years), we estimated monthly probabilities of death and disability in activities of daily living with multinomial logistic Markov models adjusted for age, sex, ethnicity, stroke in the past two years, earlier stroke, and education. A random effect accounted for the panel data repeated measures. Microsimulation created large populations with stroke incidence throughout older life, identifying life expectancy and the proportions of remaining life with and without disability. We matched individuals with strokes with randomly selected persons without strokes by age at first stroke, sex, ethnicity, and previous disability.ResultsAverage age at first stroke was higher for women, lower for African Americans. African American and White women were disabled for about two-thirds of life after stroke; results for men were 61.8% for African Americans and 37.2% for Whites. Compared to matched participants, those with strokes lived 33% fewer remaining years (95% confidence interval, CI 30.9%–34.7%) with a 31.6% greater proportion of remaining life with disability (CI 14.4%–55.6%).ConclusionsStroke greatly reduces both life expectancy and the proportion of life without disability, particularly for women and African Americans.     

Mortality and life expectancy in Denmark and in other European countries: What is happening to middle-aged Danes?

Background: The trend in life expectancy in Denmark has beenless favourable than in other European countries for severalyears. The aim of this study was to compare mortality in Denmarkwith that in selected European countries, focusing on age groupsand causes of death for which the Danish trends are particularlyunfavourable. Methods: Comparisons were made for the period1952–1993 between Denmark and Norway, the former FederalRepublic of Germany, The Netherlands, the UK, France, Italyand former Czechoslovakia of age-specific mortality rates andchanges in life expectancy specific for each age group and causeof death. Results: At the end of the period only the formerCzechoslovakia had a lower life expectancy than Denmark; thedifference in life expectancy between Denmark and the othersix countries varied between 5 and 48 months. Almost all ofthe difference was due to a higher mortality rate in the 35–74years age group. All heart diseases and ‘symptoms andill-defined conditions’ were responsible for a large proportionof the Danish high mortality, the decrease in mortality fromthis group of diseases being moderate in comparison with theother countries. Lung cancer contributed to a loss of 1–6months more of life expectancy for Danish women than in theother countries. In comparison with Norway, The Netherlandsand the UK, Danish men lost 2 more months' life expectancy dueto liver cirrhosis and Danish women lost 1 month more. Conclusions:A considerable proportion of the extra deaths in Denmark couldbe prevented.     

Correlates of Heterosexual Behavior Among 23–87 Year Olds in Denmark and Sweden, 1992–1998

Correlates of heterosexual behavior, with a particular focus on early and high sexual activity, anal intercourse, prostitute visits, and HIV test activity, were studied. Telephone interviews were conducted with 852 randomly chosen persons who participated as controls in nationwide case–control studies of anogenital cancers in Denmark and Sweden, 1992–1998. While partner numbers and the practice of anal intercourse increased, age at sexual debut declined by 4–5 years (p < 0.001) and the maturation interval between menarche and first coitus halved (from 7 to 3 years, p < 0.001) between persons born in or before 1920 and those born in or after 1960. Women having high sexual activity were more often tested for HIV than less sexually active women, but men visiting prostitutes and those with prior STDs were not HIV tested more than other men. The increasing practice of anal intercourse, particularly among women with many partners, deserves attention, since this practice may erroneously be considered a safe sexual activity. Along with their partners, men with a history of STDs and those visiting prostitutes should be targeted in future safe sex campaigns, since these men appear to be inadequately HIV tested.     

Trends in active life expectancy in Germany between 1984 and 2003—a cohort analysis with different health indicators

Aim  This article examines trends in active life expectancy and their dependency on indicators of health using data from the German Socio-Economic Panel (GSOEP).Subjects and methods  A multistate life-table modelling approach is used to estimate active life years. First, mortality risks and the rates of entering and leaving the health statuses are estimated by applying multivariate hazard models. In a second step, increment-decrement life tables are constructed by applying age-specific transition rates for three different cohorts. Two measures of limitations in the activities of daily life (ADL) and two measures of health satisfaction are used. The study uses a cohort approach instead of the more commonly used method of cross-sectional investigation.Results  Results show that trends in active life expectancy depend markedly on the indicator chosen. Substantial improvements can be observed for younger cohorts with regard to severe health states. These improvements are a result of the decline in the transition from the independent to the dependent state, whereas no advances in recovery from the dependent state could be found. In contrast, if moderate health limitations in ADLs are investigated, the improvements are less substantial, and moderate health dissatisfaction is not accompanied by any change for younger cohorts.Conclusions  These findings suggest that, rather than examining trends in the prevalence of each health status, further research should focus on the changing path in and out of differing health status.

Left behind: widening disparities for males and females in US county life expectancy, 1985–2010

Background

The United States spends more than any other country on health care. The poor relative performance of the US compared to other high-income countries has attracted attention and raised questions about the performance of the US health system. An important dimension to poor national performance is the large disparities in life expectancy.

Methods

We applied a mixed effects Poisson statistical model and Gaussian Process Regression to estimate age-specific mortality rates for US counties from 1985 to 2010. We generated uncertainty distributions for life expectancy at each age using standard simulation methods.

Results

Female life expectancy in the United States increased from 78.0 years in 1985 to 80.9 years in 2010, while male life expectancy increased from 71.0 years in 1985 to 76.3 years in 2010. The gap between female and male life expectancy in the United States was 7.0 years in 1985, narrowing to 4.6 years in 2010. For males at the county level, the highest life expectancy steadily increased from 75.5 in 1985 to 81.7 in 2010, while the lowest life expectancy remained under 65. For females at the county level, the highest life expectancy increased from 81.1 to 85.0, and the lowest life expectancy remained around 73. For male life expectancy at the county level, there have been three phases in the evolution of inequality: a period of rising inequality from 1985 to 1993, a period of stable inequality from 1993 to 2002, and rising inequality from 2002 to 2010. For females, in contrast, inequality has steadily increased during the 25-year period. Compared to only 154 counties where male life expectancy remained stagnant or declined, 1,405 out of 3,143 counties (45%) have seen no significant change or a significant decline in female life expectancy from 1985 to 2010. In all time periods, the lowest county-level life expectancies are seen in the South, the Mississippi basin, West Virginia, Kentucky, and selected counties with large Native American populations.

Conclusions

The reduction in the number of counties where female life expectancy at birth is declining in the most recent period is welcome news. However, the widening disparities between counties and the slow rate of increase compared to other countries should be viewed as a call for action. An increased focus on factors affecting health outcomes, morbidity, and mortality such as socioeconomic factors, difficulty of access to and poor quality of health care, and behavioral, environmental, and metabolic risk factors is urgently required.

     

Early life circumstances and male suicide – A 30-year follow-up of a Stockholm cohort born in 1953

This study analyses the relationship between early life circumstances and suicide during adolescence and young adulthood among men in a Stockholm birth cohort born in 1953. Relevant variables were derived from Durkheim's proposition of social integration and suicide and Merton's strain theory of deviance. The links between our background variables and suicide were estimated with rare events logistic regression, a statistical method specially developed for situations in which rare events are endemic to the data. We found that self-rated loneliness at age 12–13 as an indicator of social isolation, school absenteeism at the same age as an indicator of school integration, and growing up in a family which received means-tested social assistance at least once during the period 1953–1965 as an indicator of childhood poverty, were statistically related to subsequent suicide risk between 1970 and 1984. Furthermore, following Bourdieu's rereading of Durkheim's Suicide, we argue that social isolation and school integration can be seen as important forms of deprivation, since “social integration” can also be understood in terms of “social recognition”. This view emphasises the importance of taking the emotional and social poverty of children just as seriously as their material poverty when it comes to suicide.     

End‐of‐life decision‐making in Belgium,Denmark, Sweden and Switzerland: does place of death make a difference?

OBJECTIVE: To examine differences in end-of-life decision-making in patients dying at home, in a hospital or in a care home. DESIGN: A death certificate study: certifying physicians from representative samples of death certificates, taken between June 2001 and February 2002, were sent questionnaires on the end-of-life decision-making preceding the patient's death. SETTING: Four European countries: Belgium (Flanders), Denmark, Sweden, and Switzerland (German-speaking part). MAIN OUTCOME MEASURES: The incidence of and communication in different end-of-life decisions: physician-assisted death, alleviation of pain/symptoms with a possible life-shortening effect, and non-treatment decisions. RESULTS: Response rates ranged from 59% in Belgium to 69% in Switzerland. The total number of deaths studied was 12 492. Among all non-sudden deaths the incidence of several end-of-life decisions varied by place of death. Physician-assisted death occurred relatively more often at home (0.3-5.1%); non-treatment decisions generally occurred more often in hospitals (22.4-41.3%), although they were also frequently taken in care homes in Belgium (26.0%) and Switzerland (43.1%). Continuous deep sedation, in particular without the administration of food and fluids, was more likely to occur in hospitals. At home, end-of-life decisions were usually more often discussed with patients. The incidence of discussion with other caregivers was generally relatively low at home compared with in hospitals or care homes. CONCLUSION: The results suggest the possibility that end-of-life decision-making is related to the care setting where people die. The study results seem to call for the development of good end-of-life care options and end-of-life communication guidelines in all settings.     

Gender differences in healthy life years within the EU: an exploration of the “health–survival” paradox

Objectives

To evaluated the female–male health–survival paradox by estimating the contribution of women’s mortality advantage versus women’s disability disadvantage.

Methods

Disability prevalence was measured from the 2006 Survey on Income and Living Conditions in 25 European countries. Disability prevalence was applied to life tables to estimate healthy life years (HLY) at age 15. Gender differences in HLY were split into two parts: that due to gender inequality in mortality and that due to gender inequality in disability. The relationship between women’s mortality advantage or disability disadvantage and the level of population health between countries was analysed using random-effects meta-regression.

Results

Women’s mortality advantage contributes to more HLY in women; women’s higher prevalence of disability reduces the difference in HLY. In populations with high life expectancy women’s advantage in HLY was small or even a men’s advantage was found. In populations with lower life expectancy, the hardship among men is already evident at young ages.

Conclusions

The results suggest that the health–survival paradox is a function of the level of population health, dependent on modifiable factors.     

The health and social well-being of female sex workers’ children in Bangladesh: A qualitative study from Dhaka,Chittagong, and Sylhet

Numerous studies have documented the health problems of sex workers; however, there has been limited research documenting the well-being of children of sex workers. Threats to the health and welfare of these children span their lives. Problems among infants may be more difficult to observe, but field observations by staff at NGOs, who operate drop-in-centers for sex workers in Bangladesh, suggest that older children of sex workers experience significant risks to their health and safety.

This qualitative study explored the threats to the health and welfare of children of sex workers through focus group discussions with sex workers and brothel madams in Bangladesh, all of whom were mothers. Risks to their children were explored from the time of pregnancy through adolescence.

Findings indicate that stigmatization of and discrimination against these children and their mothers are underlying conditions that compromise their access to safe housing, childcare, health care, education, and the protection of law enforcement. The threats they face may exceed those of other children in Bangladesh and include sexual exploitation, exploitive labor, trafficking for adoption, and forced entry into crime. In addition, many children of sex workers have reportedly been traumatized after witnessing police brutality against their mothers. While both sons and daughters of sex workers face similar barriers in altering their life trajectories, gender-specific challenges were also identified.

Additional research documenting trends among children of sex workers and their mothers is needed; however, much can be done immediately to mitigate potential harm by targeting family-based support to these mothers and children to meet basic needs and ensure their basic rights. Our recommendations are to strengthen health, social welfare, and other services to address protection and prevention needs; ensure access to basic services; and provide interventions that address the marginalization resulting from stigma and discrimination.     

The ethics of being a female patient and a female care provider in a male‐dominated health‐illness system

The ethical issues involved in being a woman, either patient or provider, in our current health‐illness care system include violations of the principles of equality, justice, and fairness; allocation of scarce resources; autonomy and informed consent; beneficence and nonmaleficence. Patient and provider need to change. Ethics for women written by women may contribute to a more ethical approach to the treatment of women in general and female patients and health care providers in particular.     

A spatiotemporal analysis of inequalities in life expectancy and 20 causes of mortality in sub-neighbourhoods of Metro Vancouver,British Columbia,Canada, 1990–2016

Spatially varying baseline data can help identify and prioritise actions directed to determinants of intra-urban health inequalities. Twenty-seven years (1990–2016) of cause-specific mortality data in British Columbia, Canada were linked to three demographic data sources. Bayesian small area estimation models were used to estimate life expectancy (LE) at birth and 20 cause-specific mortality rates by sex and year. The gaps in LE for males and females ranged from 6.9 years to 9.5 years with widening inequality in more recent years. Inequality ratios increased for almost all causes, especially for HIV/AIDS and sexually transmitted infections, maternal and neonatal disorders, and neoplasms.     

Acceptability of vaginal microbicides among female sex workers and their intimate male partners in two Mexico–US border cities: A mixed methods analysis

Female sex workers (FSWs) may benefit from pre-exposure prophylaxis (PrEP) including microbicides for HIV prevention. Since adherence is a key factor in PrEP efficacy, we explored microbicide acceptability and potential barriers to use within FSWs’ intimate relationships in Tijuana and Ciudad Juárez, Mexico, where HIV prevalence is increasing. FSWs and their verified intimate (non-commercial) male partners completed quantitative and qualitative interviews from 2010 to 2012. Our complementary mixed methods design followed an iterative process to assess microbicide acceptability, explore related relationship dynamics and identify factors associated with concern about male partners’ anger regarding microbicide use. Among 185 couples (n=370 individuals), interest in microbicides was high. In qualitative interviews with 28 couples, most participants were enthusiastic about microbicides for sex work contexts but some explained that microbicides could imply mistrust/infidelity within their intimate relationships. In the overall sample, nearly one in six participants (16%) worried that male partners would become angry about microbicides, which was associated with higher self-esteem among FSWs and lower self-esteem and past year conflicts causing injury within relationships among men. HIV prevention interventions should consider intimate relationship dynamics posing potential barriers to PrEP acceptability and adherence, involve male partners and promote risk communication skills.     

Letter to the Editor: Prevalence of HIV, HTLV-I and HTLV-II among female sex workers in Spain, 2000–2001

Using an unlinked anonymous survey the seroprevalence of HIV, HTLV-I and HTLV-II was analysed among female sex workers. They were surveyed when they attended sexually transmitted disease clinics in six Spanish cities during the period 2000-2001. Fifty-eight percent of the 3149 women analysed came from Latin America or sub-Saharan Africa. The total prevalence of HIV was 0.7%, rising to 15.9% amongst injecting drug users (IDUs). When this group was not included, the prevalence amongst the Latin-Americans or sub-Saharan Africans was 0.8% and amongst the women from other origins 0.3% (p = 0.148). 33.3% of the women infected with HIV already knew about their infection. The prevalences of HTLV-I and HTLV-II were 0.3% and 0.2%, respectively. The prevalences of these three infections in this collective were low if evaluated without the IDUs.