Widening socioeconomic inequalities in mortality in six Western European countries

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.     

Trends in socioeconomic disparities in health care quality in four countries.

OBJECTIVE: To provide a targeted portrait of socioeconomic disparities in health care quality in four countries and how those disparities have changed over time. DESIGN: Within each country, comparisons between the highest and lowest quintiles of socioeconomic status were made to determine if disparities exist and if any observed disparities have been decreasing over a 5-year period. SETTING: Small geographic areas in Canada, England, New Zealand and the United States. DATA SOURCES: Data were obtained by working with national health statistics agencies in each country. RESULTS: There were socioeconomic disparities in health care quality and health status for most of the indicators studied in all four countries. The analysis included nine quality indicators in four countries, for a total of thirty-six observations. Twenty-six observations had a ratio of highest to lowest socioeconomic quintile of <0.95 or >1.05. These disparities generally persisted over time. The relative difference between the highest and lowest quintile decreased over time in eight of the twenty-one observations with time-series data available. CONCLUSION: The fact that disparities in a variety of indicators exist in four very different health systems underscores the importance of factors common to the four systems or factors outside the health system. Some successful strategies for reducing disparities could potentially be learned from the few examples of success in these countries.     

Differential mortality between metropolitan areas of Brazil, 1985-1995

OBJECTIVE: To analyze differential changes of rates and stratification of mortality by gender and causes of death in the metropolitan area of Belo Horizonte (RMBH) and Salvador (RMS) between 1985 and 1995. METHODS: The Ministry of Health's Mortality Information System (SIM) provides data on death causes by age and sex that was used for this study. The groups of death causes were classified according to two major groups (preventable and non-preventable) and the decomposition method presented by Pollard was applied to analyze the contribution of each group of death causes in the changes in life expectation. RESULTS: There have been changes in the pace of the current mortality rate decline in RMBH and RMS, which have resulted in a reduction in the differences between the mortality rates in both areas. In both areas there was a substantial reduction in the mortality rates in the group of preventable causes, especially among women. CONCLUSIONS: There is still a structure of death causes, which seems to indicate that the improvement in mortality among the poor has been lower than it was expected.     

Widening ethnic mortality disparities in New Zealand 1981-99

The aim of this paper is to determine the extent of undercounting of M?ori and Pacific deaths in New Zealand during the 1980s and 1990s, and to calculate corrected ethnic mortality and life expectancy trends. We calculated adjustment ratios for undercounting of M?ori and Pacific deaths (and over-counting of non-M?ori non-Pacific (nMnP) deaths) using the linked census-mortality data. These ratios were then used to calculate corrected mortality rates and life expectancies. M?ori deaths were underestimated by a quarter, and Pacific deaths by a third, during the 1980s and early 1990s. Undercounting was minor in the late 1990s following alignment of ethnicity collection on mortality data to approximate the census. Corrected mortality rates demonstrated 30% (males) and 26% (females) decreases among nMnP from 1980-84 to 1996-99, smaller decreases among M?ori (8% and 7%) and no clear change among Pacific people (9% decrease for males, 4% increase for females). The gap in life expectancy increased from an average of 7.7 years in 1980-84 to 10.8 years in 1996-99 for M?ori, and from 3.3 to 7.7 years for Pacific people, in comparison to nMnP people. Deaths among 45-64 and 65 plus year olds, and cardiovascular disease and cancer deaths, were the main contributors to these disparities. The economic reforms in New Zealand during the 1980s and early 1990s impacted harder upon M?ori and Pacific people in terms of unemployment and income, and are a likely explanation for the diverging mortality trends in this period. Both behavioural factors and health services probably also play a role, but in the absence of trend data by ethnicity, their contribution to diverging mortality trends is unknown. Internationally, our study demonstrates marked undercounting of M?ori and Pacific deaths. We strongly encourage researchers and custodians of vital statistics in other countries to investigate the possibility of undercounting of deaths by ethnicity.     

Racial/ethnic disparities in mortality by stroke subtype in the United States, 1995-1998.

Healthy People 2010 objectives for improving health include a goal to eliminate racial disparities in stroke mortality. Age-specific death rates by stroke subtype are not well documented among racial/ethnic minority populations in the United States. This report examines mortality rates by race/ethnicity for three stroke subtypes during 1995-1998. National Vital Statistics' death certificate data were used to calculate death rates for ischemic stroke (n = 507,256), intracerebral hemorrhage (n = 97,709), and subarachnoid hemorrhage (n = 27,334) among Hispanics, Blacks, American Indians/Alaska Natives, Asians/Pacific Islanders, and Whites by age and sex. Comparisons with Whites as the referent were made using age-standardized risk ratios and age-specific risk ratios. Age-standardized mortality rates for the three stroke subtypes were higher among Blacks than Whites. Death rates from intracerebral hemorrhage were also higher among Asians/Pacific Islanders than Whites. All minority populations had higher death rates from subarachnoid hemorrhage than did Whites. Among adults aged 25-44 years, Blacks and American Indians/Alaska Natives had higher risk ratios than did Whites for all three stroke subtypes. Increased public health attention is needed to reduce incidence and mortality for stroke, the third leading cause of death. Particular attention should be given to increasing awareness of stroke symptoms among young minority groups.     

Trends in socioeconomic health inequalities in the Netherlands, 1981-1999

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.     

Trends in infant mortality in Connecticut, 1981-1992.

Assessing infant mortality rates (IMRs) is important in public health planning. However, single year fluctuations in IMRs often receive attention without consideration of long-term trends. Trends in IMR over 12 years in Connecticut were examined using linked birth and death files. Overall, there was an exponential decline in IMR from 12.2/1,000 live births in 1981 to 7.3/1,000 live births in 1992. However, differential declines in IMRs resulted in an increased relative risk of infant death over time for infants of Black women compared with infants of White women. IMRs were also higher for infants of Black, teenaged, and less educated mothers. Targeted local maternal and child health programs are needed if IMRs are to continue to decline for all sections of the population in Connecticut.     

AIDS mortality in the State of Rio de Janeiro, 1991-1995

This article focuses on the AIDS mortality profile as related to socioeconomic and geographic variables, as well as evaluating the impact of deaths from AIDS in the State of Rio de Janeiro. The analysis included all death certificates for residents of the State from 1991-1995, 10,024 of which had AIDS recorded as the primary cause of death. In the 20-49-year age bracket, among individuals who had died of AIDS, the proportion of those with university schooling (14%) and the proportion of single individuals (75%) were greater than the respective proportions for all other causes of death (5.4% and 56.3%). For the population as a whole, the AIDS mortality rate increased from 1991 to 1995, from 20.6/100,000 to 30.2/100,000 for males and from 3.7/100,000 to 7.9/100,000 for females. For the year 1995 in the 20-49-year bracket, considering the 17 groups of causes from the ICD-9, AIDS was the third most common cause of death among men and the fifth most common among women. The proportion of Potential Loss of Life Years up to 65 years as a function of AIDS increased from 1991 to 1995, from 3.4% to 4.7% for men and from 1.4% to 2.9% for women. During this same period there was also an increase in the number of counties in the State of Rio de Janeiro with reported deaths from AIDS.     

Trends in infant mortality inequalities in the Americas: 1955-1995

STUDY OBJECTIVE:s: To describe overall and income related trends in infant mortality inequalities in the Region of the Americas from 1955 to 1995. DESIGN: Infant mortality rates (IMRs) were computed and their trends assessed by ordinary least squares. Overall trends in IMR inequalities among countries were analysed by comparing 10 year period IMRs, Gini coefficients, and Lorenz curves. Income related trends in IMR inequalities were assessed using 10 year period IMR ratios between the highest and the lowest quintiles of the per capita gross national product (GNP) distributions (adjusted for purchasing power). SETTING: Aggregated country data were used for all countries with over 200 thousand inhabitants (33 geopolitical units). The 10 year period midpoint IMR estimates used for the 1955-1995 time series were those published by the United Nations in 1997. MAIN RESULTS: IMRs decreased from 90.34 to 31.31 per 1000 live births between 1955 and 1995 at an average of 15.3 every 10 years. In contrast, Lorenz curves and Gini coefficients were similar for the five 10 year periods. After grouping by adjusted GNP distribution, a similar decreasing trend of IMR was observed in all groups. The rate ratio between the group at the lowest quintile and that at the highest quintile ranged from 4 to 5. The analysis of variance for repeated observations showed that there is a significant reduction in the IMR (F=130.18; p<0.01), that trends did not differ significantly among groups (F=1.16; p=0.32), and that they were approximately linear (F=155.83; p<0.01). CONCLUSIONS: Despite a sizable reduction in the infant mortality, whether or not income related, levels of IMR inequality among countries have remained almost constant between 1955 and 1995 in the Region of the Americas. Further analysis and focused interventions are needed to tackle the challenges of reducing these persistent mortality inequalities.     

苏州市1985～2000年围生儿死亡率变化及死因分析

目的 了解苏州市1985-2000年围生儿死亡率及死亡原因的动态变化,对进一步降低围生儿死亡率提出干预措施。 方法 对苏州市16年来围生儿死亡监测资料进行回顾性分析。 结果 苏州市围生儿死亡率从1985年的14.17‰(108/7 622)下降到2000年的6.64‰(41/6 176),围生儿死亡主要原因为脐带因素、先天畸形、母体因素、窒息、早产。 结论 降低围生期高危因素是降低围生儿死亡率的关键。     

Trends in lung cancer mortality in South Africa: 1995-2006

Background  

Cancer remains a major cause of morbidity and mortality worldwide. In developing countries, data on lung cancer mortality are scarce.     

Socioeconomic inequalities in all-cause and specific-cause mortality in Australia: 1985-1987 and 1995-1997

BACKGROUND: Socioeconomic inequalities in mortality have been repeatedly observed in Britain, the US, and Europe, and in some countries there is evidence that the differentials are widening. This study describes trends in socioeconomic mortality inequality in Australia for males and females aged 0-14, 15-24 and 25-64 years over the period 1985-1987 to 1995-1997. METHODS: Socioeconomic status (SES) was operationalized using the Index of Relative Socioeconomic Disadvantage, an area-based measure developed by the Australian Bureau of Statistics. Mortality differentials were examined using age-standardized rates, and mortality inequality was assessed using rate ratios, gini coefficients, and a measure of excess mortality. RESULTS: For both periods, and for each sex/age subgroup, death rates were highest in the most disadvantaged areas. The extent and nature of socioeconomic mortality inequality differed for males and females and for each age group: both increases and decreases in mortality inequality were observed, and for some causes, the degree of inequality remained unchanged. If it were possible to reduce death rates among the SES areas to a level equivalent to that of the least disadvantaged area, premature all-cause mortality for males in each age group would be lower by 22%, 28% and 26% respectively, and for females, 35%, 70% and 56%. CONCLUSIONS: The mortality burden in the Australian population attributable to socioeconomic inequality is large, and has profound and far-reaching implications in terms of the unnecessary loss of life, the loss of potentially economically productive members of society, and increased costs for the health care system.     

Alcohol-related hospital utilization and mortality in different occupations in Sweden in 1991-1995.

OBJECTIVES: This study investigated alcohol-related hospital utilization and alcohol-related mortality according to occupation among men and women. Whether increased rates of alcoholism in some occupations result from circumstances within the occupation or from selective recruitment of persons prone to alcohol misuse was studied. METHODS: All Swedish residents were included who reported an occupation in the censuses of 1985 and 1990 and were born in 1926-1960. The relationships between occupation and hospitalization due to an alcoholism diagnosis in 1991-1994 and alcohol-related mortality in 1991-1995 were studied among stable workers (those who held the same occupation in both censuses) and newly recruited workers (those who held different occupations in the two censuses). Incidence and mortality rates were calculated for the different occupations using the person-year method, and standardized rate ratios were used as approximations of the relative risk of disease occurrence and mortality in different occupations as compared with the corresponding statistics of the entire study population. RESULTS: Several, mostly manual, occupations showed an increased relative risk of alcoholism diagnoses and alcohol-related mortality. Nonmanual occupations had low risks. Women in male-dominated high-risk occupations often showed increased relative risks. Stable and newly recruited employees in the same occupation showed very similar relative risks. CONCLUSIONS: New recruits into high-risk occupations often have increased relative risks of at least the same magnitude as persons employed long-term in the same occupations. This finding indicates that the increased relative risk of alcoholism found in some occupations can partly be explained by selective recruitment of heavy drinkers.     

Evolution of mortality amongst the youth of Navarra: 1985-1995

Recent publications show that mortality rates amongst young people and adolescents in some industrialised countries have increased in recent years. The addition of new diseases such as AIDS, which principally affect the young population, to those inevitable deaths brought about through causes such as traffic accidents has increased interest in this public health problem. The number of deaths and the adjusted global mortality rates amongst men and women of 15-34 years did not increase in Navarra in the 1985-1995 period. These are situated around 70 per 100,000. Changes have taken place in the pattern of causes, similar to those observed in other industrialised areas, with an increase of deaths through overdose and AIDS, and a decline in mortality due to traffic accidents in recent years. Traffic accidents were the first cause of death amongst youths until 1993. From this year onwards deaths from AIDS became the first cause amongst women, while amongst men the number of deaths from AIDS is equal to those caused by traffic accidents.     

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

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.     

Trends in old-age mortality in seven European countries, 1950-1999

OBJECTIVE: Different from the general observed decline in old-age mortality, for The Netherlands and Norway there have been reports of stagnation in the decline since the 1980s. We detect periods of stagnation in recent old-age mortality trends, and explore for which causes of death the recent stagnation is most apparent. STUDY DESIGN AND SETTING: We applied Poisson regression analysis to total and cause-specific mortality data by age (80+), period (1950-1999), and sex for seven European low-mortality countries. RESULTS: We found large heterogeneity in the pace of decline in the countries under investigation, with periods of stagnation being widespread. In the 1980s and 1990s, stagnation was observed in Denmark, The Netherlands, and Norway (males). Continued mortality decline was observed especially in France. Although smoking has had a marked influence on the trends in old-age mortality, the role of smoking in the recent stagnation seems only modest and restricted to Norway. Mortality from cardiovascular diseases showed important crossnational variations in the pace of decline. Mortality from diseases specifically related to old age increased recently in all countries, except France. CONCLUSION: Old-age mortality seems highly plastic and susceptible to many factors, with both favorable and unfavorable effects on trends over time.