Subjective social status and mortality: the English Longitudinal Study of Ageing

Self-perceptions of own social position are potentially a key aspect of socioeconomic inequalities in health, but their association with mortality remains poorly understood. We examined whether subjective social status (SSS), a measure of the self-perceived element of social position, was associated with mortality and its role in the associations between objective socioeconomic position (SEP) measures and mortality. We used Cox regression to model the associations between SSS, objective SEP measures and mortality in a sample of 9972 people aged?≥?50 years from the English Longitudinal Study of Ageing over a 10-year follow-up (2002–2013). Our findings indicate that SSS was associated with all-cause, cardiovascular, cancer and other mortality. A unit decrease in the 10-point continuous SSS measure increased by 24 and 8% the mortality risk of people aged 50–64 and?≥?65 years, respectively, after adjustment for age, sex and marital status. The respective estimates for cardiovascular mortality were 36 and 11%. Adjustment for all covariates fully explained the association between SSS and cancer mortality, and partially the remaining associations. In people aged 50–64 years, SSS mediated to a varying extent the associations between objective SEP measures and all-cause mortality. In people aged?≥?65 years, SSS mediated to a lesser extent these associations, and to some extent was associated with mortality independent of objective SEP measures. Nevertheless, in both age groups, wealth partially explained the association between SSS and mortality. In conclusion, SSS is a strong predictor of mortality at older ages, but its role in socioeconomic inequalities in mortality appears to be complex.     

Socioeconomic Disparities in Colorectal Cancer Mortality in the United States, 1990–2007

United States colorectal cancer mortality rates have declined; however, disparities by socioeconomic status and race/ethnicity persist. The objective of this study was to describe the temporal association between colorectal cancer mortality and socioeconomic status by sex and race/ethnicity. Cancer mortality rates in the United States from 1990 to 2007, which were generated by the National Center for Health Statistics, and county-level socioeconomic status, which was estimated as the proportion of county residents living below the national poverty line based on 1990 US Census Bureau data, were obtained from the Surveillance, Epidemiology, and End Results program. The Kunst–Mackenbach relative index of inequality, which considers data across all poverty levels when comparing risks in the poorest (≥20 %) and richest counties (<10 %), was calculated as the measure of association. The study found that colorectal cancer mortality rates were significantly lower in the poorest counties than the richest counties during 1990–1992 among non-Hispanic whites, non-Hispanic black women and non-Hispanic API men. Over time though the tendency was for the poorest counties to have higher mortality rates. By 2003–2007 colorectal cancer mortality rates were significantly higher in the poorest than the richest counties among all sex-race/ethnicity groups. This disparity was most noticeable and appeared to be increasing most among Hispanic men. This suggests that socioeconomic disparities in colorectal cancer mortality were apparent after stratifying by sex and race/ethnicity and reversed over time. Further studies into the causes of these disparities would provide a basis for targeted cancer control interventions and allocation of public health resources.     

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.     

Socioeconomic status and health in the Japanese population

There is growing interest in the influence of socioeconomic status (SES) on health. Individual SES has been shown to be closely related to mortality, morbidity, health-related behavior and access to health care services in Western countries. Whether the same set of social determinants accounts for higher rates of mortality or morbidity in Japan is questionable, because over the past decade the magnitude of the social stratification within the society has increased due to economic and social circumstances. SES must be interpreted within the economic, social, demographic and cultural contexts of a specific country. In this report we discuss the impact of individuals' socioeconomic position on health in Japan with regard to educational attainment, occupational gradient/class, income level, and unemployment.This review is based mainly on papers indexed in Medline/PubMed between 1990 and 2007. We find that socioeconomic differences in mortality, morbidity and risk factors are not uniformly small in Japan. The majority of papers investigate the relationship between education, occupational class and health, but low income and unemployment are not examined sufficiently in Japan. The results also indicate that different socioeconomic contexts and inequality contribute to the mortality, morbidity, and biological and behavioral risk factors in Japan, although the pattern and direction of the relationships may not necessarily be the same in terms of size, pattern, distribution, magnitude and impact as in Western countries. In particular, the association between higher occupational status and lower mortality, as well as higher educational attainment and either mortality or morbidity, is not as strongly expressed among the Japanese. Japan is still one of the healthiest and most egalitarian nations in the world, and social inequalities within the population are less expressed. However, the magnitude of the social stratification has started to increase, and this is an alarming sign.     

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.     

Socioeconomic differences in mortality in Rome, 1990-1995

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 relationship 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. Rome has a population of approximately 2,800,000, with 6,100 census tracts (CTs). During the study period, 149,002 deaths occurred among residents. We compared cause-specific mortality rates among four socioeconomic categories (SES) defined by a socioeconomic index, derived from characteristics of the CT of residence. 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 due 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 breast cancer 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. 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 life style and in the prevalence of risk behaviors 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.     

Socioeconomic inequalities and low birth weight and perinatal mortality in Rio de Janeiro, Brazil

Socioeconomic inequalities in early infant mortality have been evidenced in Brazil, with a greater mortality risk associated with the mother's socioeconomic status (SES). The aim of this paper is to identify socioeconomic inequalities in relation to low birth weight and perinatal mortality in the City of Rio de Janeiro, Brazil, discussing the appropriateness of the main health inequality indexes proposed in the international literature. As the information source, we use data collected in a survey of approximately 10,000 mothers selected for interview within 48 hours after delivery in public and private hospitals in the city. Using educational level and head of household's income as indicators of SES, as well as population attributable risk and slope index of inequality as health inequality measures, the results show a steep socioeconomic gradient in the proportion of low birth weight, and especially in the perinatal mortality rate. The persistent association between socioeconomic indicators and adverse results in pregnancy indicates (at least partially) the health system's inefficacy in diminishing perinatal health inequalities in Rio de Janeiro.     

Traffic intensity, dwelling value, and hospital admissions for respiratory disease among the elderly in Montreal (Canada): a case-control analysis

BACKGROUND: Persons exposed to residential traffic have increased rates of respiratory morbidity and mortality. As poverty is an important determinant of ill health, some have argued that these associations may relate to the lower socioeconomic status of those living along major roads. AIMS: The objective was to evaluate the association between traffic intensity at home and hospital admissions for respiratory disease among Montreal residents of 60 years and older. METHODS: Case hospitalisations were those with respiratory diagnoses and control hospitalisations were those where the primary discharge diagnosis was non-respiratory. Morning peak traffic estimates from the EMME/2 Montreal traffic model (MOTREM98) were used as an indicator of exposure to road traffic outside the homes of those hospitalised. The crude association between traffic intensity and hospitalisation for respiratory disease was adjusted by an area based estimate of the appraised value of patients' residences, expressed as a dollar average over a small segment of road (lodging value). This indicator of socioeconomic status, as calculated from the Montreal property assessment database, is available at a finer geographical scale than the neighbourhood socioeconomic indicators accessible from the Canadian census. RESULTS: Increased odds of being hospitalised for a respiratory compared with a control diagnosis were associated with higher levels of estimated road traffic nearby patients' homes, even after adjustment for lodging value (crude OR 1.35, CI95% 1.22 to 1.49; adjusted OR 1.18, CI95% 1.06 to 1.31 for >3160 vehicles passing during the three hour morning traffic peak compared with secondary roads off network). CONCLUSION: The results suggest that road traffic intensity itself, may affect the respiratory health of elderly residents of a large Canadian city, an association that is not solely a reflection of socioeconomic status.     

Socioeconomic disadvantage, social participation and networks and the self-rated health of English men and women with mild and moderate intellectual disabilities: cross sectional survey

BACKGROUND: Extremely high rates of mortality and morbidity have been reported among people with intellectual disabilities. Virtually no research has addressed the potential social determinants of health status within this very vulnerable population. METHOD: Cross-sectional survey of self-reported health status and indicators of socioeconomic disadvantage and social connectedness in 1273 English adults with mild or moderate intellectual disabilities. RESULTS: Indicators of socioeconomic disadvantage accounted for a statistically significant proportion of variation in health status, over and above any variation attributable to the personal characteristics and living circumstances of participants. Indicators of social participation and networks did not add to the explanatory power of the model. Among the indicators of socioeconomic disadvantage, hardship was more strongly associated with variation in health status than either employment status or area-level deprivation. CONCLUSION: As in the general population, self-reported health was associated with indicators of socioeconomic disadvantage, especially hardship. In contrast, there was no evidence of any association between health status and social participation and networks.     

Socioeconomic status and mortality in Swedish women: opposing trends for cardiovascular disease and cancer

We examined relations between socioeconomic status and cardiovascular disease, cancer, and diabetes mellitus in a 24-year prospective study of 1,462 Swedish women. Two socioeconomic indicators were used: the husband's occupational category for married women and a composite indicator combining women's educational level with household income for all women. The husband's occupational category was strongly associated with cardiovascular disease and cancer mortality in opposite directions, independent of age and other potential confounders. Women with husbands of lower occupational categories had an increased risk of cardiovascular disease mortality [relative risk (RR) = 1.60; 95% confidence interval (95% CI) = 1.09-2.33] while experiencing lower rates of all-site cancer mortality (RR = 0.69; 95% CI = 0.50-0.96). A similar relation was seen with the composite variable: women with low socioeconomic status had an increased risk of cardiovascular disease (RR = 1.37; 95% CI = 1.01-1.84) but a somewhat lower risk for cancer of all sites (RR = 0.86; 95% CI = 0.66-1.11). Finally, morbidity data (diabetes mellitus, stroke, and breast cancer) yielded results that were consistent with the mortality trends, and breast cancer appeared to account for a major part of the association between total cancer and high socioeconomic status. In summary, higher socioeconomic status was associated with decreased cardiovascular disease mortality and excess cancer mortality, in such a way that only a weak association was seen for all-cause mortality.     

Time series analysis of air pollution and mortality: effects by cause, age and socioeconomic status

OBJECTIVE: To investigate the association between outdoor air pollution and mortality in S?o Paulo, Brazil. DESIGN: Time series study METHODS: All causes, respiratory and cardiovascular mortality were analysed and the role of age and socioeconomic status in modifying associations between mortality and air pollution were investigated. Models used Poisson regression and included terms for temporal patterns, meteorology, and autocorrelation. MAIN RESULTS: All causes all ages mortality showed much smaller associations with air pollution than mortality for specific causes and age groups. In the elderly, a 3-4% increase in daily deaths for all causes and for cardiovascular diseases was associated with an increase in fine particulate matter and in sulphur dioxide from the 10th to the 90th percentile. For respiratory deaths the increase in mortality was higher (6%). Cardiovascular deaths were additionally associated with levels of carbon monoxide (4% increase in daily deaths). The associations between air pollutants and mortality in children under 5 years of age were not statistically significant. There was a significant trend of increasing risk of death according to age with effects most evident for subjects over 65 years old. The effect of air pollution was also larger in areas of higher socioeconomic level. CONCLUSIONS: These results show further evidence of an association between air pollution and mortality but of smaller magnitude than found in other similar studies. In addition, it seems that older age groups are at a higher risk of mortality associated with air pollution. Such complexity should be taken into account in health risk assessment based on time series studies.     

膳食模式、社会经济地位对心血管病10年风险的联合影响

  目的  探讨膳食模式与社会经济地位对心血管病10年风险的联合影响,为心血管病的防控提供参考。  方法  采用多阶段抽样方法,问卷调查2 431例北京市门头沟区居民。单因素分析探索膳食模式、社会经济地位、心血管病10年风险之间的相关关系,多因素Logistic回归分析模型分析前两者对心血管病10年风险的联合影响。  结果  北京市门头沟区常住居民心血管病10年中高风险比例为38.46%。高盐饮酒膳食模式(48.93%)和低社会经济地位(58.47%)的心血管病10年中高风险比例较高(均有P < 0.001)。调整因素后,以均衡膳食且高社会经济地位为参照,高盐饮酒膳食且低社会经济地位人群的心血管病10年中高风险比例最高(OR=6.841, 95% CI: 4.518~10.540, P < 0.001)。  结论  合理膳食需要联合考虑不同群体的社会经济地位,结合实际鼓励科学营养,以促进真实世界的心血管病防控。     

Differential effects of family income on self-rated health by age: analysis of Seoul citizens health indicators survey 2001, 2005]

OBJECTIVES: This study was conducted in order to determine how the association between socioeconomic position(SEP) and health status changes with age among Seoul residents aged 25 and over. METHODS: We utilized the 2001 and 2005 Seoul Citizens Health Indicators Surveys. We used self-rated 'poor' health status as an outcome variable, and family income as an indicator of SEP. In order to characterize the differential effects of socioeconomic position on health by age, we conducted separate multivariate analyses by 10-year age groups, controlling for sociodemographic covariates. In order to assess the relative health inequality across socioeconomic groups, we estimated the Relative Index of Inequality (RII). RESULTS: The risk of 'poor health' is significantly high in low family income groups, and this increased risk is seen at all ages. However, the magnitude of relative socioeconomic inequality in health, as measured by the odds ratio and RII, is not identical across age groups. The difference in health across income groups is small in early adulthood (ages 25-34), but increases with age until relatively late in life (ages 35-64). It then decreases among the elderly population (ages more than 65). When the RII reported in 2005 is compared to that reported in 2001, RII can be seen to have increased across all ages, with the exception of individuals aged 25-34. CONCLUSIONS: The magnitude of health inequality is the greatest during mid- to late adulthood (ages 45-64). In addition, health inequalities have worsened between 2001 and 2005 across all age groups after economic crisis.     

Neighborhood social environment and risk of death: multilevel evidence from the Alameda County Study.

Recent reports suggest the importance of associations between residential area characteristics and health status, but most research uses only census data to measure these characteristics. The current research examined the effect of overall neighborhood social environment on 11-year risk of death. On the basis of data, the authors developed a three-component neighborhood social environment scale: 1) commercial stores; 2) population socioeconomic status; and 3) environment/housing. Data from the 1983 wave of the Alameda County Study (n = 1,129) and deaths over 11 years were analyzed with two-level logistic regression models. Age- and sex-adjusted risk of death was higher for residents in low social environment neighborhoods (odds ratio = 1.58, 95% confidence interval 1.15-2.18). Mortality risks were significantly higher in neighborhoods with a low social environment, even after account was taken of individual income level, education, race/ethnicity, perceived health status, smoking status, body mass index, and alcohol consumption. When each component of the neighborhood social environment characteristics score was examined separately, each was found to be associated with higher risk for mortality, independent of individual risk factors. These findings demonstrate the role of area characteristics as a health risk factor and point to the need for more focused attention to the meaning and measurement of neighborhood quality.     

Assessment of the magnitude of geographical variations and socioeconomic contextual effects on ischaemic heart disease mortality: a multilevel survival analysis of a large Swedish cohort

BACKGROUND: In a public health perspective, it is of interest to assess the magnitude of geographical variations in ischaemic heart disease (IHD) mortality and quantify the strength of contextual effects on IHD. OBJECTIVE: To investigate whether area effects vary according to the individual and contextual characteristics of the population, socioeconomic contextual influences were assessed in different age groups and within territories of differing population densities. DESIGN: Multilevel survival analysis of a 28-year longitudinal database. PARTICIPANTS: 341 048 residents of the Scania region in Sweden, reaching age 50-79 years in 1996, followed up over 7 years. RESULTS: After adjustment for several individual socioeconomic indicators over the adult age, Cox multilevel models indicated geographical variations in IHD mortality and socioeconomic contextual effects on the mortality risk. However, the magnitude of geographical variations and strength of contextual effects were modified by the age of individuals and the population density of their residential area: socioeconomic contextual effects were much stronger among non-elderly than among elderly adults, and much larger within urban territories than within rural ones. As a consequence, among non-elderly residents of urban territories, the socioeconomic contextual effect was almost as large as the effect of individual 20-year cumulated income. CONCLUSIONS: Non-elderly residents of deprived urban neighbourhoods constitute a major target for both contextual epidemiology of coronary disease and public health interventions aimed at reducing the detrimental effects of the social environment on IHD.     

Occupational social class,educational level,smoking and body mass index,and cause-specific mortality in men and women: a prospective study in the European Prospective Investigation of Cancer and Nutrition in Norfolk (EPIC-Norfolk) cohort

OBJECTIVES: To investigate the independent associations between occupational and educational based measures of socioeconomic status (SES) and cause-specific mortality, and the extent to which potentially modifiable risk factors smoking and body mass index (BMI) explain such relationships. DESIGN, SETTING AND PARTICIPANTS: Prospective population study of 22,486 men and women aged 39-79 years living in the general community in Norfolk, United Kingdom, recruited using general practice age-sex registers in 1993-1997 and followed up for total mortality using death certification to 2006. MAIN RESULTS: In men a strong inverse relationship was found between social class and all cause, cardiovascular and cancer mortality, with relative risk of social class V compared to I of 2.21 for all cause mortality (95% CI 1.54-3.17, P < 0.001). This was attenuated but not abolished after adjusting for modifiable risk factors, smoking and BMI, with relative risk of social class V compared to I for all cause mortality of 1.92 (95% CI 1.34-2.77, P < 0.001). A similar, but smaller effect was seen in women. Educational status was not associated with mortality independently of social class. CONCLUSIONS: Social class and education are not necessarily interchangeable measures of SES. Some but not all of the socioeconomic differential in mortality can be explained by potentially modifiable risk factors smoking and BMI. Further understanding of the mechanisms underlying the association of each socioeconomic indicator with specific health outcomes is needed if we are to reduce inequalities in health.     

Stomach cancer mortality in the north central states: High risk is not limited to the foreign‐born

The proportion of residents born in northern Europe best explains the pattern of stomach cancer mortality in Minnesota, Wisconsin, and upper Michigan counties. The settling patterns of Finns, and to a lesser extent of Poles, Norwegians, Danes and Swedes, are strongly associated with county stomach cancer rates. Socio‐economic status and water supply are less significant. Even after socioeconomic status and water supply are factored out, estimated stomach cancer mortality for these populations is still disproportionately high. Other researchers have identified diet as a major risk factor in stomach cancer and as the prime cause of the ethnicity‐stomach cancer association. We suggest that natives shared the stomach cancer risk, perhaps by adopting the “high risk”; diet of the foreign‐born.     

Long-term effects of wealth on mortality and self-rated health status

Epidemiologic studies seldom include wealth as a component of socioeconomic status. The authors investigated the associations between wealth and 2 broad outcome measures: mortality and self-rated general health status. Data from the longitudinal Panel Study of Income Dynamics, collected in a US population between 1984 and 2005, were used to fit marginal structural models and to estimate relative and absolute measures of effect. Wealth was specified as a 6-category variable: those with ≤0 wealth and quintiles of positive wealth. There were a 16%-44% higher risk and 6-18 excess cases of poor/fair health (per 1,000 persons) among the less wealthy relative to the wealthiest quintile. Less wealthy men, women, and whites had higher risk of poor/fair health relative to their wealthy counterparts. The overall wealth-mortality association revealed a 62% increased risk and 4 excess deaths (per 1,000 persons) among the least wealthy. Less wealthy women had between a 24% and a 90% higher risk of death, and the least wealthy men had 6 excess deaths compared with the wealthiest quintile. Overall, there was a strong inverse association between wealth and poor health status and between wealth and mortality.     

The importance of social relationships, socioeconomic status and health practices with respect to mortality among healthy Ontario males.

The associations of social relationships, socioeconomic status and health practices with 20-year mortality were examined in a cohort of 2000 Ontario males. A social relationships index comprised of marital status, number of children, family contact and participation in voluntary associations had a strong association with mortality (adjusted relative risk of 0.30, 95% CI 0.11-0.83, comparing the highest 10% with the lowest 10% scores of the index). Among indicators of socioeconomic status, only income was significantly related to mortality with an adjusted relative risk of 0.41 (95% CI 0.23-0.72) for the highest 20% compared with the lowest 20% income group. The adjusted relative risk for smokers compared with non-smokers was 2.26 (95% CI 1.51-3.37). The joint effects of a relatively high score in the social relationships index, high income and being a non-smoker is estimated to represent an approximately 18-fold reduction in the risk of mortality during the follow-up period.     

Income and mortality: the shape of the association and confounding New Zealand Census-Mortality Study, 1981-1999

OBJECTIVE: To determine the shape of the income-mortality association, before and after adjusting for confounding by other socioeconomic variables. METHODS: Poisson regression analyses were conducted on 11.7 million years of follow-up of 25-59 year old New Zealand census respondents spanning four separate cohort studies (1981-1984, 1986-1989, 1991-1994, and 1996-1999). RESULTS: Mortality among low-income people was approximately two times that among high-income people. Adjustment for potential socioeconomic confounders (marital status, education, car access, and neighbourhood socioeconomic deprivation) halved the strength of the income-mortality association, but did not appreciably change the shape of the association. Further adjustment for labour force status largely removed the income-mortality association. The association of non-transformed income with mortality was non-linear, with a flattening out of the slope at higher incomes. Both the logarithm and rank of income appeared to have a better linear fit with the mortality rate, although the association of mortality with the logarithm of income flattened out notably at low incomes. CONCLUSIONS: Much, but not all, of the crude association of income with mortality could be due to confounding. Adjusting income-mortality associations for labour force status (also a proxy for health status) is problematic: on the one hand, it over-adjusts the association as poor health will be on the pathway from income to mortality; on the other hand, it appropriately adjusts for both confounding by labour force status and reverse causation whereby income changes as a result of poor health. Both logarithmic and rank transformations of income have a reasonable linear fit with income.