Stable and dynamic differences in injury mortality between the Nordic countries. What do they say about inherent national characteristics with regard to risk?

The aim of this study was to analyse long-term trends and patterns in injury mortality between the Nordic countries and to distinguish differences that are relatively temporary from those that are more durable. Both total injury mortality and special subcategories were examined. Some stable similarities and differences were found. Two kinds of injuries are distinguished: those that largely have a social genesis and those to which environmental causality applies. The general pattern is that there has been an increase in injuries with a social genesis and a decrease in those with an environment-related genesis. Finland has high rates of both types of injuries. Denmark has high rates of injuries with a social genesis, but low rates of those with an environmental genesis. By contrast, Norway has high rates of injuries with an environmental genesis and low rates of those with a social genesis. Sweden has low or medium rates of both types of injuries.     

Mapping high or low mortality places across time in the United States: a research note on a health visualization and analysis project

This research note reports progress in visualizing and analyzing United States mortality data at the county level. The data visualization technique employed here may be applicable to other research situations. We dichotomized the range of mortality rates into high or low mortality counties, mapped them, and explored the clustering of high or low mortality rate counties across both space and time. We find visual evidence that high or low mortality counties spatially cluster together during individual periods of time (5 years). We find further visual evidence that there is a spatial persistence over time (30 years) of these counties with high or low mortality. This evidence leads us to conclude that relatively high or low mortality is anchored over time within a spatial region and population, suggesting that research efforts may be focused on these clusters to assess local causes of high or low mortality rates. Future research will examine the permanence of the resident population (i.e., population mixing), characteristics of the resident population, and characteristics of their place of residence over time.     

Assessment of a national health interview survey-based method of measuring community socioeconomic status

PURPOSE: Increasingly researchers are interested in assessing the role of community socioeconomic status (SES) in poor health outcomes, above and beyond the influence of low individual SES. However, the feasibility of conducting these multi-level studies is often limited by restrictions on release of confidential identifiers for linkage to census data, resources for the linkage, and the availability of data sources with individual SES measures. This study assessed a new method of measuring community socioeconomic status (SES) that can be used with the publicly available National Health Interview Survey (NHIS) and preserves confidentiality and can be used with individual SES measures from the NHIS. METHODS: The associations between community SES and mortality from all causes and breast cancer in women were assessed in two samples: 1) deaths in 1987-1993 NHIS respondents linked to community SES measures developed with the new method; and 2) deaths in 1991 from the National Multiple Cause of Death Files linked to 1990 county-level census SES measures. The magnitude of crude mortality rates, direction of trend, and age-adjusted relative risk of mortality for low vs. high SES were compared in the two samples. RESULTS: Crude all-cause mortality and breast cancer mortality rates were similar in both samples in terms of magnitude and direction of trend. In both samples, as SES decreased, rates of all-cause mortality increased, whereas breast cancer mortality rates tended to decrease. Age-adjusted relative risks of mortality from all causes and breast cancer for low vs. high SES were similar in the two samples. CONCLUSIONS: Similarity of associations between community SES and mortality from all causes and breast cancer in the two samples provides support for the validity of a new NHIS-based method of measuring community SES. Since the NHIS is a large, nationally representative survey with high response rates and low loss to mortality follow-up, this method represents an important resource for multi-level studies.     

Migration and geographical inequalities in health in Britain

This paper explores the role of migration in creating geographical inequalities in mortality at the district level in Britain for the British Household Panel Study sample--a representative sample of 10264 British residents born after 1890 and enumerated in 1991. Analysis of the mortality rates of migrants showed that male migration accounts for nearly all the differences in mortality rates between districts. The BHPS was then utilised to look at the lifetime socio-economic characteristics of these migrants and to compare men and women. It was found that the health of both men and women moving from high mortality districts to low mortality districts could be explained by advantage over their lifetimes. The small proportion of men and women moving from low mortality districts to high mortality districts represent a very mixed group and their contribution, whilst small, is intriguing, as is the very different mortality rates of men and women in this group.     

Metal Ions in Biological System,Volume 36: Interrelations Between Free Radicals and Metal Ions in Life Processes.

Physical inactivity is associated with higher mortality rates in most studies in men, but studies in women are more equivocal. The purpose of this study was to evaluate the relationship of sedentary living habits to all-cause mortality in women. A group of 3,120 adult women completed a preventive medical examination, and were followed for approximately 8 years for mortality. There were 43 deaths and a total of 25,433 person-years observed during follow-up. Physical fitness was assessed at baseline by a maximal exercise test on a treadmill, and physical activity was estimated by a self-administered questionnaire. Age-adjusted all-cause mortality rates were significantly inversely associated with physical fitness. Death rates were 40, 16, and 7 per 10,000 person-years of follow-up across low, moderate, and high categories of physical fitness, respectively. However, death rates did not differ across low, moderate, and high categories of physical activity. These findings are different than for men in the same study, where both physical activity and physical fitness were inversely associated with mortality risk. We attribute the lack of association between physical activity and mortality in women to be due to inadequate assessment of activity, and that this also is the likely explanation for the difference in results between women and men in published studies of physical activity and mortality.     

Respiratory disease mortality in New Mexico's American Indians and Hispanics.

To determine the effect of ethnic group on respiratory disease occurrence, average annual sex, ethnic, and disease specific mortality rates for the period of 1969 to 1977 were calculated for New Mexico's American Indian, Hispanic, and Anglo populations. Incidence data were available for respiratory tract cancer. This study corroborates previous findings of reduced mortality from lung cancer in American Indians of both sexes and in Hispanic males. American Indian mortality from tuberculosis and from influenza and pneumonia was high. Hispanic males and American Indians of both sexes showed low mortality rates for chronic obstructive pulmonary disease (COPD). Differing cigarette usage is the most obvious explanation for the variations in COPD and lung cancer occurrence with ethnic group.     

Infant mortality, public policy and inequality – a comparison of 18 industrialised countries 1950–85

Using new comparative data bases this paper examines whether infant mortality rates in industrialised nations are affected by public policies and income inequality. Particular attention is given to the role of the level of economic development, public policy and the distribution of economic resources. The study shows that the level of economic development has a strong, but decreasing impact on the infant mortality rate. Income inequality and relative poverty rates appear to be of greater importance for the variation in infant mortality rates than the level of economic development between rich countries. Levels of unemployment and of social security benefits seems to affect the infant mortality rate; the combination of high unemployment and low unemployment benefits seems to be associated with particularly high mortality rates. A high level of family benefits is also associated with low infant mortality rates.     

Stroke mortality and its socioeconomic,racial, and behavioral correlates in Florida.

Stroke mortality is associated both with being black and with having low socioeconomic status. However, it is uncertain to what extent that increased risk is related to rates of behavior-related risk factors, such as hypertension, cigarette smoking, obesity, or alcohol consumption. The investigators performed an ecologic analysis to estimate the contributions of behavioral risks, socioeconomic status, and black race to regional variations in stroke mortality rates among persons 55-84 years of age in Florida. They used data from the 1980 census and from the Behavioral Risk Factor Surveillance System (BRFSS) for 1986 through 1988. Weighted multiple linear regression models indicated that regions in Florida with high stroke mortality rates were characterized by high prevalences of poverty, obesity, and hypertension. Although limited by its ecologic design, this study suggests that socioeconomic status and prevalence of behavioral risks contribute independently to interregional disparities in stroke mortality rates in Florida. BRFSS data, now available for more than 45 States, can be used to help clarify the relative contributions of behavioral and other risks to population-based mortality rates.     

Hypertension-related mortality in California

Death rates in California for hypertension-related diseases during 1969-71 and 1979-81 are compared. During both periods, age-standardized rates for a composite hypertension-related mortality category are highest for blacks, followed by whites, and lowest for Asians and Pacific Islanders. Filipinos who have high prevalence rates of hypertension record low rates of hypertension-related mortality. After adjusting for the comparability ratio, the age-standardized hypertension-related death rate declined by more than 28 percent between 1969-71 and 1979-81. The decrease was greatest at age 15-44 years. Of all major hypertension-related diseases, cerebrovascular diseases registered consistently large percentage declines in mortality for all age and race groupings examined. Possible reasons for the considerable decline in hypertension-related mortality and low death rates for Asians and Pacific Islanders are discussed. The combined effects of improved population awareness, level of treatment, and control of hypertension; a greater knowledge of cardiovascular risk factors and associated modifications of behavior; and improved medical technology and care may have contributed to the decline.     

Use of hospital mortality rates following myocardial revascularization surgery to monitor hospital care

Brazilian hospitals performing coronary artery by-pass graft surgery (CABG) from 1996 to 1998 and covered by the Ministry of Health were ranked according to their risk-adjusted hospital mortality rates. Seventy-six hospitals that performed more than 150 CABGs (total of 38,962 surgical interventions) were classified as low or high outliers according to the ratio between observed and expected hospital mortality rates. Overall hospital mortality rate was 7.20%. The rate was 3.48% among patients treated in the low outliers and 13.96% among the high outliers. The methodology was useful for discriminating Brazilian hospitals according to their post-CABG mortality rates and may be a useful tool for identifying hospitals with possible quality-of-care problems.     

Adjusted mortality rates: a tool for creating more meaningful league tables for stillbirth and infant mortality rates

A number of problems associated with league tables of performance indicators have been discussed in the literature. This paper attempts to address these problems for stillbirth and infant mortality rates in order to produce meaningful and useful information for the government, general public and health professionals. Composite stillbirth and infant mortality rates, low birth-weight and very low birth-weight rates were determined for the 100 English Health Authorities for 1996-1997. Townsend deprivation scores for these districts were also obtained. The mortality rates were adjusted by multiple regression for very low birth-weight and Townsend score separately and together. Confidence intervals were calculated for the dual-adjusted rates. Almost 60% of the variability in mortality rates were explained by Townsend score and very low birth-weight rates together. Adjusted league tables showed how the individual and combined predictors affect the individual mortality rates for each Health Authority. There was considerable overlap in the confidence intervals for the adjusted rates although there were a few Health Authorities whose mortality rates were clearly below most others. We conclude that fairer and more useful information is provided by geographically based league tables which give both crude rates and rates adjusted for single and multiple predictor variables. The inclusion of confidence intervals aids interpretation of annual random variations and knowledge of differences in the effects of the individual predictors enables better resource targeting.     

Avoidable mortality in Belgium

The concept of avoidable mortality leads to an attempt at using specific mortality rates as output measures of health services. The analysis covered 43 Belgian districts between the years 1974 and 1978. Two Belgian areas were compared along a dimension defined by two axes of a correspondence factor analysis: Flanders which is associated with low SMR of avoidable mortality and Wallonia which has high rates. The persistence of high mortality in Wallonia was confirmed. Factorial scores for each district were used as indexes for geographical heterogeneity. Variations in these indices, including patient consultation rates and technical medical procedures, remained even after adjustment for socio-economic differences.     

Social patterning of myocardial infarction and stroke in Sweden: incidence and survival

Cardiovascular disease morbidity and mortality rates show marked social patterning in industrialized countries. The aim of this study was to analyze if not only incidence but also survival after acute myocardial infarction (AMI) and stroke differ among socioeconomic groups. Within the framework of the population-based World Health Organization's Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) Project, all first-ever AMI (ages 25-64 years) and stroke (ages 25-74 years) events were recorded in northern Sweden during the period 1985-1994. The numbers of first-ever AMI and stroke patients included in the study were 3,466 and 4,215, respectively. Incidence rates for both AMI and stroke showed a distinct social pattern, with high rates in workers and self-employed nonprofessionals and low rates in professionals. The pattern was similar in men and women. In men, early survival after an AMI follows the same socioeconomic pattern, whereas it is less clear if socioeconomic differences in survival contribute to explain differences in mortality in AMI among women and mortality in stroke (both sexes). The high case fatality among male workers and self-employed professionals with AMI is, in turn, attributed to a very marked increase in the risk for sudden death.     

Narrowing inequalities in infant mortality in Southern Brazil

OBJECTIVE: To determine the trends of infant mortality from 1995 to 1999 according to a geographic area-based measure of maternal education in Porto Alegre, Brazil. METHODS: A registry-based study was carried out and a municipal database created in 1994 was used. All live births (n=119,170) and infant deaths (n=1,934) were considered. Five different geographic areas were defined according to quintiles of the percentage of low maternal educational level (<8 years of schooling): high, medium high, medium, medium low, and low [corrected]. The chi-square test for trend was used to compare rates between years. Incidence rate ratio was calculated using Poisson regression to identify excess infant mortality in poorer areas compared to higher schooling areas. RESULTS: The infant mortality rate (IMR) decreased steadily from 18.38 deaths per 1,000 live births in 1995 to 12.21 in 1999 (chi-square for trend p<0.001). Both neonatal and post-neonatal mortality rates decreased although the drop seemed to be steeper for the post-neonatal component. The higher decline was seen in poorer areas. CONCLUSION: Inequalities in IMR seem to have decreased due to a steeper reduction in both neonatal and post-neonatal components of infant mortality in lower maternal schooling area.     

Antenatal booking and perinatal mortality in Scotland 1972-1982

Data from Scottish maternity hospital discharge returns (SMR2) were analysed to determine the relationship between gestational age at antenatal booking and perinatal mortality during 1972-82, controlling for maternal age, parity, socioeconomic and marital status. Maternal youth, multiparity and unmarried status were independently associated with both a high perinatal mortality and a low proportion of maternities booked before 17 weeks gestation. However, among primiparae and mothers aged 30 years or more relatively high perinatal mortality rates were associated with high proportions booking early for antenatal care. Socioeconomic status amongst married women, independent of age and parity, influenced perinatal mortality but had little effect on booking behaviour. Between 1972-75 and 1980-82, there was a general increase in the proportion of maternities booked before 17 weeks gestation, but no significant difference was found between the standardized perinatal mortality rates for pregnancies booked before and after 17 weeks gestation. More detailed analysis for different gestational ages at booking during 1980-82 revealed no trend of increasing risk with later booking. Despite technological advances, antenatal care during the first half of pregnancy is unlikely to have made a substantial contribution to the fall in perinatal mortality over this period.     

Is the high ischemic heart disease mortality rate in New York State just an urban effect?

To determine whether New York State''s high ischemic heart disease mortality rate was due primarily to an urban effect, rates for regions in the State were compared with each other and with national data. New York State mortality rates for the period 1980-87 were highest for New York City (344.5 per 100,000 residents), followed by upstate urban and rural areas (267.1-285.1), and New York City suburbs (272.5). However, the overall 1986 age-adjusted rate for the New York State region with the lowest mortality rate (265.7) exceeded that of 42 States. New York State''s number one ischemic heart disease mortality ranking reflects the need for statewide intervention programs, because even regions with relatively low mortality rates are high when they are compared with national rates.     

Antioxidants and Cancer

The possible epidemiologic relationship between selenium occurrence and cancer mortality was studied in cities and states located in areas with different levels of selenium bioavailability. Statistically significant differences were found in age-specific cancer death rates among states with high, medium, and low selenium levels. The death rates for specific types of cancer showed a larger difference in males than in females in the states with high selenium levels. The greater difference between males and females may be related to sex difference or to the fact that males are heavier smokers and are also more likely to be exposed to industrial pollution. In the states with high selenium levels, there was significantly lower mortality in both males and females from several types of cancer, particularly the environmental problem indicators, such as gastrointestinal and urogenital types of cancer.     

Ethnic differences in pregnancy outcome

The relationship between perinatal mortality and low birthweight was investigated using routinely available birth statistics for the administrative health areas of England and Wales. Perinatal mortality rates tended to be low in areas with a high proportion of births to ethnic minorities, compared to areas with a similar incidence of low birthweight.     

Childhood blood pressure, body build, and birthweight: geographical associations with cardiovascular mortality.

STUDY OBJECTIVE--The aim was to examine whether blood pressure, body build, and birthweight differ between areas of England and Wales with widely differing adult cardiovascular mortality rates. DESIGN--This was a cross sectional survey of children in five towns with exceptionally high and five towns with exceptionally low current adult cardiovascular mortality. SETTING--The study was a school based survey. SUBJECTS--3842 children aged 5.0-7.5 years were selected by stratified random sampling of primary schools (response rate 76%). MEASUREMENTS AND MAIN RESULTS--Blood pressure, pulse rate, height, and weight were measured and birthweight was assessed by maternal recall. Children in towns with high cardiovascular mortality rates were significantly shorter than those in towns with low cardiovascular mortality rates (mean difference 0.9 cm, 95% confidence interval 0.4 to 1.4 cm) and had slightly higher body mass indices (mean difference 0.12 kg/m2, 95% CI -0.03 to 0.27 kg/m2). Mean birthweights were slightly lower in high mortality towns (mean difference 34 g, 95% CI -10 to 78 g), while the proportion of children with low birthweight (< 2500 g) (8.1%) was significantly higher than that in low mortality towns (5.5%) (p = 0.005). Mean differences in blood pressure between high and low mortality towns were small and non-significant, even after adjustment for height. The differences in height between high and low mortality towns were largely independent of social class. However, differences in mean birthweight were markedly reduced once social class was taken into account. CONCLUSIONS--No geographical relationship between childhood blood pressure and adult cardiovascular mortality was detected. Although it is possible that the differences in mean height and body mass index between towns with differing adult cardiovascular mortality may have implications for future patterns of health in these towns, the absence of marked differences in birthweight and blood pressure suggests that hypotheses proposing a direct relationship between intrauterine experience and adult cardiovascular mortality will have limited relevance to geographical variation in cardiovascular disease in this generation.