Trends in inequalities in premature mortality: a study of 3.2 million deaths in 13 European countries

Changing social inequalities in smoking, obesity and cause-specific mortality: Cross-national comparisons using compass typology

BACKGROUND

In many countries smoking rates have declined and obesity rates have increased, and social inequalities in each have varied over time. At the same time, mortality has declined in most high-income countries, but gaps by educational qualification persist-at least partially due to differential smoking and obesity distributions. This study uses a compass typology to simultaneously examine the magnitude and trends in educational inequalities across multiple countries in: a) smoking and obesity; b) smoking-related mortality and c) cause-specific mortality.

METHODS

Smoking prevalence, obesity prevalence and cause-specific mortality rates (35-79 year olds by sex) in nine European countries and New Zealand were sourced from between 1980 and 2010. We calculated relative and absolute inequalities in prevalence and mortality (relative and slope indices of inequality, respectively RII, SII) by highest educational qualification. Countries were then plotted on a compass typology which simultaneously examines trends in the population average rates or odds on the x-axis, RII on the Y-axis, and contour lines depicting SII.

FINDINGS

Smoking and obesity. Smoking prevalence in men decreased over time but relative inequalities increased. For women there were fewer declines in smoking prevalence and relative inequalities tended to increase. Obesity prevalence in men and women increased over time with a mixed picture of increasing absolute and sometimes relative inequalities. Absolute inequalities in obesity increased for men and women in Czech Republic, France, New Zealand, Norway, for women in Austria and Lithuania, and for men in Finland. Cause-specific mortality. Average rates of smoking-related mortality were generally stable or increasing for women, accompanied by increasing relative inequalities. For men, average rates were stable or decreasing, but relative inequalities increased over time. Cardiovascular disease, cancer, and external injury rates generally decreased over time, and relative inequalities increased. In Eastern European countries mortality started declining later compared to other countries, however it remained at higher levels; and absolute inequalities in mortality increased whereas they were more stable elsewhere.

CONCLUSIONS

Tobacco control remains vital for addressing social inequalities in health by education, and focus on the least educated is required to address increasing relative inequalities. Increasing obesity in all countries and increasing absolute obesity inequalities in several countries is concerning for future potential health impacts. Obesity prevention may be increasingly important for addressing health inequalities in some settings. The compass typology was useful to compare trends in inequalities because it simultaneously tracks changes in rates/odds, and absolute and relative inequality measures.

The association between education level and chronic liver disease of any etiology

BACKGROUND

The potential link between educational level and chronic liver diseases (CLD) were explored using the mortality records of liver cirrhosis, which lack accuracy and are unable to identify the different etiological factors of liver cirrhosis. Information on the association of low educational level with the severity of CLD is lacking.

AIM

To evaluate the potential association linking education level to etiology and clinical stage of CLD cases.

METHODS

Consecutive enrolment of 11,107 subjects with CLD aged≥18 years prospectively recruited in two national surveys in 2001 and 2014 at one of the participating Italian liver units throughout the country. Subjects were pooled in two groups: low education level (less than high school) and high education level (completed high school or beyond). The association of demographic, etiological, and clinical stage of subjects with educational level was assessed using logistic regression analysis. In the analysis low educational level was the outcome variable.

RESULTS

A total of 11,107 subjects born in Italy (mean age 55.5 years, sex ratio 1.5) were evaluated. Multiple logistic regression analysis shows that chronic HCV infection (O.R.1,38:95%,C.I.1.23-1.55), risky alcohol intake (O.R.1.96;95%,C.I.1.73-2.21) and liver cirrhosis (O.R.1.65;95%,C.I.1.46-1.85) all resulted independently associated with less than a completed high school education. HBV infection resulted independently associated with high education level (O.R.0.74;95%,C.I.0.64-0.86), reflecting changes in HBV modes of transmission in recent decades. No association was found with CLD related to non-alcoholic fatty liver disease (O.R.1.03;95%, C.I.0.81-1.30).

CONCLUSIONS

These findings show an independent association linking education level with viruses and alcohol-related CLD. Low educational level is associated with the severity of CLD.

Socio-economic inequalities in life expectancy of older adults with and without multimorbidity: a record linkage study of 1.1 million people in England

Background

Age of onset of multimorbidity and its prevalence are well documented. However, its contribution to inequalities in life expectancy has yet to be quantified.

Methods

A cohort of 1.1 million English people aged 45 and older were followed up from 2001 to 2010. Multimorbidity was defined as having 2 or more of 30 major chronic diseases. Multi-state models were used to estimate years spent healthy and with multimorbidity, stratified by sex, smoking status and quintiles of small-area deprivation.

Results

Unequal rates of multimorbidity onset and subsequent survival contributed to higher life expectancy at age 65 for the least (Q1) compared with most (Q5) deprived: there was a 2-year gap in healthy life expectancy for men [Q1: 7.7 years (95% confidence interval: 6.4–8.5) vs Q5: 5.4 (4.4–6.0)] and a 3-year gap for women [Q1: 8.6 (7.5–9.4) vs Q5: 5.9 (4.8–6.4)]; a 1-year gap in life expectancy with multimorbidity for men [Q1: 10.4 (9.9–11.2) vs Q5: 9.1 (8.7–9.6)] but none for women [Q1: 11.6 (11.1–12.4) vs Q5: 11.5 (11.1–12.2)]. Inequalities were attenuated but not fully attributable to socio-economic differences in smoking prevalence: multimorbidity onset was latest for never smokers and subsequent survival was longer for never and ex smokers.

Conclusions

The association between social disadvantage and multimorbidity is complex. By quantifying socio-demographic and smoking-related contributions to multimorbidity onset and subsequent survival, we provide evidence for more equitable allocation of prevention and health-care resources to meet local needs.

Changing relative and absolute socioeconomic health inequalities in Ontario, Canada: A population-based cohort study of adult premature mortality, 1992 to 2017

BACKGROUND

This study aimed to characterize trends in absolute and relative socioeconomic inequalities in adult premature mortality between 1992 and 2017, in the context of declining population-wide mortality rates. We conducted a population-based cohort study of all adult premature deaths in Ontario, Canada using provincial vital statistics data linked to census-based, area-level deprivation indices for socioeconomic status.

METHODS

The cohort included all individuals eligible for Ontario's single-payer health insurance system at any time between January 1, 1992 and December 31, 2017 with a recorded Ontario place of residence and valid socioeconomic status information (N = 820,370). Deaths between ages 18 and 74 were used to calculate adult premature mortality rates per 1000, stratified by provincial quintile of material deprivation. Relative inequalities were measured using Relative Index of Inequality (RII) measures. Absolute inequalities were estimated using Slope Index of Inequality (SII) measures. All outcome measures were calculated as sex-specific, annual measures for each year from 1992 to 2017.

RESULTS

Premature mortality rates declined in all socioeconomic groups between 1992 and 2017. Relative inequalities in premature mortality increased over the same period. Absolute inequalities were mostly stable between 1992 and 2007, but increased dramatically between 2008 and 2017, with larger increases to absolute inequalities seen in females than in males.

CONCLUSIONS

As in other developed countries, long-term downward trends in all-cause premature mortality in Ontario, Canada have shifted to a plateau pattern in recent years, especially in lower- socioeconomic status subpopulations. Determinants of this may differ by setting. Regular monitoring of mortality by socioeconomic status is the only way that this phenomenon can be detected sensitively and early, for public health attention and possible corrective action.

Changes in inequalities of mortality by education level in Lithuania between 2001 and 2014

OBJECTIVE

The aim of the study is to analyse the changes in inequalities of mortality by education level in Lithuania between 2001 and 2014.

STUDY DESIGN

This is a record-linked cohort study.

METHODS

Information on deaths (in the population aged ≥30 years) from all causes and cardiovascular diseases, cancer, external causes and diseases of the digestive system was obtained from Statistics Lithuania. Mortality rates for these causes were calculated by the level of education per 100,000 person-years. Inequalities in mortality were assessed using a rate ratio and a relative index of inequality with 95% confidence intervals (CIs). Joinpoint regression analysis was used to assess inequality trends between 2001 and 2014.

RESULTS

During the study period, mortality from all causes and from cardiovascular diseases, cancer, external causes and diseases of the digestive system was statistically significantly higher in the group with less education for both men and women, with the exception for female mortality from cancer in 2001. The highest decline was observed in the inequalities of mortality from external causes, whereas a major increase was observed in the inequalities of mortality from diseases of the digestive system. A large increase in inequalities was observed in mortality from external causes for men (on average by 3.5% per year [95% CI = 2-5.1]), whereas, for women, the highest increase in inequalities was observed in mortality from diseases of the digestive system (on average by 3% per year [95% CI = 0.6-5.5]). The slowest increase in mortality inequalities was noted for cardiovascular diseases for both men (on average by 1.1% per year [95% CI = 0.4-1.9]) and women (on average by 0.8% per year [95% CI = 0.3-1.3]).

CONCLUSION

Between 2001 and 2014, the inequalities in mortality by level of education in Lithuania significantly increased in terms of mortality from all causes, cardiovascular diseases, cancer, external causes and diseases of the digestive system.

Trends in life expectancy: did the gap between the healthy and the ill widen or close?

BACKGROUND

During the past decades, life expectancy has continued to increase in most high-income countries. Previous research suggests that improvements in life expectancy have primarily been driven by advances at the upper end of the health distribution, while parts of the population have lagged behind. Using data from the entire Swedish population, this study aims to examine the life expectancy development among subgroups of individuals with a history of common diseases relative to that of the general population.

METHODS

The remaining life expectancy at age 65 was estimated for each year in 1998-2017 among individuals with a history of disease, and for the total Swedish population. We defined population subgroups as individuals with a history of myocardial infarction, ischemic or hemorrhagic stroke, hip fracture, or colon, breast, or lung cancer. We further distinguished between different educational levels and Charlson comorbidity index scores.

RESULTS

Life expectancy gains have been larger for men and women with a history of myocardial infarction, ischemic or hemorrhagic stroke, and colon or breast cancer than for the general population. The life expectancy gap between individuals with a history of hip fracture or lung cancer and the general population has, however, been growing. Education and comorbidity have affected mortality levels, but have not altered the rate of increase in life expectancy among individuals with disease history. The female advantage in life expectancy was less pronounced among individuals with disease history than among the general population.

CONCLUSIONS

Life expectancy has increased faster in many subpopulations with a history of disease than in the general population, while still remaining at lower levels. Improvements in life expectancy have been observed regardless of comorbidity or educational level. These findings suggest that the rise in overall life expectancy reflects more than just improved survival among the healthy or the delayed onset of disease.

New perspective on geographical mortality divide in Russia: a district-level cross-sectional analysis, 2008-2012

BACKGROUND

Prior studies on spatial inequalities in mortality in Russia were restricted to the highest level of administrative division, ignoring variations within the regions. Using mortality data for 2239 districts, this study is the first analysis to capture the scale of the mortality divide at a more detailed level.

METHODS

Age-standardised death rates are calculated using aggregated deaths for 2008-2012 and population exposures from the 2010 census. Inequality indices and decomposition are applied to quantify both the total mortality disparities across the districts and the contributions of the variations between and within regions.

RESULTS

Regional variations in mortality mask one-third (males) and one-half (females) of the inequalities observed at the district level. A comparison of the 5% of individuals residing in the districts with the highest and the lowest mortality shows a gap of 15.5 years for males and 10.3 years for females. The lowest life expectancy levels are in the shrinking areas of the Far East and Northwest of Russia. The highest life expectancy clusters are in the intercity districts of Moscow and Saint Petersburg, and in several science cities. Life expectancy in these best-practice districts is close to the national averages of Poland and Estonia, but is still substantially below the averages in Western countries.

CONCLUSION

The large between-regional and within-regional disparities suggest that national-level mortality could be lowered if these disparities are reduced by improving health in the laggard areas. This can be achieved by introducing policies that promote health convergence both within and between the Russian regions.

Small Successes Make Big Wins: A Retrospective Case Study towards Community Engagement of Low-SES Families

In health-promoting interventions, a main difficulty is that low socioeconomic status (SES) groups especially seem to experience barriers to participation. To overcome this barrier, the current study focused on the success factors and obstacles in the process of supporting low-SES families in becoming partners, while carrying out small-scale activities based on their needs. A retrospective case study design was used to construct a timeline of activities organized by and together with low-SES families based on mainly qualitative data. Next, key events were grouped into the four attributes of the resilience activation framework: human, social, political, and economic capital. The following key lessons were defined: professionals should let go of work routines and accommodate the talents of the families, start doing, strive for small successes; create a functional social network surrounding the families, maintaining professional support over time as back-up; and create collaborative governance to build upon accessibility, transparency and trust among the low-SES families. Continuous and flexible ‘navigating the middle’ between bottom-up and top-down approaches was seen as vital in the partnership process between low-SES families and local professional partners. Constant feedback loops made the evaluation points clear, which supported both families and professionals to enhance their partnership.

Premature mortality attributable to socioeconomic inequality in England between 2003 and 2018: an observational study

BACKGROUND

Low socioeconomic position is consistently associated with increased risk of premature death. The aim of this study is to measure the aggregate scale of inequality in premature mortality for the whole population of England.

METHODS

We used mortality records from the UK Office for National Statistics to study all 2 465 285 premature deaths (defined as those before age 75 years) in England between Jan 1, 2003, and Dec 31, 2018. Socioeconomic position was defined using deciles of the Index of Multiple Deprivation: a measure of neighbourhood income, employment, education levels, crime, health, availability of services, and local environment. We calculated the number of expected deaths by applying mortality in the least deprived decile to other deciles, within the strata of age, sex, and time. The mortality attributable to socioeconomic inequality was defined as the difference between the observed and expected deaths. We also used life table modelling to estimate years-of-life lost attributable to socioeconomic inequality.

FINDINGS

35·6% (95% CI 35·3-35·9) of premature deaths were attributable to socioeconomic inequality, equating to 877 082 deaths, or one every 10 min. The biggest contributors were ischaemic heart disease (152 171 excess deaths), respiratory cancers (111 083) and chronic obstructive pulmonary disease (83 593). The most unequal causes of death were tuberculosis, opioid use, HIV, psychoactive drugs use, viral hepatitis, and obesity, each with more than two-thirds attributable to inequality. Inequality was greater among men and peaked in early childhood and at age 40-49 years. The proportion of deaths attributable to inequality increased during the study period, particularly for women, because mortality rates among the most deprived women (excluding cardiovascular diseases) plateaued, and for some diseases increased. A mean of 14·4 months of life before age 75 years are lost due to socioeconomic inequality.

INTERPRETATION

One in three premature deaths are attributable to socioeconomic inequality, making this our most important public health challenge. Interventions that address upstream determinants of health should be prioritised.

FUNDING

National Institute of Health Research; Wellcome Trust.

Identifying patients with familial hypercholesterolemia using data mining methods in the Northern Great Plain region of Hungary

BACKGROUND AND AIMS

Familial hypercholesterolemia (FH) is one of the most frequent diseases with monogenic inheritance. Previous data indicated that the heterozygous form occurred in 1:250 people. Based on these reports, around 36,000-40,000 people are estimated to have FH in Hungary, however, there are no exact data about the frequency of the disease in our country. Therefore, we initiated a cooperation with a clinical site partner company that provides modern data mining methods, on the basis of medical and statistical records, and we applied them to two major hospitals in the Northern Great Plain region of Hungary to find patients with a possible diagnosis of FH.

METHODS

Medical records of 1,342,124 patients were included in our study. From the mined data, we calculated Dutch Lipid Clinic Network (DLCN) scores for each patient and grouped them according to the criteria to assess the likelihood of the diagnosis of FH. We also calculated the mean lipid levels before the diagnosis and treatment.

RESULTS

We identified 225 patients with a DLCN score of 6-8 (mean total cholesterol: 9.38 ± 3.0 mmol/L, mean LDL-C: 7.61 ± 2.4 mmol/L), and 11,706 patients with a DLCN score of 3-5 (mean total cholesterol: 7.34 ± 1.2 mmol/L, mean LDL-C: 5.26 ± 0.8 mmol/L).

CONCLUSIONS

The analysis of more regional and country-wide data and more frequent measurements of total cholesterol and LDL-C levels would increase the number of FH cases discovered. Data mining seems to be ideal for filtering and screening of FH in Hungary.

Socioeconomic differences in mortality among 27 million economically active Germans: a cross-sectional analysis of the German Pension Fund data

OBJECTIVES

To assess disparities in mortality by socioeconomic status in Germany.

DESIGN AND PARTICIPANTS

We analyse a large administrative dataset of the German Pension Fund (DRV), including 27 million person-years of exposure and 42 000 deaths in 2013. The data cover the economically active population, stratified by sex and by East and West.

OUTCOME MEASURES

Age-standardised mortality rates and Poisson regression mortality rate ratios (MRRs).

RESULTS

The risk of dying increases with decreasing income: the MRRs of the lowest to the highest income quintile are 4.66 (95% CI 4.48 to 4.85) among men and 3.06 (95% CI 2.90 to 3.23) among women. The impact of income attenuates after controlling for education and other explanatory variables, especially for females. In the fully controlled model for females, individual income is a weaker predictor of mortality, but there is a clear educational mortality gradient. In the fully controlled model, the MRRs of the unemployed to the employed are 2.09 (95% CI 2.03 to 2.15) among men and 2.01 (95% CI 1.92 to 2.10) among women. The risk of dying is around half as high among foreigners as among German citizens. The socioeconomic disparities are greater among East than West German men.

CONCLUSIONS

Low socioeconomic status is a major determinant of excess adult mortality in Germany. The persisting East-West differences in male adult mortality can be explained by the higher socioeconomic status of men living in the West, rather than by contextual differences between East and West. These differences can be further monitored using DRV data.

Life-course socioeconomic differences and social mobility in preventable and non-preventable mortality: a study of Swedish twins

BACKGROUND

Despite advances in life expectancy, low socioeconomic status is associated with a shorter lifespan. This study was conducted to investigate socioeconomic differences in mortality by comparing preventable with non-preventable causes of death in 39 506 participants from the Swedish Twin Registry born before 1935.

METHODS

Childhood social class, own education, own social class and social mobility were used as separate indicators of socioeconomic status. These data were linked to the Swedish Cause of Death Register. Cause of death was categorized as preventable or non-preventable mortality according to indicators presented in the Avoidable Mortality in the European Union (AMIEHS) atlas. Using Cox proportional hazard models, we tested the association between the socioeconomic measures and all-cause mortality, preventable mortality and non-preventable mortality. Additional co-twin control analyses indicated whether the associations reflected genetic confounding.

RESULTS

The social gradient for mortality was most prominent for the adult socioeconomic measures. There was a social gradient in both preventable mortality and non-preventable mortality, but with an indication of a moderately stronger effect in preventable causes of death. In analyses of social mobility, those who experienced life-time low socioeconomic status (SES) or downward social mobility had an increased mortality risk compared with those with life-time high SES and upward social mobility. Adjustments for genetic confounding did not change the observed associations for education, social class or social mobility and mortality. In the co-twin control analyses of reared-apart twins, the association between childhood social class and mortality weakened, indicating possible genetic influences on this association.

CONCLUSIONS

Our results indicate that there is an association between low adult socioeconomic status and increased mortality independent of genetic endowment. Thus, we do not find support for indirect social selection as the basis for mortality inequalities in Sweden.

Changing educational gradient in long-term care-free life expectancy among German men, 1997-2012

BACKGROUND

The inverse association between mortality and individual socioeconomic status is well-documented. Due to the lack of appropriate data, little is known about the nature of this association among individuals with long-term care (LTC) needs.

OBJECTIVES

We aim to fill in this knowledge gap by estimating life expectancy (LE), life expectancy without (CFLE) and with (CLE) long-term care by education for older German men; and by assessing the trends in the education-LE/CFLE/CLE gradient over time.

DATA AND METHODS

We apply survival analysis and Gompertz regression to German Socioeconomic Panel data (1997-2012) to estimate the mortality levels and to construct the life tables for three educational categories. Using the administrative data from the health insurance, we adjust mortality rates upward to account for the institutionalized population. We estimate age-specific LTC prevalence from the German Microcensus data (2004, 2012) and compute life expectancy with and without LTC by employing Sullivan's method. Slope and Relative Indices of Inequality are computed to evaluate the magnitude of educational inequalities in CFLE.

RESULTS

There is a clear and growing educational gradient in LE and CFLE among older men in Germany. In 2004, LE at age 65 among men with low education was 14.2 years, or 3.3 years lower than among highly educated individuals. The CFLE of these two educational categories ranged from 13.6 to almost 17 years. The gradient increased over time and in 2012 the difference constituted 4.6 years. The gaps between educational groups were not pronounced for CLE. The declining health ratio of years without LTC to remaining LE suggests the expansion of LTC needs, irrespective of the educational level.

CONCLUSIONS

Growing inequalities by educational status among older German men with care needs demand the attention of policy-makers. Prompt actions are needed to increase the survival chances of the most vulnerable groups.

Assessing the Effects on Health Inequalities of Differential Exposure and Differential Susceptibility of Air Pollution and Environmental Noise in Barcelona, 2007-2014

The hypotheses we intended to contrast were, first, that the most deprived neighborhoods in Barcelona, Spain, present high exposure to environmental hazards (differential exposure) and, secondly, that the health effects of this greater exposure were higher in the most deprived neighborhoods (differential susceptibility). The population studied corresponded to the individuals residing in the neighborhoods of Barcelona in the period 2007–2014. We specified the association between the relative risk of death and environmental hazards and socioeconomic indicators by means of spatio-temporal ecological regressions, formulated as a generalized linear mixed model with Poisson responses. There was a differential exposure (higher in more deprived neighborhoods) in almost all the air pollutants considered, when taken individually. The exposure was higher in the most affluent in the cases of environmental noise. Nevertheless, for both men and women, the risk of dying due to environmental hazards in a very affluent neighborhood is about 30% lower than in a very depressed neighborhood. The effect of environmental hazards was more harmful to the residents of Barcelona’s most deprived neighborhoods. This increased susceptibility cannot be attributed to a single problem but rather to a set of environmental hazards that, overall, a neighborhood may present.

Combined Effect of Marriage and Education on Mortality: A Cross-national Study of Older Japanese and Finnish Men and Women

Background

While marriage and education help maintain older adults’ health, their joint association with mortality remains unclear. This cross-national study examined the combined effect of marriage and education on the mortality of older Japanese and Finnish adults.

Methods

Data on 22,415 Japanese and 11,993 Finnish adults, aged 65–74 years, were obtained from the Japan Gerontological Evaluation Study of 2010–2012 and the Finnish Public Sector Study of 2008–2009 and 2012–2013. We followed up on respondents’ survival status for 5 years using public records. Marital status, educational level, and other variables in both datasets were harmonized.

Results

The Cox proportional hazards model showed that unmarried men had a higher mortality risk than married men in both countries (hazard ratio [HR] 1.47; 95% confidence interval [CI], 1.21–1.79 for Japanese and HR 1.94; 95% CI, 1.29–2.91 for Finnish); no such difference was observed in women. The highest mortality risk was observed in unmarried men with tertiary education in both Japan (HR 1.85; 95% CI, 1.21–2.83) and Finland (HR 2.21; 95% CI, 1.26–3.89), when adjusted for baseline age, health-related behaviors, and illnesses.

Conclusions

Our findings showed similarity in the combined effect of marriage and education between Japan and Finland, differing from observations in countries with more apparent socioeconomic health disparities. Further studies should examine the reasons for the excessive mortality risk in highly educated, unmarried men in both countries and consider whether selection bias led to underestimation of the true risk in unmarried older adults with lower education.

Years of life lost due to diseases of the digestive system in Poland according to socioeconomic factors: a cross-sectional study

OBJECTIVES

To analyse years of life lost (YLLs) due to digestive diseases in Poland according to: marital status, education, working status and place of residence.

DESIGN

A cross-sectional study.

SETTING

The study was based on a dataset containing information from death certificates of Poles who died in 2002 and in 2011.

PARTICIPANTS

The analysis covered records with codes K00-K93 according to the International Classification of Diseases and Related Health Problems, 10th Revision.

OUTCOME MEASURES

YLL values were calculated using the Standard Expected Years of Life Lost measure. For each socioeconomic variable, the rate ratio (RR) was calculated as the quotient of YLLs in the less privileged group to the more privileged group.

RESULTS

Among the categories of marital status, the smallest YLL values (per 10 000) were recorded among singles (men: 100.63 years in 2002, 121.10 years in 2011; women: 26.99, 33.33, respectively), and the most among divorced men (657.87, 689.32) and widowed women (173.97, 169.46). YLL analysis according to education level revealed the lowest values in people with higher education (men: 54.20, 57.66; women: 17.31, 18.31) and the highest in people with lower than secondary education (men: 178.85, 198.32; women: 104.95, 125.76). Being economically active was associated with a smaller YLL score (men: 39.93, 59.51; women: 10.31, 14.96) than being inactive (men: 340.54, 219.93; women: 126.86, 96.80). Urban residents had higher YLL score (men: 159.46, 174.18, women: 73.03, 78.12) than rural ones (men: 126.83, 137.11, women: 57.32, 57.56).In both sexes, RR according to education level and place of residence increased, and those according to marital status and working status decreased with time.

CONCLUSIONS

Activities aimed at reducing health inequalities in terms of YLL due to digestive diseases should be primarily addressed to inhabitants with lower than secondary education, divorced and widowed people, urban residents and those who are economically inactive.

Epidemiology of Mortality Due to Prostate Cancer in Poland, 2000-2015

The aim of the study was to assess trends in mortality and years of life lost due to prostate cancer (PCa) in Poland in 2000–2015. The crude death rates (CDR), standardised death rates (SDR), standard expected years of life lost per living person (SEYLL_p) and per death (SEYLL_d) values were calculated. Joinpoint models were used to analyse time trends. In the study period, 61,928 men died of PCa. The values of mortality rates in 2000 (per 100,000) were: CDR = 16.97, SDR = 16.17, SEYLL_p = 332.1. In 2015, the values of all rates increased: CDR = 26.22, SDR = 16.69, SEYLL_p = 429.5. However, the SEYLL_d value decreased from 15.62 to one man who died due to PCa in 2000 to 13.78 in 2015. The highest SEYLL_p values occurred in the group of men with primary education (619.5 in 2000 and 700.7 in 2015). They were respectively 2.24 and 2.96 times higher than in men with higher education (275.7 and 237.1). SEYLL_p values increased in urban areas (from 295.7 to 449.4), slightly changed in the rural areas (from 391.5 to 400.2). Unfavorable trends in mortality due to PCa in Poland require explanation of the causes and implementation of appropriate actions aimed at mortality reducing.

Avoidable Cancer Mortality in Germany Since Reunification: Regional Variation and Sex Differences

Background: Regional comparisons of cancer-related mortality in Germany are traditionally focused on disparities between East and West Germany. Recent improvements in all-cause and cancer-related mortality show a diverse regional pattern beyond the known East-West mortality divide. A generalized approach of the avoidable/amenable cancer mortality definition is applied for suitable regional comparisons of long-term trends. Methods: Standardized death rates of preventable and amenable cancer mortality for men and women were computed for the period 1990-2014 to observe sex-specific excess mortality due to specific cancers after the German reunification. For regional comparison, three German super regions were defined in Eastern, Northwestern, and Southwestern Germany to account for similarities in long-term regional premature and cancer-related mortality patterns, socioeconomic characteristics, and age structure. Results: Since preventable and amenable cancer mortality rates typically have driven the recent trends in premature mortality, our findings underline the current regional pattern of preventable cancer mortality for males with disadvantages for Eastern Germany, and advantages for Southwestern Germany. Among women, the preventable cancer mortality has increased in Northwestern and Southwestern Germany after the German reunification but has decreased in Eastern Germany and converged to the pattern of Southwestern Germany. Similar patterns can be observed for females in amenable cancer mortality. Conclusions: Although the "traditional" East-West gap in preventable cancer mortality was still evident in males, our study provides some hints for more regional diversity in avoidable cancer mortality in women. An establishing north-south divide in avoidable cancer mortality could alter the future trends in regional cancer-related mortality in Germany.

Trends in Absolute and Relative Educational Inequalities in Adult Smoking Since the Early 2000s: The Case of Germany

Introduction

Since the early 2000s, several tobacco control policies have been implemented in Germany. Current research is inconsistent about how strengthening tobacco control can affect social inequalities in smoking. This study examines whether educational inequalities in adult smoking have widened in Germany since 2003.

Methods

Data were used from four cross-sectional national health surveys conducted between 2003 and 2012 (n = 54,197; age = 25-69 years). Participants who smoked daily or occasionally were classified as smokers. The regression-based Slope Index of Inequality and Relative Index of Inequality (RII) were calculated to estimate the extent of absolute and relative educational inequalities in smoking, respectively.

Results

In each survey year, smoking was associated with lower education. Overall, crude and age-standardized smoking rates declined over time. Stratified by education, trends of declining smoking rates were observed only in the high and medium education groups, whereas no statistically significant trend was found in the low education group. Relative educational inequalities in smoking increased significantly in men (2003: RII=1.74, 95% confidence interval 1.46 to 2.07; 2012: RII = 2.25, 95% confidence interval 1.90 to 2.67; p-trend = .019). Absolute educational inequalities in smoking were not found to have changed significantly during the study period.

Conclusions

In the course of declining smoking rates, educational inequalities in smoking persisted in both absolute and relative terms. In men, relative inequalities in smoking may even have widened within only 9 years. Tobacco control policies should not only be targeted at the entire population but also attempt to reduce social inequalities in smoking by focusing more on socially disadvantaged groups.

Implications

Smoking is associated with lower education in most European countries and contributes to social inequalities in health. Since the beginning of the 2000s, Germany has implemented a variety of tobacco control policies to reduce smoking in the population. This study reveals that despite a general decline in adult smoking, educational inequalities in smoking have persisted and even widened in Germany since 2003. The findings emphasize that more targeted efforts are needed to tackle smoking-induced inequalities in health.

The dynamics of health poverty in Spain during the economic crisis (2008-2016)

In recent years, and because of the economic crisis, Spain's government has been worried about changes in health poverty. In this paper, we examine individual health status measured subjectively (SAH) and we decompose some socio-economic determinants to analyse how this situation affects health. We focus on SAH to estimate the poverty trends over time using the Foster-Greer-Thorbecke (FGT) index. For this purpose, we have used data provided by the European Union Statistics on Income and Living Conditions (EU-SILC). Our results show a negative growth if a poor SAH status is chosen as a health poverty threshold, and a positive growth of health poverty, if a fair SAH status is chosen. Furthermore, we decompose some socio-economic factors (such as gender, age and education level) to study how these characteristics affect health poverty. Our findings, based on different subgroup decompositions, reveal a rise of health poverty in Spain.

Educational inequalities in self-rated health and social relationships - analyses based on the European Social Survey 2002-2016

BACKGROUND

While there is evidence for educational health inequalities in Europe, studies on time trends and on the explanatory contribution of social relations are less consistent. It has been shown that the use of welfare state typologies can be helpful to examine health inequalities in a comparative perspective. Against this background, analyses are focused on three research questions: (1) How did educational inequalities in self-rated health (SRH) develop between 2002 and 2016 in different European countries? (2) In how far can structural and functional aspects of social relations help to explain these inequalities? (3) Do these explanatory contributions vary between different types of welfare states?

METHODS

Data stem from the European Social Survey. Data from 20 countries across 8 waves (2002-2016) was included in the sample (allocated to 5 types of welfare states). Structural aspects of social relations were measured by living with a partner, frequency of social contacts and social participation. Availability of emotional support was used as functional dimension. Educational level was assessed based on the International Standard Classification of Education. SRH was measured in all waves on a five-point scale by one question: "How is your health in general? Would you say it is very good, good, fair, bad or very bad?"

RESULTS

Across all countries, educational inequalities were increasing between 2002 and 2016. Explanatory contribution of emotional support, living with a partner, and social contacts was small (5% or less across the eight waves). Social participation explained 11% of the educational inequalities in SRH in the European countries. There were small variations in the explanatory contribution of social participation between welfare states.

CONCLUSIONS

Promoting social participation, especially of people with low education is a possible intervention to reduce inequalities in SRH in Europe.

Monitoring health inequalities when the socio-economic composition changes: are the slope and relative indices of inequality appropriate? Results of a simulation study

BACKGROUND

The slope (SII) and relative (RII) indices of inequality are commonly recommended to monitor health inequality policies. As an upwards shift of the educational level distribution (ELD) can be part of those policies, we examine how such a shift affects the SII, the RII and the population attributable fraction (PAF).

METHODS

We simulated 632 distributions of 4 educational levels (ELs) by varying the share (p1 to p4) of each EL, with constant mortality rates (MR) and calculated the corresponding RII, SII and PAF. Second, we decomposed the effect on the three indices of a change affecting both the ELD and the MRs, into the contributions of each component.

RESULTS

RIIs and SIIs sharply increase with p4 at fixed p1 values and evolve as reversed U-curves for p1 changing in complement to p4. The RII reaches a maximum, at much higher p4 values than the SII. PAFs monotonically decrease when p4 increases.

CONCLUSION

If improving the educational attainment is part of a policy, an upwards shift of EL should be assessed as a progress; however the RII, and to a lesser extent the SII, frequently translate an increased EL4 share as a worsening. We warn against the use of SII and RII for monitoring inequality-tackling policies at changing socio-economic structures. Rather, we recommend to complement the assessment of changes in absolute and relative pairwise differentials, with changes in PAF and in the socio-economic group shares.

Financial Incentives to Increase Cardiac Rehabilitation Participation Among Low-Socioeconomic Status Patients: A Randomized Clinical Trial

OBJECTIVES

This study sought to examine the efficacy of financial incentives to increase Medicaid patient participation in and completion of cardiac rehabilitation (CR).

BACKGROUND

Participation in CR reduces morbidity, mortality, and hospitalizations while improving quality of life. Lower-socioeconomic status (SES) patients are much less likely to attend and complete CR, despite being at increased risk for recurrent cardiovascular events.

METHODS

A total of 130 individuals enrolled in Medicaid with a CR-qualifying cardiac event were randomized 1:1 to receive financial incentives on an escalating schedule ($4 to $50) for completing CR sessions or to receive usual care. Primary outcomes were CR participation (number of sessions completed) and completion (≥30 sessions completed). Secondary outcomes included changes in sociocognitive measurements (depressive/anxious symptoms, executive function), body composition (waist circumference, body mass index), fitness (peak VO₂) over 4 months, and combined number of hospitalizations and emergency department (ED) contacts over 1 year.

RESULTS

Patients randomized to the incentive condition completed more sessions (22.4 vs. 14.7, respectively; p = 0.013) and were almost twice as likely to complete CR (55.4% vs. 29.2%, respectively; p = 0.002) as controls. Incentivized patients were also more likely to experience improvements in executive function (p < 0.001), although there were no significant effects on other secondary outcomes. Patients who completed ≥30 sessions had 47% fewer combined hospitalizations and ED visits (p = 0.014), as reflected by a nonsignificant trend by study condition with 39% fewer hospital contacts in the incentive condition group (p = 0.079).

CONCLUSIONS

Financial incentives improve CR participation among lower-SES patients following a cardiac event. Increasing participation among lower-SES patients in CR is critical for positive longer-term health outcomes. (Increasing Cardiac Rehabilitation Participation Among Medicaid Enrollees; NCT02172820).

The role of financial strain and self-control in explaining health behaviours: the GLOBE study

Background

Why lower socioeconomic groups behave less healthily can only partly be explained by direct costs of behaving healthily. We hypothesize that low income increases the risk of facing financial strain. Experiencing financial strain takes up cognitive 'bandwidth' and leads to less self-control, and subsequently results in more unhealthy behaviour. We therefore aim to investigate (i) whether a low income increases the likelihood of experiencing financial strain and of unhealthy behaviours, (ii) to what extent more financial strain is associated with less self-control and, subsequently, (iii) whether less self-control is related to more unhealthy behaviour.

Methods

Cross-sectional survey data were obtained from participants (25-75 years) in the fifth wave of the Dutch GLOBE study (N = 2812) in 2014. The associations between income, financial strain, self-control and health-behaviour-related outcomes (physical inactivity in leisure-time, obesity, smoking, excessive alcohol intake, and weekly fruit and vegetable intake) were analysed with linear regression and generalized linear regression models (log link).

Results

Experiencing great compared with no financial strain increased the risk of all health-behaviour-related outcomes, independent of income. Low self-control, as compared with high self-control, also increased the risk of an unhealthy lifestyle. Taking self-control into account slightly attenuated the associations between financial strain and the outcomes.

Conclusion

Great financial strain and low self-control are consistently associated with unhealthy behaviours. Self-control may partly mediate between financial strain and unhealthy behaviour. Interventions that relieve financial strain may free up cognitive bandwidth and improve health behaviour.

Socioeconomic disparities in life expectancy gains among retired German men, 1997-2016

Background

Although estimates of socioeconomic mortality disparities in Germany exist, the trends in these disparities since the 1990s are still unknown. This study examines mortality trends across socioeconomic groups since the late 1990s among retired German men aged 65 and above.

Methods

Large administrative data sets were used to estimate mortality among retired German men, grouped according to their working-life biographies. The data covered the years 1997–2016 and included more than 84.1 million person-years and 4.3 million deaths. Individual pension entitlements served as a measure of lifetime income. Changes in total life expectancy at age 65 over time were decomposed into effects of group-specific mortality improvements and effects of compositional change.

Results

Over the two decades studied, male mortality declined in all income groups in both German regions. As mortality improved more rapidly among higher status groups, the social gradient in mortality widened. Since 1997, the distribution of pension entitlements of retired East German men has shifted substantially downwards. As a result, the impact of the most disadvantaged group on total mortality has increased and has partly attenuated the overall improvement.

Conclusion

Our results demonstrate that socioeconomic deprivation has substantial effects on levels of mortality in postreunification Germany. While East German retirees initially profited from the transition to the West German pension system, subsequent cohorts had to face challenges associated with the transition to the market economy. The results suggest that postreunification unemployment and status decline had delayed effects on old-age mortality in East Germany.

Dimensions of Social Stratification and Their Relation to Mortality: A Comparison Across Gender and Life Course Periods in Finland

Differences in mortality between groups with different socioeconomic positions (SEP) are well-established, but the relative contribution of different SEP measures is unclear. This study compares the correlation between three SEP dimensions and mortality, and investigates differences between gender and age groups (35-59 vs. 60-84). We use an 11% random sample with an 80% oversample of deaths from the Finnish population with information on education, occupational class, individual income, and mortality (n = 496,658; 274,316 deaths between 1995 and 2007). We estimate bivariate and multivariate Cox proportional hazard models and population attributable fractions. The total effects of education are substantially mediated by occupation and income, and the effects of occupation is mediated by income. All dimensions have their own net effect on mortality, but income shows the steepest mortality gradient (HR 1.78, lowest vs. highest quintile). Income is more important for men and occupational class more important among elderly women. Mortality inequalities are generally smaller in older ages, but the relative importance of income increases. In health inequality studies, the use of only one SEP indicator functions well as a broad marker of SEP. However, only analyses of multiple dimensions allow insights into social mechanisms and how they differ between population subgroups.

Health inequalities in terms of myocardial infarction and all-cause mortality: a study with German claims data covering 2006 to 2015

OBJECTIVES

International comparisons are suggesting that mortality inequalities may have changed in the last years, although not always into the same direction. Only a few studies examined myocardial infarction (MI). In our study, long-term developments of MI and all-cause mortality were considered by analysing social gradients by income.

METHODS

German claims data covering 2006 to 2015 (N = 2,474,448) were used with myocardial infarction and all-cause mortality as outcomes. Socio-economic position was depicted by individual income. Health inequalities were measured by hazard ratios between and within income groups for 10 consecutive calendar years.

RESULTS

In men, income gradients of MI and all-cause mortality were decreasing. In women, no income gradients emerged for MI, and they disappeared in mortality. In men, hazard ratios of MI and mortality decreased in the intermediate and in the lowest income thirds, thus leading to a reduction of MI-related health inequalities.

CONCLUSIONS

Income inequalities in terms of myocardial infarction and of mortality have narrowed in men, and those in the lowest income third were profiting most. No such changes were observed in women.

Trends in mortality inequalities in an urban area: the influence of immigration

BACKGROUND

Nearly 20% of the population in Barcelona is foreign-born and this percentage rises to up to 40% in some neighborhoods. Consequently, migration health patterns may play an important role in trends in socioeconomic geographical inequalities in mortality. The objective of this study was to analyze the trend in socioeconomic inequalities in mortality between neighborhoods in Barcelona during the period 2001-2012 in the foreign-born and Spanish-born population.

METHODS

Repeated cross-sectional design of the population aged 25-64 years in Barcelona between 2001 and 2012. Hierarchical data consisted of yearly mortality linked-population. The variables analyzed were age, sex, education, and country of birth (Spanish-born, foreign-born), neighborhood of residence, and the socioeconomic level of the neighborhoods using quartiles of unemployment rates. Age-standardized mortality rates were estimated, and mixed Poisson regressions were applied using generalized linear mixed models, including two random effects to consider the intracorrelation within neighborhoods and across years.

RESULTS

The number of foreign-born residents aged 25-64 increased notably in disadvantaged neighborhoods. Approximately 9% of premature deaths occurred in foreign-born individuals. Premature mortality rates were higher in disadvantaged neighborhoods and in the Spanish-born population in all periods. Despite the stabilized socioeconomic inequalities in mortality in the Spanish-born population, no inequalities were found between neighborhoods in foreign-born men and women.

CONCLUSIONS

Evidence of the 'healthy migrant' effect in mortality and socioeconomic inequalities in mortality was found in Barcelona, which seems to alter the distribution of mortality through time and space, related to the low levels of premature mortality and the selective residence of immigrants in socioeconomically disadvantaged neighborhoods.

Evolution of educational inequalities in life and health expectancies at 25 years in Belgium between 2001 and 2011: a census-based study

Background

Reducing socio-economic health inequalities is a public health priority, necessitating careful monitoring that should take into account changes in the population composition. We analyzed the evolution of educational inequalities in life expectancy and disability-free life expectancy at age 25 (LE₂₅ and DFLE₂₅) in Belgium between 2001 and 2011.

Methods

The 2001 and 2011 census data were linked with the national register data for a five-year mortality follow up. Disability prevalence estimates from the health interview surveys (2001 to 2013) were used to compute DFLE according to Sullivan’s method. LE₂₅ and DFLE₂₅ were computed by educational level (EL). Absolute differentials of LE₂₅ and DFLE₂₅ were calculated for each EL and for each period, as well as composite inequality indices (CII) of population-level impact of inequality. Changes over the 10-year period were then calculated for each inequality index.

Results

The LE₂₅ increased in all ELs and both genders, except in the lowest EL for women. The increase was larger in the highest EL, leading in 2011 to 6.07 and 4.58 years for the low-versus-high LE₂₅ gaps respectively in men and women, compared to 5.19 and 3.76 in 2001, namely 17 and 22% increases. The upwards shift of the EL distribution led to a limited 7% increase of the CII among men but no change in women.

The substantial increase of the DFLE₂₅ in males with high EL (+ 4.5 years) and the decrease of the DFLE₂₅ in women with low EL, results in a substantial increase of all considered DFLE₂₅ inequality measures in both genders. In 2011, DFLE₂₅ gaps were respectively 10.4 and 13.5 years in males and females compared to 6.51 and 9.30 in 2001, representing increases of 61 and 44% for the gaps, and 72 and 20% for the CII.

Conclusion

The LE₂₅ increased in all ELs, but at a higher pace in highly educated, leading to an increase in the LE₂₅ gaps in both genders. After accounting for the upwards shift of the educational distribution, the population-level inequality index increased only for men. The DFLE₂₅ increased only in highly educated men, and decreased in low educated women, leading to large increases of inequalities in both genders. A general plan to tackle health inequality should be set up, with particular efforts to improve the health of the low educated women.

Electronic supplementary material

The online version of this article (10.1186/s13690-019-0330-8) contains supplementary material, which is available to authorized users.

Divergence and Convergence: How Do Income Inequalities in Mortality Change over the Life Course?

BACKGROUND

Do inequalities in health by income increase or decrease with age? The empirical evidence is not conclusive and competing theories arrive at different conclusions.

OBJECTIVE

This study examined inequality in mortality by income over the adult life course with longitudinal data on people aged 30-99 between the years 1990 and 2009. Each person was followed for 19 years.

METHODS

We used Swedish total population data with 5,011,414 individual observations. We calculated the probability of having died for ages between 31 and 99. This approach to calculating death risk incorporates selective mortality during the follow-up period into the measure. Age and year standardized income positions were calculated for all individuals. Inequality was assessed by comparing the top 10% income group and the bottom 10% income group. Relative inequality was measured by risk ratios (RR) and absolute inequality by percentage point differences.

RESULTS

The results showed that the highest relative income inequality in mortality was at age 56 for men (RR: 4.7) and at age 40 for women (RR: 4.1) with differing patterns across the younger age categories between the sexes. The highest absolute income inequality in mortality was found at age 78 for men (19% difference) and at age 89 for women (14% difference) with similar patterns for both sexes. Both measures of inequality decreased after the peak, with small or no inequalities above age 95. Income inequality in mortality remained in advanced age, with larger absolute inequalities in older ages and larger relative inequalities in younger ages.

CONCLUSION

The results for absolute and relative measures of inequality differed substantially; this highlights the importance of discussing and making an active choice of inequality measure. To explain and understand the patterns of inequality in mortality over the adult life course, we conclude that the "age-as-leveler" and "cumulative disadvantage" theories are best applied to an absolute measure of inequality.

The impact of social assistance programs on population health: a systematic review of research in high-income countries

Background

Socioeconomic disadvantage is a fundamental cause of morbidity and mortality. One of the most important ways that governments buffer the adverse consequences of socioeconomic disadvantage is through the provision of social assistance. We conducted a systematic review of research examining the health impact of social assistance programs in high-income countries.

Methods

We systematically searched Embase, Medline, ProQuest, Scopus, and Web of Science from inception to December 2017 for peer-reviewed studies published in English-language journals. We identified empirical patterns through a qualitative synthesis of the evidence. We also evaluated the empirical rigour of the selected literature.

Results

Seventeen studies met our inclusion criteria. Thirteen descriptive studies rated as weak (n = 7), moderate (n = 4), and strong (n = 2) found that social assistance is associated with adverse health outcomes and that social assistance recipients exhibit worse health outcomes relative to non-recipients. Four experimental and quasi-experimental studies, all rated as strong (n = 4), found that efforts to limit the receipt of social assistance or reduce its generosity (also known as welfare reform) were associated with adverse health trends.

Conclusions

Evidence from the existing literature suggests that social assistance programs in high-income countries are failing to maintain the health of socioeconomically disadvantaged populations. These findings may in part reflect the influence of residual confounding due to unobserved characteristics that distinguish recipients from non-recipients. They may also indicate that the scope and generosity of existing programs are insufficient to offset the negative health consequences of severe socioeconomic disadvantage.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6337-1) contains supplementary material, which is available to authorized users.

Widening health inequalities between the employed and the unemployed: A decomposition of trends in Canada (2000-2014)

Recent developments in the social epidemiological literature indicate that health inequalities between the employed and the unemployed are widening in many advanced capitalist countries. At present, we know relatively little about why these inequalities are worsening. Drawing on nationally-representative data from the largest health survey in Canada, we explored this question by analyzing changes in self-rated health inequalities between employed and unemployed Canadians from 2000 to 2014. Using a regression-based method that decomposes a given inequality into its component sources, we investigated the extent to which risk factors that account for unemployment-related health inequalities at a single point in time can also explain the extent and direction of change in these unemployment-related health inequalities over time. Our results indicate that relative and absolute health inequalities between employed and unemployed Canadians widened over the study period. Between 2000 and 2014, the prevalence of poor self-rated health among unemployed Canadians increased from 10.8% to 14.6%, while rates among employed Canadians were stable at around 6%. Our findings suggest that the demographic, socioeconomic, and proximal risk factors that are routinely used to explain unemployment-related health inequalities may not be as powerful for explaining how and why these inequalities change over time. In the case of unemployment-related health inequalities in Canada, these risk factors explain neither the increasing prevalence of poor self-rated health among the unemployed nor the growing gap between the unemployed and their employed counterparts. We provide several possible explanations for these puzzling findings. We conclude by suggesting that widening health inequalities may be driven by macrosocial trends (e.g. widening income inequality and declining social safety nets) which have changed the meaning and context of unemployment, as well as its associated risk factors, in ways that are not easy to capture using routinely available survey data.

Socioeconomic Inequalities in Total and Site-Specific Cancer Incidence in Germany: A Population-Based Registry Study

Most chronic diseases follow a socioeconomic gradient with higher rates in lower socioeconomic groups. A growing body of research, however, reveals cancer to be a disease group with very diverse socioeconomic patterning, even demonstrating reverse socioeconomic gradients for certain cancers. To investigate this matter at the German national level for the first time, this study examined socioeconomic inequalities in cancer incidence in Germany, both for all cancers combined as well as for common site-specific cancers. Population-based data on primary cancers newly diagnosed in 2010-2013 was obtained from the German Centre for Cancer Registry Data. Socioeconomic position was assessed at the district level using the German Index of Socioeconomic Deprivation, which is a composite index of area-based socioeconomic indicators. Absolute and relative socioeconomic inequalities in total and site-specific cancer incidence were analyzed using multilevel Poisson regression models with the logarithm of the number of residents as an offset. Among men, socioeconomic inequalities in cancer incidence with higher rates in more deprived districts were found for all cancers combined and various site-specific cancers, most pronounced for cancers of the lung, oral and upper respiratory tract, stomach, kidney, and bladder. Among women, higher rates in more deprived districts were evident for kidney, bladder, stomach, cervical, and liver cancer as well as for lymphoid/hematopoietic neoplasms, but no inequalities were evident for all cancers combined. Reverse gradients with higher rates in less deprived districts were found for malignant melanoma and thyroid cancer in both sexes, and in women additionally for female breast and ovarian cancer. Whereas in men the vast majority of all incident cancers occurred at cancer sites showing higher incidence rates in more deprived districts and cancers with a reverse socioeconomic gradient were in a clear minority, the situation was more balanced for women. This is the first national study from Germany examining socioeconomic inequalities in total and site-specific cancer incidence. The findings demonstrate that the socioeconomic patterning of cancer is diverse and follows different directions depending on the cancer site. The area-based cancer inequalities found suggest potentials for population-based cancer prevention and can help develop local strategies for cancer prevention and control.

Mind over matter. The impact of subjective social status on health outcomes and health behaviors

Recent insights have shown subjective status to impact health and health behavior. It is however unclear how this exactly happens. In this study we explore two mechanisms: this of a direct, mediating effect of subjective status explaining the impact of material class on health outcomes and behavior and an indirect, moderating impact on the relationship between material class and health outcomes and behavior. To test this empirically we conduct two studies, focusing on Great-Britain, using survey-data from the English Longitudinal Study of Ageing (N: 2709-3448) and the Whitehall II-study (N: 6275-6467). Our linear and logistic regression analyses show subjective status has a mainly direct impact on health outcomes and has both a direct, mediating and indirect, moderating impact on health behavior. In the conclusion of our article we reflect on the theoretical reasons why subjective status has a direct impact in certain cases, while playing an indirect role in other cases.

Variations in diagnostic testing utilization in Italy: Secondary analysis of a national survey

Background

According to the principle of horizontal equity, individuals with similar need may have the same possibility of access to health services. The aim of this study is to identify patterns of diagnostic services utilization, in people with, and without chronic disease in Italy.

Methods

Secondary analysis of data from the national survey on Health and use of health care in Italy, carried out in 2013, including 99,497 participants. Multilevel analysis has been used to study the variables associated to diagnostic services utilization.

Results

13.78% of participants have had one diagnostic testing in the four weeks before the interview. In healthy people, utilization of diagnostic testing is reduced in people with low educational level (OR 0.75; 95%CI 0.67–0.84), in housewives (OR 0.66; 95%CI 0.51–0.87), or in those unable to work (OR 0.48; 95%CI 0.26–0.87), while increased in those perceiving a worse health status (up to OR 4.00, 95%CI 2.00–8.01 in very bad health). In people afflicted with chronic disease, access to diagnostic assessment is impaired by educational level (OR 0.69; 95%CI 0.61–0.78) and low household income (OR 0.75; 95%CI 0.58–0.97), while it is increased in the presence of a ticket exemption (OR 1.55, 95%CI 1.42–1.68), and fixed-term occupation (OR2.28, 95%CI 1.31–3.95). Being former-smokers in associated to an increased utilization of services in both groups.

Conclusions

Despite a universal and theoretically egalitarian, public, health care system, variations in diagnostic services utilization are still registered in Italy, both in healthy people and those afflicted by chronic diseases, on socio-economic/occupational basis, and self-perceived health status. Moreover, this significant effect of occupation on healthcare utilization, suggests the need for a comprehensive evaluation of economics in occupational health.

Educational inequalities in subjective health in Germany from 1994 to 2014: a trend analysis using the German Socio-Economic Panel study (GSOEP)

INTRODUCTION

As trend studies have shown, health inequalities by income and occupation have widened or remained stable. However, research on time trends in educational inequalities in health in Germany is scarce. The aim of this study is to analyse how educational inequalities in health evolved over a period of 21 years in the middle-aged population in Germany, and whether the trends differ by gender.

METHODS

Data were obtained from the German Socio-Economic Panel covering the period from 1994 to 2014. In total, n=16 339 participants (106 221 person years) aged 30-49 years were included in the study sample. Educational level was measured based on the 'Comparative Analysis of Social Mobility in Industrial Nations' (CASMIN) classification. Health outcomes were self-rated health (SRH) as well as (mental and physical) health-related quality of life (HRQOL, SF-12v2). Absolute Index of Inequality (Slope Index of Inequality (SII)) and Relative Index of Inequality (RII) were calculated using linear and logarithmic regression analyses with robust SEs.

RESULTS

Significant educational inequalities in SRH and physical HRQOL were found for almost every survey year from 1994 to 2014. Relative inequalities in SRH ranged from 1.50 to 2.10 in men and 1.25 to 1.87 in women (RII). Regarding physical HRQOL, the lowest educational group yielded 4.5 to 6.6 points (men) and 3.3 to 6.1 points (women) lower scores (SII). Although educational level increased over time, absolute and relative health inequalities remained largely stable over the last 21 years. For mental HRQOL, only few educational inequalities were found.

DISCUSSION

This study found persistent educational inequalities in SRH and physical HRQOL among adults in Germany from 1994 to 2014. Our findings highlight the need to intensify efforts in social and health policies to tackle these persistent inequalities.

Social class and infirmity. The role of social class over the life-course

In an aging society, it is important to promote the compression of poor health. To do so, we need to know more about how life-course trajectories influence late-life health and health inequalities. In this study, we used a life-course perspective to examine how health and health inequalities in late-midlife and in late-life are influenced by socioeconomic position at different stages of the life course. We used a representative sample of the Swedish population born between 1925 and 1934 derived from the Swedish Level of Living Survey (LNU) and the Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD) to investigate the impact of socioeconomic position during childhood (social class of origin) and of socioeconomic position in young adulthood (social class of entry) and late-midlife (social class of destination) on infirmity in late-midlife (age 60) and late-life (age 80). The results of structural equation modelling showed that poor social class of origin had no direct effect on late-midlife and late-life infirmity, but the overall indirect effect through chains of risks was significant. Thus, late-midlife and late-life health inequalities are the result of complex pathways through different social and material conditions that are unevenly distributed over the life course. Our findings suggest that policies that break the chain of disadvantage may help reduce health inequalities in late-midlife and in late-life.

Cohort profile: the Italian Network of Longitudinal Metropolitan Studies (IN-LiMeS), a multicentre cohort for socioeconomic inequalities in health monitoring

PURPOSE

The Italian Network of Longitudinal Metropolitan Studies (IN-LiMeS) is a system of integrated data on health outcomes, demographic and socioeconomic information, and represents a powerful tool to study health inequalities.

PARTICIPANTS

IN-LiMeS is a multicentre and multipurpose pool of metropolitan population cohorts enrolled in nine Italian cities: Turin, Venice, Reggio Emilia, Modena, Bologna, Florence, Leghorn, Prato and Rome. Data come from record linkage of municipal population registries, the 2001 population census, mortality registers and hospital discharge archives. Depending on the source of enrolment, cohorts can be closed or open. The census-based closed cohort design includes subjects resident in any of the nine cities at the 2001 census day; 4 466 655 individuals were enrolled in 2001 in the nine closed cohorts. The open cohort design includes subjects resident in 2001 or subsequently registered by birth or immigration until the latest available follow-up (currently 31 December 2013). The open cohort design is available for Turin, Venice, Reggio Emilia, Modena, Bologna, Prato and Rome. Detailed socioeconomic data are available for subjects enrolled in the census-based cohorts; information on demographic characteristics, education and citizenship is available from population registries.

FINDINGS TO DATE

The first IN-LiMeS application was the study of differentials in mortality between immigrants and Italians. Either using a closed cohort design (nine cities) or an open one (Turin and Reggio Emilia), individuals from high migration pressure countries generally showed a lower mortality risk. However, a certain heterogeneity between the nine cities was noted, especially among men, and an excess mortality risk was reported for some macroareas of origin and specific causes of death.

FUTURE PLANS

We are currently working on the linkage of the 2011 population census data, the expansion of geographical coverage and the implementation of the open design in all the participating cohorts.

Does an elite education benefit health? Findings from the 1970 British Cohort Study

Background: Attending private school or a higher-status university is thought to benefit future earnings and occupational opportunities. We examined whether these measures were beneficially related to health and selected health-related behaviours in midlife.

Methods: Data were from up to 9799 participants from the 1970 British birth Cohort Study. The high school attended (private, grammar or state) was ascertained at 16 years, and the university attended reported at 42 years [categorised as either higher (Russell Group) or normal-status institutions]. Self-reported health, limiting illness and body mass index (BMI) were reported at 42 years, along with television viewing, take-away meal consumption, physical inactivity, smoking and high risk alcohol drinking. Associations were examined using multiple regression models, adjusted for gender and childhood socioeconomic, health and cognitive measures.

Results: Private school and higher status university attendance were associated with favourable self-rated health and lower BMI, and beneficially associated with health-related-behaviours. For example, private school attendance was associated with 0.56 [95% confidence interval (CI): 0.48, 0.65] odds of lower self-rated health [odds ratio (OR) for higher-status university: 0.32 (0.27, 0.37)]. Associations were largely attenuated by adjustment for potential confounders, except for those of private schooling and higher-status university attendance with lower BMI and television viewing, and less frequent take-away meal consumption.

Conclusions: Private school and higher-status university attendance were related to better self-rated health, lower BMI and multiple favourable health behaviours in midlife. Findings suggest that type or status of education may be an important under-researched construct to consider when documenting and understanding socioeconomic inequalities in health.

Targeting "hardly reached" people with chronic illness: a feasibility study of a person-centered self-management education approach

BACKGROUND

Self-management education is critical to the development of successful health behavior changes related to chronic illness. However, people in high-risk groups attend less frequently or benefit less from patient education programs than do people with more socioeconomic advantages.

AIM

The aim was to test the feasibility of a participatory person-centered education approach and tool-kit targeting self-management of chronic illness in hardly reached people.

METHODS

After participating in a training program, educators (n=77) tested the approach in practice. Data collection included online questionnaires for educators (n=65), observations of education sessions (n=7), and interviews with educators (n=11) and participants (n=22). Descriptive statistics were calculated. Transcripts of interviews and observations were analyzed using systematic text condensation. Feasibility was examined in terms of practicality, integration, suitability, and efficacy.

RESULTS

Educators had a positive response to the approach and found that the tools supported involving participants in education and support. Participant satisfaction varied, depending on the ability of educators to integrate the tools into programs in a meaningful way. The tools provided time for reflection in the education process that benefited participants and educators alike. Educators found it challenging to allow participants to help set the agenda and to exchange experiences without educator control. Barriers to use reported by educators included lack of time for both training and preparation.

LIMITATIONS

The testing included varied groups of participants, some groups included members of hardly reached populations and others did not. Also, some tools were only tried in practice by a few educators.

CONCLUSION

The approach was feasible in terms of practicality, integration, acceptability, and efficacy and perceived by educators as suitable for both hardly reached participants and those who are less disadvantaged. Implementation of the approach requires time for training and preparation.

The contribution of differences in adiposity to educational disparities in mortality in the United States

BACKGROUND

There are large differences in life expectancy by educational attainment in the United States. Previous research has found obesity’s contribution to these differences to be small. Those findings may be sensitive to how obesity is estimated.

METHODS

This analysis uses discrete-time logistic regressions with data from the National Health and Nutrition Examination Survey (NHANES), pooled from 1988 to 1994 and 1999 to 2010, to estimate the contribution of differences in adiposity, or body fat, to educational differences in mortality. I show that results depend upon the measure of adiposity used: body mass index (BMI) at the time of survey or lifetime maximum BMI.

RESULTS

College graduates were less likely than high school graduates to be obese at the time of survey (25% vs. 34.6%, respectively) and were also less likely to have ever been obese (35.7% vs. 49.4%, respectively). Lifetime maximum BMI performed better than BMI at the time of survey in predicting mortality using criteria for model selection. Differences in maximum BMI were associated with between 10.3% and 12% of mortality differences between college graduates and all others, compared to between 3.3% and 4.6% for BMI at the time of survey. Among nonsmokers, between 18.4% and 27.6% of mortality differences between college graduates and all others were associated with differences in maximum BMI.

CONTRIBUTION

Adiposity is an overlooked contributor to educational differences in mortality. Previous findings that obesity does not contribute to educational disparities were based on BMI at the time of survey, which is less informative than maximum BMI. The contribution of adiposity to educational mortality differences will likely grow as smoking prevalence declines. Health surveys should collect information on weight history.