Longevity and Lifespan Variation by Educational Attainment in Spain: 1960-2015

Average lifespan variation among people with mental disorders in Denmark: a nationwide, register-based cohort study

AIMS

Mortality associated with mental disorders has been estimated using metrics such as mortality rate ratios and life expectancy. However, the variation around the average life expectancy has never been quantified. The main aim of this study was to measure life disparity for people with mental disorders as a measure of inequality at the time of death.

METHODS

Using data from Danish registries, average life disparity was introduced and calculated to measure the lifespan variation associated with major types of mental disorders. Average life expectancy is also reported for completeness.

RESULTS

Compared with the general population, people with mental disorders not only had shorter average life expectancy, but experienced larger average life disparity. For those diagnosed with a mental disorder, average life expectancy increased between 1995 and 2021; however, average life disparity declined in women only, and did not change for men. In addition, the differences in both metrics between those with mental disorders and the general population were largest for substance use disorders and schizophrenia spectrum disorders. For these disorders, the differences even increased during the study period.

CONCLUSIONS

Mortality rates for individuals with mental disorders have been declining in recent decades in Denmark; however, the increase in the average life disparity emphasizes the increasing heterogeneity and inequality in lifespans within this group, which requires measures to promote a longer and more equal life for those with mental disorders.

Educational Disparities in Preventable Deaths: Do They Explain the Longevity Gap Between Mexico and Spain?

OBJECTIVE

Determine how preventable causes of death contribute to the life expectancy gap between Mexico and Spain.

METHODS

We used a linear integral decomposition to analyze the impact of preventable mortality on life expectancy between ages 30-75 (temporary life expectancy) between Mexico and Spain in 2018. Additionally, we computed cause-deleted life tables to estimate potential gains in temporary life expectancy. Analyses were stratified by educational attainment, sex, and age.

RESULTS

Low-educated Mexicans showed the largest gains in temporary life expectancy from removing preventable deaths (3.4 years for males, 1.6 for females), partially explaining the gap with Spain. Removing these deaths would close the gap almost entirely due to a higher relative decrease for middle- and high-educated individuals.

DISCUSSION

While access to adequate healthcare is crucial for improving population health, appropriate non-medical public policies can significantly reduce mortality disparities between Mexico and Spain, especially for individuals from higher educational backgrounds.

Socio-cognitive mindfulness predicts memory complaint and cognitive performance of older adults with different years of education

BACKGROUND

Even though the effect of education on cognitive performance has been widely reported, the relationship between socio-cognitive mindfulness, cognitive performance, and memory complaint among the elderly with heterogeneous educational levels has not yet been investigated.

AIM

This study aimed to analyze the potential relationship between cognitive performance, memory complaint, and socio-cognitive mindfulness in a sample of healthy older adults with different years of education.

METHODS

In this quantitative, cross-sectional, observational, and analytical study, participants (n = 68) were assessed with a sociodemographic questionnaire, cognitive performance test (ACE-III), levels of socio-cognitive mindfulness (LSM-21), and memory complaint (Memory Complaint Scale). Descriptive statistics, as well as Pearson's correlation, and linear regression analysis were performed, and significance was assumed if p < .05.

RESULTS

Years of education correlated with cognitive performance and socio-cognitive mindfulness, but not with memory complaint. Socio-cognitive mindfulness had a positive correlation with cognitive performance and a negative correlation with memory complaint. Also, socio-cognitive mindfulness predicted cognitive performance and memory complaint both in bivariate analysis and when controlling for years of education.

CONCLUSION

Our findings suggested that older adults with higher levels of socio-cognitive mindfulness showed better cognitive performance and less memory complaint.

Decomposition of life expectancy differentials with (and without) conditions by educational attainment for major groups of causes in contemporary Spain: where is the advantage?

Introduction

Healthy life expectancy is higher among individuals with higher socioeconomic standing. However, it is unclear whether such advantage is attributable to longer (i.e., mortality advantage) or to healthier (morbidity advantage) lifespans across different health conditions.

Objective

Estimate the contribution of mortality and morbidity components in differences in condition-free life expectancies (CFLE) and life expectancy with conditions (LEWC) for five major groups of conditions by sex and educational attainment, instead of using a global indicator of morbidity.

Methods

Using the Sullivan Method, we computed remaining life expectancies at age 40 and 65, CFLE, and LEWC and applied a stepwise decomposition technique, using national health surveys along with mortality data, in a cross-sectional analysis.

Results

An educational gradient was present in almost all conditions, with different intensities. For females, morbidity was the main contributor to educational differences in health expectancies, but mainly in the older age groups. For males, the drivers behind higher health expectancies for high-educated males were evenly distributed across mortality and morbidity between ages 40 and 65, but after that, the mortality gradient vanished between high-educated and middle-educated individuals.

Discussion

The changing contribution of the mortality and morbidity gradient for different conditions across age-groups brings evidence to adequately plan health policies to mitigate health gaps and improve quality of life of the populations in a lower social standing.

Trends in socioeconomic inequalities in life expectancy and lifespan variation in Chile

Background

Socioeconomic disparities in life expectancy are well-documented in various contexts, including Chile. However, there is a lack of research examining trends in life expectancy inequalities and lifespan variation over time. Addressing these gaps can provide crucial insights into the dynamics of health inequalities.

Methods

This study utilizes data from census records, population surveys, and death certificates to compare the life expectancy and the lifespan variation at age 26 of individuals according to their rank in the distribution of years of education within their own birth cohort. The analysis spans three periods (1991, 2002, and 2017) and focuses on two educational groups: individuals in the first (lowest) quintile and tenth (highest) decile of educational attainment. Changes in life expectancy are disaggregated by major causes of death to elucidate their contributions to overall trends.

Results

Consistent with existing literature, our findings confirm that individuals with lower education levels experience lower life expectancy and higher lifespan variation compared to their more educated counterparts. Notably, by 2017, life expectancy for individuals in the lowest quintile of education has caught up with that of the top decile in 1991, albeit with contrasting trends between genders. Among women, the gap has reduced, while it has increased for males. Moreover, lifespan variation decreased (increased) over time for individuals in the tenth decile (first quintile). The leading causes of death that explain the increase in life expectancy in women and men in the tenth decile as well as women in the first quintile are cardiovascular, cancer, respiratory and digestive diseases. In the case of males in the first quintile, few gains have been made in life expectancy resulting from cancer and a negative contribution is associated with digestive conditions.

Conclusions

This study underscores persistent socioeconomic disparities in life expectancy in Chile, emphasizing the importance of ongoing monitoring of health inequalities across different demographic segments. The gender-specific and educational gradient trends highlight areas for targeted interventions aimed at reducing health disparities and improving overall population health outcomes. Further research is warranted to delve into specific causes of death driving life expectancy differentials and to inform evidence-based policy interventions.

Cause-of-Death Determinants of Lifespan Inequality

We propose a novel decomposition approach that breaks down the levels and trends of lifespan inequality as the sum of cause-of-death contributions. The suggested method shows whether the levels and changes in lifespan inequality are attributable to the levels and changes in (1) the extent of inequality in the cause-specific age-at-death distribution (the "Inequality" component), (2) the total share of deaths attributable to each cause (the "Proportion" component), or (3) the cause-specific mean age at death (the "Mean" component). This so-called Inequality-Proportion-Mean (or IPM) method is applied to 10 low-mortality countries in Europe. Our findings suggest that the most prevalent causes of death (in our setting, "circulatory system" and "neoplasms") do not necessarily contribute the most to overall levels of lifespan inequality. In fact, "perinatal and congenital" causes are the strongest drivers of lifespan inequality declines. The contribution of the IPM components to changes in lifespan inequality varies considerably across causes, genders, and countries. Among the three components, the Mean one explains the least lifespan inequality dynamics, suggesting that shifts in cause-specific mean ages at death alone contributed little to changes in lifespan inequality.

Contributions of age groups and causes of death to the sex gap in lifespan variation in Europe

Much less is known about the sex gap in lifespan variation, which reflects inequalities in the length of life, than about the sex gap in life expectancy (average length of life). We examined the contributions of age groups and causes of death to the sex gap in lifespan variation for 28 European countries, grouped into five European regions. In 2010-15, males in Europe displayed a 6.8-year-lower life expectancy and a 2.3-year-higher standard deviation in lifespan than females, with clear regional differences. Sex differences in lifespan variation are attributable largely to higher external mortality among males aged 30-39, whereas sex differences in life expectancy are due predominantly to higher smoking-related and cardiovascular disease mortality among males aged 60-69. The distinct findings for the sex gap in lifespan variation and the sex gap in life expectancy provide additional insights into the survival differences between the sexes.

Impact of COVID-19 on subnational variations in life expectancy and life disparity at birth in India: evidence from NFHS and SRS data

BACKGROUND

Measuring life expectancy and life disparity can assist in comprehending how the COVID-19 pandemic has affected the mortality estimates in the Indian population. The present study aims to study the life expectancy and life disparity at birth at the national and subnational levels before and during the COVID-19 pandemic using the NFHS and SRS data.

METHODS

The measures Life expectancy at birth ([Formula: see text]) and Life disparity at birth ([Formula: see text]) were computed for the non-pandemic and pandemic years from NFHS (2015-16), SRS (2015) and NFHS (2019-21), SRS (2020) respectively at the national and Subnational level in India. Using NFHS data for the 36 states and SRS data for the 22 states, the study calculates [Formula: see text] and [Formula: see text] by total, male and female population.

RESULTS

The [Formula: see text] for male and female decline from 64.3 years and 69.2 years in 2015-16 to 62.9 years and 68.9 years in 2019-21. The [Formula: see text] shows a drop of approximately 1.4 years for males and 0.3 years for females in the pandemic year 2019-21 when compared to the non-pandemic year 2015-16. At the subnational level [Formula: see text] shows a decline for 22 states in person, 23 states in males and 21 states in females in the pandemic year 2019-21 as compared to the non-pandemic years 2015-16. The [Formula: see text] shows a increase for 21 states in person, 24 states in females and 17 states in males in the pandemic year than non-pandemic year. The findings shows a significant losses in [Formula: see text] and gains in [Formula: see text] for males than females in the pandemic year as compared to the non-pandemic year at the subnational level in India.

CONCLUSIONS

COVID-19 pandemic has decreased [Formula: see text] and increased [Formula: see text] in the pandemic year 2019-21 at the national and subnational level in India. COVID-19 had a significant impact on the age pattern of mortality for many states and male, female population and delayed the mortality transition in India.

Age and cause-of-death contributions to educational inequalities in life expectancy and lifespan variation in a low-mortality country: A cross-sectional study of 1.67 million deaths in Spain (2016-19)

BACKGROUND

We aim to assess the age- and cause-specific contributions to differences in life expectancy and lifespan variation between the high- and low-educated groups in Spain.

METHODS

We use sex-, age-, education- and cause-specific mortality and population data for individuals aged 30 and over for 2016-19 in Spain. We estimated life expectancies, and standard deviations of the age-at-death distribution (lifespan variation), and we disentangled the contribution of age-causes of death to educational differences in both indicators.

FINDINGS

Life expectancy at age 30 was higher for high-educated groups compared to low-educated groups, 5.5 years for males and 3.0 years for females. Lifespan variation was higher for low-educated groups compared to high-educated groups, 2.9 years for males and 2.2 years for females. The main contributors to the life expectancy gaps in males were lung cancer (0.58 years) and ischaemic heart diseases (0.42 years), and in females were other cardiovascular causes (0.26 years), and ischaemic heart diseases (0.22 years). The main contributors to the lifespan variation gaps were in males lung cancer (-0.25 years) and ischaemic heart diseases (-0.22 years), while in females were other neoplasms and other diseases of the nervous system.

INTERPRETATION

Whereas behavioural causes are more important in explaining educational inequalities in mortality among men, ageing-related causes of death seem more important among women. Attempts at narrowing socioeconomic gaps in mortality may benefit from applying gender-specific preventive policy measures.

Lifespan variation among people with a given disease or condition

In addition to fundamental mortality metrics such as mortality rates and mortality rate ratios, life expectancy is also commonly used to investigate excess mortality among a group of individuals diagnosed with specific diseases or conditions. However, as an average measure, life expectancy ignores the heterogeneity in lifespan. Interestingly, the variation in lifespan-a measure commonly used in the field of demography-has not been estimated for people with a specific condition. Based on recent advances in methodology in research within epidemiology and demography, we discuss two metrics, namely, the average life disparity and average lifetable entropy after diagnosis, which estimate the variation in lifespan for time-varying conditions in both absolute and relative aspects. These metrics are further decomposed into early and late components, separated by their threshold ages. We use mortality data for women with mental disorders from Danish registers to design a population-based study and measure such metrics. Compared with women from the general population, women with a mental disorder had a shorter average remaining life expectancy after diagnosis (37.6 years vs. 44.9 years). In addition, women with mental disorders also experienced a larger average lifespan variation, illustrated by larger average life disparity (9.5 years vs 9.1 years) and larger average lifetable entropy (0.33 vs 0.27). More specifically, we found that women with a mental disorder had a larger early average life disparity but a smaller late average life disparity. Unlike the average life disparity, both early and late average lifetable entropy were higher for women with mental disorders compared to the general population. In conclusion, the metric proposed in our study complements the current research focusing merely on life expectancy and further provides a new perspective into the assessment of people's health associated with time-varying conditions.

The socioeconomic distribution of life expectancy and healthy life expectancy in Chile

BACKGROUND

Life expectancy (LE) has usually been used as a metric to monitor population health. In the last few years, metrics such as Quality-Adjusted-Life-Expectancy (QALE) and Health-Adjusted-Life- Expectancy (HALE) have gained popularity in health research, given their capacity to capture health related quality of life, providing a more comprehensive approach to the health concept. We aimed to estimate the distribution of the LE, QALEs and HALEs across Socioeconomic Status in the Chilean population.

METHODS

Based on life tables constructed using Chiang II´s method, we estimated the LE of the population in Chile by age strata. Probabilities of dying were estimated from mortality data obtained from national registries. Then, life tables were stratified into five socioeconomic quintiles, based on age-adjusted years of education (pre-school, early years to year 1, primary level, secondary level, technical or university). Quality weights (utilities) were estimated for age strata and SES, using the National Health Survey (ENS 2017). Utilities were calculated using the EQ-5D data of the ENS 2017 and the validated value set for Chile. We applied Sullivan´s method to adjust years lived and convert them into QALEs and HALEs.

RESULTS

LE at birth for Chile was estimated in 80.4 years, which is consistent with demographic national data. QALE and HALE at birth were 69.8 and 62.4 respectively. Men are expected to live 6.1% less than women. However, this trend is reversed when looking at QALEs and HALEs, indicating the concentration of higher morbidity in women compared to men. The distribution of all these metrics across SES showed a clear gradient in favour of a better-off population-based on education quintiles. The absolute and relative gaps between the lowest and highest quintile were 15.24 years and 1.21 for LE; 18.57 HALYs and 1.38 for HALEs; and 21.92 QALYs and 1.41 for QALEs. More pronounced gradients and higher gaps were observed at younger age intervals.

CONCLUSION

The distribution of LE, QALE and HALEs in Chile shows a clear gradient favouring better-off populations that decreases over people´s lives. Differences in LE favouring women contrast with differences in HALEs and QALEs which favour men, suggesting the need of implementing gender-focused policies to address the case-mix complexity. The magnitude of inequalities is greater than in other high-income countries and can be explained by structural social inequalities and inequalities in access to healthcare.

Levels, trends, and determinants of cause-of-death diversity in a global perspective: 1990-2019

BACKGROUND

While much is known about the leading causes of death (CoD) and how they have evolved over time, much less is known about the diversity of such causes of death. CoD diversity is an important marker of population health heterogeneity that has been largely overlooked in the study of contemporary health dynamics.

METHODS

We provide regional and national estimates of CoD diversity from 1990 to 2019. We rely on data from the Global Burden of Disease project, using information on 21 CoD. Results are presented for 204 countries and territories, for women and men separately. CoD diversity is measured with the index of Fractionalization. Results are disaggregated by age and cause of death.

RESULTS

CoD diversity has declined across world regions, except for Latin America and the Caribbean, the region of High-income countries and women in Central Europe, Eastern Europe, and Central Asia. Changes in mortality at adult and older ages have been mostly responsible for CoD diversity dynamics, except for the regions of South Asia and Sub-Saharan Africa, where infant and child mortality still play a non-negligible role. The relationship between CoD diversity, life expectancy, and lifespan inequality is strongly non-monotonic, with turning points differing by sex and indicator. Among longevity vanguard countries, further increases in life expectancy are associated with decreasing lifespan inequality but increasing CoD diversity.

CONCLUSION

As mortality declines, there is no universal pathway toward low CoD diversity, thus casting doubts on the ability of Epidemiological Transition Theory to predict prospective CoD dynamics among high- and middle-mortality countries. Despite the postponement and increasing predictability of the ages at which individuals die, low-mortality populations are composed of an increasingly heterogenous mix of robust and frail individuals, thus increasing the diversity of health profiles among older persons - an issue that could potentially complicate further improvements in longevity.

Dynamic Changes in the Association Between Education and Health in the United States

Policy Points We reviewed some of the recent advances in education and health, arguing that attention to social contextual factors and the dynamics of social and institutional change provide critical insights into the ways in which the association is embedded in institutional contexts. Based on our findings, we believe incorporating this perspective is fundamentally important to ameliorate current negative trends and inequality in Americans' health and longevity.

A distributional approach to measuring lifespan stratification

The study of the mortality differences between groups has traditionally focused on metrics that describe average levels of mortality, for example life expectancy and standardized mortality rates. Additional insights can be gained by using statistical distance metrics to examine differences in lifespan distributions between groups. Here, we use a distance metric, the non-overlap index, to capture the sociological concept of stratification, which emphasizes the emergence of unique, hierarchically layered social strata. We show an application using Finnish registration data that cover the entire population over the period from 1996 to 2017. The results indicate that lifespan stratification and life-expectancy differences between income groups both increased substantially from 1996 to 2008; subsequently, life-expectancy differences declined, whereas stratification stagnated for men and increased for women. We conclude that the non-overlap index uncovers a unique domain of inequalities in mortality and helps to capture important between-group differences that conventional approaches miss.

Cause-of-Death Diversity From a Multiple-Cause Perspective in the United States

Cause-of-death diversity captures the variability of deaths across causes and is an important marker of heterogeneity in a population's health. We contribute to the debate of cause-of-death diversity dynamics by following a novel multiple causes of death (MCOD) approach and applying it to the U.S. context between 2003 and 2018 and across education groups. Results show that cause-of-death diversity increased over this period, especially up to 2012. These trends were mainly driven by increases in the groups aged 65 years or more. The inclusion of MCOD resulted in higher increases in cause-of-death diversity over time compared with merely using underlying causes of death, except for the 85 or more age group, where no difference was observed for males and a reverted gradient was observed for females. Results by educational attainment reveal lower diversity among the highest educated groups and widening differences across groups from around 2012 onward. The clear educational gradient observed at ages 30-64 diminished at older ages. The observed increases in cause-of-death diversity should be monitored to better understand mortality dynamics in aging populations. Our new MCOD diversity measures suggest that traditional approaches relying on single causes of death might be underestimating cause-of-death diversity dynamics, particularly for males.

The evolution of personality disorders: A review of proposals

Personality disorders (PDs) are currently considered dysfunctions. However, personality differences are older than humanity and are ubiquitous in nature, from insects to higher primates. This suggests that a number of evolutionary mechanisms-other than dysfunctions-may be able to maintain stable behavioral variation in the gene pool. First of all, apparently maladaptive traits may actually improve fitness by enabling better survival or successful mating or reproduction, as exemplified by neuroticism, psychopathy, and narcissism. Furthermore, some PDs may harm important biological goals while facilitating others, or may be globally beneficial or detrimental depending on environmental circumstances or body condition. Alternatively, certain traits may form part of life history strategies: Coordinated suites of morphological, physiological and behavioral characters that optimize fitness through alternative routes and respond to selection as a whole. Still others may be vestigial adaptations that are no longer beneficial in present times. Finally, variation may be adaptative in and by itself, as it reduces competition for finite resources. These and other evolutionary mechanisms are reviewed and illustrated through human and non-human examples. Evolutionary theory is the best-substantiated explanatory framework across the life sciences, and may shed light on the question of why harmful personalities exist at all.

A GBD 2019 study of health and Sustainable Development Goal gains and forecasts to 2030 in Spain

This study aimed to report mortality, risk factors, and burden of diseases in Spain. The Global Burden of Disease, Injuries, and Risk Factors 2019 estimates the burden due to 369 diseases, injuries, and impairments and 87 risk factors and risk factor combinations. Here, we detail the updated Spain 1990-2019 burden of disease estimates and project certain metrics up to 2030. In 2019, leading causes of death were ischaemic heart disease, stroke, chronic obstructive pulmonary disease, Alzheimer's disease, and lung cancer. Main causes of disability adjusted life years (DALYs) were ischaemic heart disease, diabetes, lung cancer, low back pain, and stroke. Leading DALYs risk factors included smoking, high body mass index, and high fasting plasma glucose. Spain scored 74/100 among all health-related Sustainable Development Goals (SDGs) indicators, ranking 20 of 195 countries and territories. We forecasted that by 2030, Spain would outpace Japan, the United States, and the European Union. Behavioural risk factors, such as smoking and poor diet, and environmental factors added a significant burden to the Spanish population's health in 2019. Monitoring these trends, particularly in light of COVID-19, is essential to prioritise interventions that will reduce the future burden of disease to meet population health and SDG commitments.

(Healthy) Aging Patterns in Europe: A Multistate Health Transition Approach

We explore patterns and determinants of health transition probabilities by combining outcomes of morbidity and mortality to examine different aging patterns across Europe, and to ascertain how individual socio-demographic characteristics modify these patterns. We use panel data from the Survey of Health, Ageing and Retirement in Europe (2004– 2017) for 76,536 individuals aged 50 + in 20 European countries who participated in at least two waves. All transition probabilities were calculated applying a multistate analytical approach. Our findings show significant gender, education, and cohort differences in health transition probabilities and marked cross-country group differences. Central and Northern European countries present lower probabilities of health deterioration than Southern and, especially, Eastern European countries. Having a high level of education, living in Central Europe, and being younger are associated with lower probabilities of health deterioration and, if any, a higher probability of being restored to good health. We found less evidence of differences when transitions end in death. Our study contributes to this line of research by implementing a multistate approach using European harmonized panel dataset, to examine the effects of birth cohort, educational attainment and gender differences on health transitions. Our findings point to the need to consider the specific influence of individual factors in the aging process in different transitions according to the context and with reference to specific vulnerable groups. In the context of aging societies, such a consideration is both essential and policy relevant.

Inequalities in life expectancy by educational level and its decomposition in Barcelona, 2004-2018

OBJECTIVE

To analyse the gap in life expectancy by educational level in the city of Barcelona from 2004 to 2018 and to decompose this gap by age and causes of death.

METHOD

We computed abridged life tables at the age of 25 years by sex from 2004 to 2018 using standard methods. Educational level was categorised in two groups (lower secondary or less vs. upper secondary or higher education). The life expectancy gap was further decomposed by age and by causes of death based in Arriaga's method in 5-year age blocks up to the age of ≥ 90 years and broad causes of death using ICD-10 codes.

RESULTS

The life expectancy gap at 25 years by educational level oscillated without trend at around 3.08 years for men and 1.93 years for women. Decomposition by age showed a favourable significant shift in the contribution to this gap from young to older ages for men, with few changes for women. Decomposition by causes of death showed that the diseases concentrating the largest share of the contribution were neoplasms and respiratory and circulatory disease. There was a significant downward trend in external causes for men and in infectious diseases for both men and women but a significant upward trend for respiratory disease for both sexes.

CONCLUSIONS

The stability of the life expectancy gap by educational level during the period analysed resulted from a combination of divergent trends by age and causes of death among high and low educational levels.

Extreme Temperature and Mortality by Educational Attainment in Spain, 2012-2018

Extreme temperatures are a threat to public health, increasing mortality in the affected population. Moreover, there is substantial research showing how age and gender shape vulnerabilities to this environmental risk. However, there is only limited knowledge on how socioeconomic status (SES), operationalized using educational attainment, stratifies the effect of extreme temperatures on mortality. Here, we address this link using Poisson regression and administrative data from 2012 to 2018 for 50 Spanish Provinces on individuals aged above 65 matched with meteorological data provided by the E-OBS dataset. In line with previous studies, results show that hot and cold days increase mortality. Results on the interaction between SES and extreme temperatures show a positive and significant effect of exposure to heat and cold for individuals with medium and low SES level. Conversely, for high SES individuals we do not find evidence of a robust association with heat or cold. We further investigate how the local climate moderates these associations. A warmer climate increases risks with exposures to low temperatures and vice versa for hot temperatures in the pooled sample. Moreover, we observe that results are mostly driven by low SES individuals being particularly vulnerable to heat in colder climates and cold in warmer climates. In conclusion, results highlight how educational attainment stratifies the effect of extreme temperatures and the relevance of the local climate in shaping risks of low SES individuals aged above 65.

Macro-level factors explaining inequalities in expected years lived free of and with chronic conditions across Spanish regions and over time (2006-2019)

Life expectancy has long been associated with macro-level factors, including health expenditures, but little research has focused on the relationship with morbidity measures. This paper examines the relationship between the expected years lived free of and with chronic conditions (YLFCC and YLCC) at age 50 and macroeconomic and social factors including, for the first time, several indicators of public health expenditure. We calculate YLFCC and YLCC for Spanish regions using the Sullivan method over a long period of time (2006-2019). Spain is a good case study due to two reasons. First, its national health system is decentralized among regional administrations since 2002. Second, the financial crisis of 2008 led to public health cuts in 2010-2014 that each region handled differently. We use fixed-effects models to assess the relationship between changes in macro-level regional indicators (socioeconomic factors, healthcare resources, health behavior and public health expenditures) with YLFCC and YLCC across regions and over time. Results show that socioeconomic levels, public health expenditure, healthcare resources and health behaviors are associated with years lived free of and with chronic conditions when analyzing them independently. However, in the global model including all these dimensions only public health expenditure is associated with both YLFCC and YLCC for men and women, showing that a higher level of expenditures is correlated with more YLFCC and less YLCC. Therefore, regional authorities need to pay special attention to the level of investments on health services, as they are clearly associated with a better quality of living of the middle age and older population.

Significant impacts of the COVID-19 pandemic on race/ethnic differences in US mortality

The coronavirus 2019 (COVID-19) pandemic triggered global declines in life expectancy. The United States was hit particularly hard among high-income countries. Early data from the United States showed that these losses varied greatly by race/ethnicity in 2020, with Hispanic and Black Americans suffering much larger losses in life expectancy compared with White people. We add to this research by examining trends in lifespan inequality, average years of life lost, and the contribution of specific causes of death and ages to race/ethnic life-expectancy disparities in the United States from 2010 to 2020. We find that life expectancy in 2020 fell more for Hispanic and Black males (4.5 and 3.6 y, respectively) compared with White males (1.5 y). These drops nearly eliminated the previous life-expectancy advantage for the Hispanic compared with the White population, while dramatically increasing the already large gap in life expectancy between Black and White people. While the drops in life expectancy for the Hispanic population were largely attributable to official COVID-19 deaths, Black Americans saw increases in cardiovascular diseases and "deaths of despair" over this period. In 2020, lifespan inequality increased slightly for Hispanic and White populations but decreased for Black people, reflecting the younger age pattern of COVID-19 deaths for Hispanic people. Overall, the mortality burden of the COVID-19 pandemic hit race/ethnic minorities particularly hard in the United States, underscoring the importance of the social determinants of health during a public health crisis.

Gender Gap in Unhealthy Life Expectancy: The Role of Education Among Adults Aged 45

Objectives: This paper examines the gender gap in unhealthy life expectancy across education levels and age in Spain to understand the extent to which the gender paradox exists over education and across ages. Methods: Death registrations and vital status were taken from the Spanish Statistical Office, while the three health measures (chronic conditions, bad-self rated health and cognitive impairment) from the 2019 European Health Interview Survey. We used Sullivan's method to compute unhealthy life expectancy by education level. We computed the gender and the education ratios of the proportion of unhealthy life years in each health measure by education and age. Results: At almost all ages and all education levels, women significantly lived longer but in poorer health than men. Marked gender differences are seen across most age-groups, particularly among the low educated. We detected greater health inequalities by education level for women (confirming the gender paradox) and a health gradient due to aging and across the health measures charting the disablement process. Conclusion: The new education distribution might improve the unhealthy life expectancy and might reduce the gender gap in the number of years spent in poor health.

Estimation of smoking-related mortality and its contribution to educational inequalities in life expectancy in Spain: an observational study, 2016-2019

OBJECTIVE

To estimate smoking-related mortality and its contribution to educational inequalities in life expectancy in Spain.

DESIGN

Nationwide, observational study from 2016 to 2019. Population-attributable fractions were used to estimate age, sex and education-specific cause-of-death smoking-attributable mortality. Life table techniques and decomposition methods were used to estimate potential gains in life expectancy at age 35 and the cause-specific contributions of smoking-related mortality to life expectancy differences across educational groups.

SETTING

Spain.

PARTICIPANTS

We use cause-specific mortality data from population registers and smoking prevalence from the National and the European Health Survey for Spain from 2017 and 2019/2020, respectively.

RESULTS

We estimated 219 086 smoking-related deaths during 2016-2019, equalling 13% of all deaths, 83.7% of those in men. In the absence of smoking, potential gains in male life expectancy were higher among the low-educated than the high-educated (3.1 vs 2.1 years). For women, educational differences were less and also in the opposite direction (0.6 vs 0.9 years). The contribution of smoking to life expectancy differences between high-educated and low-educated groups accounted for 1.5 years among men, and -0.2 years among women. For men, the contribution of smoking to these differences was mostly driven by cancer in middle age, cardiometabolic diseases at younger ages and respiratory diseases at older ages. For women, the contribution to this gap, although negligible, was driven by cancer at older ages among the higher educated.

CONCLUSIONS

Smoking remains a relevant preventable risk factor of premature mortality in Spain, disproportionately affecting life expectancy of low-educated men.

Mortality and life expectancy trends in Spain by pension income level for male pensioners in the general regime retiring at the statutory age, 2005-2018

Background

Research has generally found a significant inverse relationship in mortality risk across socioeconomic (SE) groups. This paper focuses on Spain, a country for which there continues to be very little evidence available concerning retirement pensioners. We draw on the Continuous Sample of Working Lives (CSWL) to investigate disparities in SE mortality among retired men aged 65 and above over the longest possible period covered by this data source: 2005–2018. We use the initial pension income (PI) level as our single indicator of the SE status of the retired population.

Methods

The mortality gradient by income is quantified in two ways: via an indicator referred to as “relative mortality”, and by estimating changes in total life expectancy (LE) by PI level at ages 65 and 75 over time. We show that, should the information provided by the relative mortality ratio not be completely clear, a second indicator needs to be introduced to give a broad picture of the true extent of inequality in mortality.

Results

The first indicator reveals that, for the period covered and for all age groups, the differences in death rates across PI levels widens over time. At older age groups, these differences across PI levels diminish. The second indicator shows that disparities in LE at ages 65 and 75 between pensioners in the lowest and highest income groups are relatively small, although slightly higher than previously reported for Spain. This gap in LE widens over time, from 1.49 to 2.54 years and from 0.71 to 1.40 years respectively for pensioners aged 65 and 75. These differences are statistically significant.

Conclusions

Along with other behavioral and structural aspects, a combination of factors such as the design of the pension system, the universality and quality of the health system, and high levels of family support could explain why LE inequalities for retired Spanish men are relatively small. To establish the reasons for this increased inequality in LE, more research needs to be carried out. An analysis of all Spanish social security records instead of just a sample would provide us with more information.

Why we should monitor disparities in old-age mortality with the modal age at death

Indicators based a fixed “old” age threshold have been widely used for assessing socioeconomic disparities in mortality at older ages. Interpretation of long-term trends and determinants of these indicators is challenging because mortality above a fixed age that in the past would have reflected old age deaths is today mixing premature and old-age mortality. We propose the modal (i.e., most frequent) age at death, M, an indicator increasingly recognized in aging research, but which has been infrequently used for monitoring mortality disparities at older ages. We use mortality and population exposure data by occupational class over the 1971-2017 period from Finnish register data. The modal age and life expectancy indicators are estimated from mortality rates smoothed with penalized B-splines. Over the 1971-2017 period, occupational class disparities in life expectancy at 65 and 75 widened while disparities in M remained relatively stable. The proportion of the group surviving to the modal age was constant across time and occupational class. In contrast, the proportion surviving to age 65 and 75 has roughly doubled since 1971 and showed strong occupational class differences. Increasing socioeconomic disparities in mortality based on fixed old age thresholds may be a feature of changing selection dynamics in a context of overall declining mortality. Unlike life expectancy at a selected fixed old age, M compares individuals with similar survival chances over time and across occupational classes. This property makes trends and differentials in M easier to interpret in countries where old-age survival has improved significantly.

Educational differences in alcohol-related mortality and their impact on life expectancy and lifespan variation in Spain (2016-2018): a cross-sectional analysis using multiple causes of death

BACKGROUND

Socioeconomic inequalities in alcohol-related mortality in Spain exists, and are postulated to contribute to inequalities in all-cause mortality. We aim to assess absolute and relative educational inequalities in alcohol-related mortality, and to estimate the role of alcohol in educational inequalities in both life expectancy and lifespan variation in Spain.

METHODS

We used multiple cause-of-death (MCOD) mortality data for individuals aged 30 and over for Spain (2016-2018) by educational attainment. We estimated by sex and educational attainment age-standardised alcohol-attributable mortality rates, relative and absolute indices of educational inequalities; and total life expectancy and lifespan variation at age 30 for all-cause mortality and after eliminating alcohol-attributable mortality.

RESULTS

The use of MCOD resulted in an additional 2543 annual alcohol-related deaths (+75% among men and +50% among women) compared with estimates derived from underlying causes of death. In absolute terms, educational inequalities were the highest among men aged 45-84 and among women aged 45-64. In relative terms, higher inequalities raised in working ages, whereas at older ages inequalities tended to be lower, although still important among men. Alcohol contributed to educational inequalities in life expectancy (men: 0.13 years (3.2%); women 0.02 years (0.7%)) and lifespan variation (2.1% and 1.4% for men and women, respectively).

CONCLUSION

Alcohol consumption remains an important lifestyle habit to be tackled in order to reduce socioeconomic inequalities in mortality in Spain, particularly among men.

Normalized lifespan inequality: disentangling the longevity-lifespan variability nexus

Previous studies have documented a historically strong and negative association between countries’ life expectancy (i.e., average longevity) and length-of-life inequality (i.e., variability in ages at death). The relationship between both variables might be partially explained by life expectancy increasing at a faster pace than maximal length of life, a phenomenon that mechanically compresses the age-at-death distribution and has not been taken into consideration in previous studies. In this paper, we propose a new approach to lifespan inequality measurement that accounts for the (uncertainly) bounded nature of length-of-life. Applying the new approach to the countries of the Human Mortality Database, we observe that the decline in overall lifespan variability typically associated with increases in longevity seems to stop and even reverse at higher levels of life expectancy. This suggests the emergence of worrying ethical dilemmas, whereby higher achievements in longevity would only be possible at the expense of higher lifespan variability.

On the measurement of healthy lifespan inequality

Background

Current measures to monitor population health include indicators of (i) average length-of-life (life expectancy), (ii) average length-of-life spent in good health (health expectancy), and (iii) variability in length-of-life (lifespan inequality). What is lacking is an indicator measuring the extent to which healthy lifespans are unequally distributed across individuals (the so-called ‘healthy lifespan inequality’ indicators).

Methods

We combine information on age-specific survival with the prevalence of functional limitation or disability in Spain (2014–2017) by sex and level of education to estimate age-at-disability onset distributions. Age-, sex- and education-specific prevalence rates of adult individuals’ daily activities limitations were based on the GALI index derived from Spanish National Health Surveys held in 2014 and 2017. We measured inequality using the Gini index.

Results

In contemporary Spain, education differences in health expectancy are substantial and greatly exceed differences in life expectancy. The female advantage in life expectancy disappears when considering health expectancy indicators, both overall and across education groups. The highly educated exhibit lower levels of lifespan inequality, and lifespan inequality is systematically higher among men. Our new healthy lifespan inequality indicators suggest that the variability in the ages at which physical daily activity limitations start are substantially larger than the variability in the ages at which individuals die. Healthy lifespan inequality tends to decrease with increasing educational attainment, both for women and for men. The variability in ages at which physical limitations start is slightly higher for women than for men.

Conclusions

The suggested indicators uncover new layers of health inequality that are not traceable with currently existing approaches. Low-educated individuals tend to not only die earlier and spend a shorter portion of their lives in good health than their highly educated counterparts, but also face greater variation in the eventual time of death and in the age at which they cease enjoying good health—a multiple burden of inequality that should be taken into consideration when evaluating the performance of public health systems and in the elaboration of realistic working-life extension plans and the design of equitable pension reforms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12963-021-00279-8.

What have we learned about mortality patterns over the past 25 years?

In this paper, I examine progress in the field of mortality over the past 25 years. I argue that we have been most successful in taking advantage of an increasingly data-rich environment to improve aggregate mortality models and test pre-existing theories. Less progress has been made in relating our estimates of mortality risk at the individual level to broader mortality patterns at the population level while appropriately accounting for contextual differences and compositional change. Overall, I find that the field of mortality continues to be highly visible in demographic journals, including Population Studies. However much of what is published today in field journals could just as easily appear in neighbouring disciplinary journals, as disciplinary boundaries are shrinking.

From convergence to divergence: Lifespan variation in US states, 1959-2017

BACKGROUND

Large disparities in life expectancy exist across US states and the gaps have been widening in recent decades. Less is known about the lifespan variability - a measure that can provide important insights into mortality inequalities both between and within states.

METHOD

Using yearly lifetables from the United States Mortality Database, we explore geographic and temporal patterns in lifespan variation (unconditional and conditional on survival to age 10, 35 and 65) across US states between 1959 and 2017. We also examine the contribution of state differences in life expectancy to overall lifespan variation using standard decomposition techniques.

RESULTS

Despite overall convergence in lifespan variation across states over the last six decades, in more recent years there has been notable divergence. Gender-specific analyses show that lifespan variation was generally greater among males than among females; but this pattern reverses for mortality past age 65. Much of the state disparities in lifespan variation, unconditional and conditional on survival to age 10 and 35, were due to mortality differences under the age 65. Decomposition analysis shows that while within-state variability remains the primary driver of overall lifespan variation, the contribution of cross-state differences in life expectancy is growing.

CONCLUSIONS

Variation in longevity is greater within US States than between them, yet cross-states disparities in mortality are increasing. This likely reflects the long-term consequences of rising social, economic, and political stratification for health inequalities both within and across states.

The Cross-sectional Average Inequality in Lifespan (CAL†): A Lifespan Variation Measure That Reflects the Mortality Histories of Cohorts

Lifespan variation is a key metric of mortality that describes both individual uncertainty about the length of life and heterogeneity in population health. We propose a novel and timely lifespan variation measure, which we call the cross-sectional average inequality in lifespan, or CAL†. This new index provides an alternative perspective on the analysis of lifespan inequality by combining the mortality histories of all cohorts present in a cross-sectional approach. We demonstrate how differences in the CAL† measure can be decomposed between populations by age and cohort to explore the compression or expansion of mortality in a cohort perspective. We apply these new methods using data from 10 low-mortality countries or regions from 1879 to 2013. CAL† reveals greater uncertainty in the timing of death than the period life table-based indices of variation indicate. Also, country rankings of lifespan inequality vary considerably between period and cross-sectional measures. These differences raise intriguing questions as to which temporal dimension is the most relevant to individuals when considering the uncertainty in the timing of death in planning their life courses.

Investigating causal relationships between exposome and human longevity: a Mendelian randomization analysis

BACKGROUND

Environmental factors are associated with human longevity, but their specificity and causality remain mostly unclear. By integrating the innovative "exposome" concept developed in the field of environmental epidemiology, this study aims to determine the components of exposome causally linked to longevity using Mendelian randomization (MR) approach.

METHODS

A total of 4587 environmental exposures extracting from 361,194 individuals from the UK biobank, in exogenous and endogenous domains of exposome were assessed. We examined the relationship between each environmental factor and two longevity outcomes (i.e., surviving to the 90th or 99th percentile age) from various cohorts of European ancestry. Significant results after false discovery rates correction underwent validation using an independent exposure dataset.

RESULTS

Out of all the environmental exposures, eight age-related diseases and pathological conditions were causally associated with lower odds of longevity, including coronary atherosclerosis (odds ratio = 0.77, 95% confidence interval [0.70, 0.84], P = 4.2 × 10-8), ischemic heart disease (0.66, [0.51, 0.87], P = 0.0029), angina (0.73, [0.65, 0.83], P = 5.4 × 10-7), Alzheimer's disease (0.80, [0.72, 0.89], P = 3.0 × 10-5), hypertension (0.70, [0.64, 0.77], P = 4.5 × 10-14), type 2 diabetes (0.88 [0.80, 0.96], P = 0.004), high cholesterol (0.81, [0.72, 0.91], P = 0.0003), and venous thromboembolism (0.92, [0.87, 0.97], P = 0.0028). After adjusting for genetic correlation between different types of blood lipids, higher levels of low-density lipoprotein cholesterol (0.72 [0.64, 0.80], P = 2.3 × 10-9) was associated with lower odds of longevity, while high-density lipoprotein cholesterol (1.36 [1.13, 1.62], P = 0.001) showed the opposite. Genetically predicted sitting/standing height was unrelated to longevity, while higher comparative height size at 10 was negatively associated with longevity. Greater body fat, especially the trunk fat mass, and never eat sugar or foods/drinks containing sugar were adversely associated with longevity, while education attainment showed the opposite.

CONCLUSIONS

The present study supports that some age-related diseases as well as education are causally related to longevity and highlights several new targets for achieving longevity, including management of venous thromboembolism, appropriate intake of sugar, and control of body fat. Our results warrant further studies to elucidate the underlying mechanisms of these reported causal associations.

Changes in life expectancy and lifespan variability by income quartiles in four Nordic countries: a study based on nationwide register data

OBJECTIVES

Levels, trends or changes in socioeconomic mortality differentials are typically described in terms of means, for example, life expectancies, but studies have suggested that there also are systematic social disparities in the dispersion around those means, in other words there are inequalities in lifespan variation. This study investigates changes in income inequalities in mean and distributional measures of mortality in Denmark, Finland, Norway, and Sweden over two decades.

DESIGN

Nationwide register-based study.

SETTING

The Danish, Finnish, Norwegian and Swedish populations aged 30 years or over in 1997 and 2017.

MAIN OUTCOME MEASURES

Income-specific changes in life expectancy, lifespan variation and the contribution of 'early' and 'late' deaths to increasing life expectancy.

RESULTS

Increases in life expectancy has taken place in all four countries, but there are systematic differences across income groups. In general, the largest gains in life expectancy were observed in Denmark, and the smallest increase among low-income women in Sweden and Norway. Overall, life expectancy increased and lifespan variation decreased with increasing income level. These differences grew larger over time. In all countries, a marked postponement of early deaths led to a compression of mortality in the top three income quartiles for both genders. This did not occur for the lowest income quartile.

CONCLUSION

Increasing life expectancy is typically accompanied by postponement of early deaths and reduction of lifespan inequality in the higher-income groups. However, Nordic welfare societies are challenged by the fact that postponing premature deaths among people in the lowest-income groups is not taking place.

Diversification in causes of death in low-mortality countries: emerging patterns and implications

INTRODUCTION

An important role of public health organisations is to monitor indicators of variation, so as to disclose underlying inequality in health improvement. In industrialised societies, more individuals than ever are reaching older ages and have become more homogeneous in their age at death. This has led to a decrease in lifespan variation, with substantial implications for the reduction of health inequalities. We focus on a new form of variation to shed further light on our understanding of population health and ageing: variation in causes of death.

METHODS

Data from the WHO Mortality Database and the Human Mortality Database are used to estimate cause-of-death distributions and life tables in 15 low-mortality countries. Cause-of-death variation, using 19 groups of causes, is quantified using entropy measures and analysed from 1994 to 2017.

RESULTS

The last two decades have seen increasing diversity in causes of death in low-mortality countries. There have been important reductions in the share of deaths from diseases of the circulatory system, while the share of a range of other causes, such as diseases of the genitourinary system, mental and behavioural disorders, and diseases of the nervous system, has been increasing, leading to a more complex cause-of-death distribution.

CONCLUSIONS

The diversification in causes of death witnessed in recent decades is most likely a result of the increase in life expectancy, together with better diagnoses and awareness of certain diseases. Such emerging patterns bring additional challenges to healthcare systems, such as the need to research, monitor and treat a wider range of diseases. It also raises new questions concerning the distribution of health resources.

The contribution of social participation to differences in life expectancy and healthy years among the older population: A comparison between Chile, Costa Rica and Spain

We study the health trajectories of the population aged over 60, comparing between one European and two Latin American countries (Spain, Chile and Costa Rica) which have similar longevity patterns. Our focus is on functional limitation and mortality risks, considering differences by gender, education and social participation. Data come from national panel surveys (EPS, CRELES, SHARE). Multistate modelling is used to estimate transition probabilities between two health states: healthy to unhealthy, unhealthy to healthy as well as the transition to death from healthy or unhealthy states, to estimate the duration of stay in a specific state (computing healthy and unhealthy life expectancies) and the effect of the selected covariates. Results show that older Costa Ricans have the smallest gender gap in life expectancy but women have a lower healthy life expectancy compared to those in Chile and Spain. Participation in social activities leads to higher healthy life expectancy among the elderly in Costa Rica and Spain, whilst there were no relevant educational differences observed in longevity in the analysed countries. To conclude: despite the different patterns observed in health transitions and survival across the three countries, social participation is associated with greater health and longevity among people of old age, with little effect coming from educational attainment. Public policies should therefore be aimed at reducing unhealthy life years and dependency at advanced ages by promoting more engagement in social activities, especially among vulnerable groups who are more likely to experience impairment from a younger age.

Happiness and life expectancy by main occupational position among older workers: Who will live longer and happy?

Current concerns about aging populations are being translated into legislations to postpone the statutory age at retirement. However, if this is done without considering inequalities in longevity across occupational groups, some may face higher vulnerabilities than others. We examine differences in life expectancy and happiness by occupational position for the Spanish population aged 50 and over. We use happiness as a measure of subjective wellbeing, and compute life expectancy and happy life expectancy by sex and main occupation. Age-specific death rates are calculated using administrative data, and happiness prevalence comes from the European Social Survey. We show that both men and women in managerial positions were advantaged in terms of life expectancy, but only men record more years with happiness. In addition, women in routine jobs were the ones who could expect to live shorter and unhappier. Postponing the statutory age at retirement without considering these differences could be detrimental to women's wellbeing and health.

Black-white disparities during an epidemic: Life expectancy and lifespan disparity in the US, 1980-2000

Covid-19 has demonstrated again that epidemics can affect minorities more than the population in general. We consider one of the last major epidemics in the United States: HIV/AIDS from ca. 1980-2000. We calculate life expectancy and lifespan disparity (a measure of variance in age at death) for thirty US states, finding noticeable differences both between states and between the black and white communities. Lifespan disparity allows us to examine distributional effects, and, using decomposition methods, we find that for six states lifespan disparity for blacks increased between 1980 and 1990, while life expectancy increased less than for whites. We find that we can attribute most of this to the impact of HIV/AIDS.

Insight into stagnating adult life expectancy: Analyzing cause of death patterns across socioeconomic groups

This study analyzes the complexity of female longevity improvements. As socioeconomic status is found to influence health and mortality, we partition all individuals, at each age in every year, into five socioeconomic groups based on an affluence measure that combine an individual's income and wealth. We identify the particular socioeconomic groups that have been driving the standstill for Danish females at older ages. Within each socioeconomic group, we further analyze the cause of death patterns. The decline in life expectancy for Danish females is present for four out of five subgroups, however, with particular large decreases for the low-middle and middle-affluence groups. Cancers, smoking-related lung and bronchus causes, and other diseases particularly contribute to the stagnation. For four of the five socioeconomic groups only small cardiovascular improvement are experienced during the period of stagnating life expectancy compared to an equally long and subsequent period.

Educational Inequalities in Life and Healthy Life Expectancies among the 50-Plus in Spain

This study computes educational inequalities in life expectancy (LE), healthy life expectancy (HLE), and unhealthy life expectancy (ULE) by gender and education level in Spain in 2012. Death registrations and vital status by level of education were obtained from Spain’s National Institute of Statistics. Health prevalences were estimated from the National Health Survey for Spain. We used Sullivan’s method to compute HLE, ULE, and the proportion of time lived with health problems. Our results reveal that Spanish women live longer than men in all education groups, but a higher proportion of women report poor health. We detect substantial differences in unhealthy life by gender and education, with higher effect for women and for those with low levels of education. Poor self-perceived health shows the largest educational gradient; chronic diseases present the lowest. This is the first work that provides evidence on health inequalities by education level in Spain. Our findings seem to be in line with reports of the smaller social inequalities experienced in Southern Europe and highlight the importance of education level on extending the proportion of years spent in good health in a Mediterranean country.

Income-related inequality in quality-adjusted life expectancy in Korea at the national and district levels

BACKGROUND

The aim of this study was to measure differences in quality-adjusted life expectancy (QALE) by income in Korea at the national and district levels.

METHODS

Mortality rates and EuroQol-5D (EQ-5D) scores were obtained from the National Health Information Database of the National Health Insurance Service and the Korea Community Health Survey, respectively. QALE and differences in QALE among income quintiles were calculated using combined 2008-2014 data for 245 districts in Korea. Correlation analyses were conducted to investigate the associations of neighborhood characteristics with QALE and income gaps therein.

RESULTS

QALE showed a graded pattern of inequality according to income, and increased over time for all levels of income and in both sexes, except for low-income quintiles among women, resulting in a widened inequality in QALE among women. In all 245 districts, pro-rich inequalities in QALE were found in both men and women. Districts with higher QALE and smaller income gaps in QALE were concentrated in metropolitan areas, while districts with lower QALE and larger income gaps in QALE were found in rural areas. QALE and differences in QALE by income showed relatively close correlations with socioeconomic characteristics, but relatively weak correlations with health behaviors, except for smoking and indicators related to medical resources.

CONCLUSIONS

This study provides evidence of income-based inequalities in health measured by QALE in all subnational areas in Korea. Furthermore, QALE and differences in QALE by income were closely associated with neighborhood-level socioeconomic characteristics.

The increasing lifespan variation gradient by area-level deprivation: A decomposition analysis of Scotland 1981-2011

Life expectancy inequalities are an established indicator of health inequalities. More recent attention has been given to lifespan variation, which measures the amount of heterogeneity in age at death across all individuals in a population. International studies have documented diverging socioeconomic trends in lifespan variation using individual level measures of income, education and occupation. Despite using different socioeconomic indicators and different indices of lifespan variation, studies reached the same conclusion: the most deprived experience the lowest life expectancy and highest lifespan variation, a double burden of mortality inequality. A finding of even greater concern is that relative differences in lifespan variation between socioeconomic group were growing at a faster rate than life expectancy differences. The magnitude of lifespan variation inequalities by area-level deprivation has received limited attention. Area-level measures of deprivation are actively used by governments for allocating resources to tackle health inequalities. Establishing if the same lifespan variation inequalities emerge for area-level deprivation will help to better inform governments about which dimension of mortality inequality should be targeted. We measure lifespan variation trends (1981-2011) stratified by an area-level measure of socioeconomic deprivation that is applicable to the entire population of Scotland, the country with the highest level of variation and one of the longest, sustained stagnating trends in Western Europe. We measure the gradient in variation using the slope and relative indices of inequality. The deprivation, age and cause specific components driving the increasing gradient are identified by decomposing the change in the slope index between 1981 and 2011. Our results support the finding that the most advantaged are dying within an ever narrower age range while the most deprived are facing greater and increasing uncertainty. The least deprived group show an increasing advantage, over the national average, in terms of deaths from circulatory disease and external causes.

Global trends in lifespan inequality: 1950-2015

Using data from the UN World Population Prospects, we document global trends in lifespan inequality from 1950 until 2015. Our findings indicate that (i) there has been a sustained decline in overall lifespan inequality, (ii) adult lifespan variability has also declined, but some plateaus and trend reversals have been identified, (iii) lifespan inequality among the elderly has increased virtually everywhere, and (iv) most of the world variability in age-at-death can be attributed to within-country variability. Such changes have occurred against a backdrop of generalized longevity increases. Our analyses suggest that the world is facing a new challenge: the emergence of diverging trends in longevity and age-at-death inequality among the elderly around the globe-particularly in high-income areas. As larger fractions of the world population survive to more advanced ages, it will be necessary for national and international health planners to recognize the growing heterogeneity that characterizes older populations.

Changing contribution of area-level deprivation to total variance in age at death: a population-based decomposition analysis

OBJECTIVES

Two processes generate total variance in age at death: heterogeneity (between-group variance) and individual stochasticity (within-group variance). Limited research has evaluated how these two components have changed over time. We quantify the degree to which area-level deprivation contributed to total variance in age at death in Scotland between 1981 and 2011.

DESIGN

Full population and mortality data for Scotland were obtained and matched with the Carstairs score, a standardised z-score calculated for each part-postcode sector that measures relative area-level deprivation. A z-score above zero indicates that the part-postcode sector experienced higher deprivation than the national average. A z-score below zero indicates lower deprivation. From the aggregated data we constructed 40 lifetables, one for each deprivation quintile in 1981, 1991, 2001 and 2011 stratified by sex.

PRIMARY OUTCOME MEASURES

Total variance in age at death and the proportion explained by area-level deprivation heterogeneity (between-group variance).

RESULTS

The most deprived areas experienced stagnating or slightly increasing variance in age at death. The least deprived areas experienced decreasing variance. For males, the most deprived quintile life expectancy was between 7% and 11% lower and the SD is between 6% and 25% higher than the least deprived. This suggests that the effect of deprivation on the SD of longevity is comparable to its effect on life expectancy. Decomposition analysis revealed that contributions from between-group variance doubled between 1981 and 2011 but at most only explained 4% of total variance.

CONCLUSIONS

This study adds to the emerging body of literature demonstrating that socio-economic groups have experienced diverging trends in variance in age at death. The contribution from area-level deprivation to total variance in age at death, which we were able to capture, has doubled since 1981. Area-level deprivation may play an increasingly important role in mortality inequalities.