Mortality by occupational class among men 30-64 years in 11 European countries. EU Working Group on Socioeconomic Inequalities in Health

Income and professional inequalities in chronic diseases: prevalence and incidence in France

OBJECTIVES

In France, almost nine of 10 deaths are caused by non-communicable diseases, and there is significant social inequality in mortality rates. However, it is not easy to collect robust data on the incidence and prevalence of such diseases according to socio-economic status. Based on data from the link between the primary longitudinal population sample and the national health data system, the aim of our study was to compute the standardised incidence and prevalence of seven major groups of chronic diseases according to socio-economic status.

STUDY DESIGN

Descriptive retrospective cohort study.

METHODS

This was a descriptive retrospective cohort study on a weighted representative sample of the French population, comprising 3.4 million individuals from data collected 2016-2017. Main chronic disease categories include diabetes, cancers, psychiatric disorders, liver and pancreatic diseases, neurological conditions, respiratory and cardiovascular diseases, calculated from the 2016-2017 period by combining health care consumption and diagnoses received during hospitalisations and/or associated with specific full healthcare coverage. Socio-economic status was measured by disposable income from the 2013-2014 tax returns and census-derived socioprofessional groups, and findings were standardised for age and sex.

RESULTS

For all disease categories except cancers, standardised incidence rates showed a gradient favouring the wealthiest, with a risk ratio between the first and tenth standard of living deciles ranging from 1.4 (cardiovascular diseases) to 2.8 (diabetes). Incidence of all disease categories, except cancers, was higher for all groups compared with executives and higher academic professions (risk ratios between workers and executives ranged from 2.0 to 1.3 in psychiatric and cardiovascular diseases, respectively). Conversely, cancer incidence rate followed a flat curve, reduced in the two poorest standard of living deciles, and there were no significant differences between socioprofessional groups. Standardised prevalence rates followed the same patterns, although risk ratios were highest for psychiatric diseases, varying according to sex and disease.

CONCLUSIONS

Deep social inequalities in incidence and prevalence of chronic diseases were observed in a large representative sample of the French population. The reverse social inequalities in cancer incidence and prevalence calls for more detailed research into cancer types and selection mechanisms, the data from which would allow the long-term monitoring of such disparities.

Exposure to environmental occupational constraints and all-cause mortality: Results for men and women from a 20-year follow-up prospective cohort, the VISAT study. Be aware of shift-night workers!

Objective

To determine the predictive value of the large panel of occupational constraints (OC) on all-cause mortality with a 20-year follow-up, in general population of workers.

Methods

In VISAT prospective cohort study, 3,138 workers (1,605 men; 1,533 women) were recruited during the periodic work health visits conducted by occupational physicians. OC (physical, organizational, psychological and employment categories) were collected through self-questionnaires. Exposure durations of each OC were divided by tertile distribution. Cox-regression models were performed to analyze the associations between all-cause mortality and each OC first separately and simultaneously in a single model.

Results

The mortality rates were higher among exposed participants to most of OC compared to those unexposed. Being exposed and longer exposure increased the risks of all-cause mortality for exposures to carrying heavy loads, loud noise, working more than 48 h/week, starting its first job before 18 years old although these risks became non-significant after adjustments for cardiovascular risk factors. Shift work and night work confirmed a high risk of mortality whatever the adjustments and notably when the other occupational exposures were taking into account, with, respectively: HR: 1.38 (1.01-1.91) and 1.44 (1.06-1.95). After adjustments being exposed more than 13 years to a work requiring getting-up before 5:00 a.m. and more than 16 years in rotating shift work significantly increased the risk of mortality by one and a half.

Conclusion

The links between each OC and all-cause mortality and the role of individual factors were stressed. For night-shift workers, it is urgent to implement preventive strategies at the workplace.

Improving job strain might reduce inequalities in cardiovascular disease mortality in european men

Unfavorable psychosocial working conditions can lead to cardiovascular disease (CVD) mortality. Lower-occupational groups typically experience unfavorable psychosocial working conditions as compared to higher-occupational groups. We investigate the extent to which CVD mortality inequalities might be reduced if psychosocial working conditions for manual workers are raised to the level experienced by non-manual workers (upward-leveling scenario). We also investigate what would occur if psychosocial working conditions among manual and non-manual workers are raised to better levels as observed in the 'ideal' region (best practice scenario). Individual-level CVD mortality data from 12 European countries were obtained from the EURO-GBD-SE project (1998-2007). Psychosocial working conditions data (i.e. job strain) were extracted from the European Working Conditions Survey (2005) and rate ratios from literature reviews. Population attributable fractions (PAF) and two counterfactual scenarios (namely, upward-leveling scenario and best-practice scenario) were developed to examine employed male non-manual and manual workers. Results appeared to show that CVD mortality might be reduced in men when unfavorable psychosocial working conditions are improved for manual workers (PAF = 7.7%, 95% CI: 6.5-10.0). The upward-leveling scenario seems to reduce CVD mortality inequalities for manual workers, by 13-74%. Best-practice scenario shows the largest reduction in CVD mortality in the Baltic region (87 deaths per 100,000 person years). Findings suggest that rendering job strain in manual workers to the level experienced by non-manual workers might substantially reduce CVD mortality inequalities in European men.

Mortality by occupation and industry among Japanese men in the 2015 fiscal year

BACKGROUND

Although previous studies have underscored some unique inequalities in occupational mortality in Japan, many of these trends have been dramatically altered during recent decades. We analyzed mortality data by occupation and industry in Japan, to determine whether differences remained by the mid-2010s for men in working-age population.

METHODS

We calculated age-standardized all-cause and cause-specific mortality, according to occupation and industry, among men aged 25-64 years in the 2015 fiscal year (1 April 2015 to 31 March 2016). Occupational and industry-specific categories were defined using the Japan Standard Occupational Classification and Japan Standard Industrial Classification, respectively. Age-standardized mortality rates were computed using 5-year age intervals. Mortality rate ratios adjusted for age and 95% confidence intervals (CIs) were estimated using Poisson regression. Cause-specific deaths were classified into four broad groups (cancers [C00-D48], cardiovascular diseases [I00-I99], external causes [V01-Y98], and all other diseases) based on the International Statistical Classification of Diseases 10th Revision (ICD-10).

RESULTS

Clear mortality differences were identified by both occupation and industry among Japanese males. All-cause mortality ranged from 53.7 (clerical workers) to 240.3 (service workers) per 100,000 population for occupation and from 54.3 (workers in education) to 1169.4 (workers in mining) for industry. In relative terms, service workers and agriculture, forestry, and fishing workers had 2.89 and 2.50 times higher all-cause mortality than sales workers. Administrative and managerial workers displayed higher mortality risk (1.86; 95% CI 1.76-1.97) than sales workers. Similar patterns of broad cause-specific mortality inequality were identified in terms of both absolute and relative measures, and all broad cause-specific deaths contributed to the differences in mortality by occupation and industry.

CONCLUSIONS

Substantial differences in mortality among Japanese male workers, according to occupation and industry, were still present in 2015.

Progress in reducing inequalities in cardiovascular disease mortality in Europe

OBJECTIVE

To assess whether recent declines in cardiovascular mortality have benefited all socioeconomic groups equally and whether these declines have narrowed or widened inequalities in cardiovascular mortality in Europe.

METHODS

In this prospective registry-based study, we determined changes in cardiovascular mortality between the 1990s and the early 2010s in 12 European populations by gender, educational level and occupational class. In order to quantify changes in the magnitude of differences in mortality, we calculated both ratio measures of relative inequalities and difference measures of absolute inequalities.

RESULTS

Cardiovascular mortality has declined rapidly among lower and higher socioeconomic groups. Relative declines (%) were faster among higher socioeconomic groups; absolute declines (deaths per 100 000 person-years) were almost uniformly larger among lower socioeconomic groups. Therefore, although relative inequalities increased over time, absolute inequalities often declined substantially on all measures used. Similar trends were seen for ischaemic heart disease and cerebrovascular disease mortality separately. Best performer was England and Wales, which combined large declines in cardiovascular mortality with large reductions in absolute inequalities and stability in relative inequalities in both genders. In the early 2010s, inequalities in cardiovascular mortality were smallest in Southern Europe, of intermediate magnitude in Northern and Western Europe and largest in Central-Eastern European and Baltic countries.

CONCLUSIONS

Lower socioeconomic groups have experienced remarkable declines in cardiovascular mortality rates over the last 25 years, and trends in inequalities can be qualified as favourable overall. Nevertheless, further reducing inequalities remains an important challenge for European health systems and policies.

Mortality inequalities by occupational class among men in Japan, South Korea and eight European countries: a national register-based study, 1990-2015

BACKGROUND

We compared mortality inequalities by occupational class in Japan and South Korea with those in European countries, in order to determine whether patterns are similar.

METHODS

National register-based data from Japan, South Korea and eight European countries (Finland, Denmark, England/Wales, France, Switzerland, Italy (Turin), Estonia, Lithuania) covering the period between 1990 and 2015 were collected and harmonised. We calculated age-standardised all-cause and cause-specific mortality among men aged 35-64 by occupational class and measured the magnitude of inequality with rate differences, rate ratios and the average inter-group difference.

RESULTS

Clear gradients in mortality were found in all European countries throughout the study period: manual workers had 1.6-2.5 times higher mortality than upper non-manual workers. However, in the most recent time-period, upper non-manual workers had higher mortality than manual workers in Japan and South Korea. This pattern emerged as a result of a rise in mortality among the upper non-manual group in Japan during the late 1990s, and in South Korea during the late 2000s, due to rising mortality from cancer and external causes (including suicide), in addition to strong mortality declines among lower non-manual and manual workers.

CONCLUSION

Patterns of mortality by occupational class are remarkably different between European countries and Japan and South Korea. The recently observed patterns in the latter two countries may be related to a larger impact on the higher occupational classes of the economic crisis of the late 1990s and the late 2000s, respectively, and show that a high socioeconomic position does not guarantee better health.

Discovering pockets of complexity: Socioeconomic status, stress exposure, and the nuances of the health gradient

One of the most pervasive statements about stratification and health identifies the strong inverse relationship-or gradient-between socioeconomic status (SES) and poor health. We elaborate on the ways that the SES-based gradient in stress exposure contributes to nuances in the SES-health association. In analyses of the 2008 National Study of the Changing Workforce, we find some evidence that the inverse association between SES and health outcomes is finely graded-but several 'pockets of complexity' emerge. First, education and income have different associations with health and well-being. Second, those associations depend on the outcome being assessed. Education is more influential for predicting anxiety and poor health than for depression or life dissatisfaction, while income is more influential for predicting depression and, to a lesser extent, life dissatisfaction. Third, different patterns of explanation or suppression reflect resource advantage or stress of higher status dynamics. Some impactful stressors that people encounter-especially job pressure and work-family conflict-are not neatly graded in ways that corroborate the conventional SES-health narrative. Instead, these mask the size of the overall health differences between lower versus higher SES groups. Our mapping of the SES gradient in stressors extends that story and complicates the conventional view of the association between SES and health/well-being.

Socioeconomic differentials in mortality by cause of death in the Republic of Ireland, 1984-2008

CONTEXT/PROBLEM

Comparative analysis of relative and absolute mortality differentials between socioeconomic groups are now available. These show consistently increasing relative increases in mortality differentials but complex trends in absolute mortality differentials.

OBJECTIVE

This paper provides an analysis of relative and absolute trends in mortality by cause of death and socioeconomic group (SEG) from 1984 to 2008 among men and active women aged 30-64 years in Ireland and compares these results with recent European and US studies to give an overview of trends.

METHODS

This paper uses mortality data from the Irish Central Statistics Office from 1984 to 2008 to calculate standardized death rates by age, sex, socioeconomic status and cause of death showing trends in SEG inequalities in mortality in Ireland. These show which specific causes of death are driving all-cause mortality trends.

RESULTS

SEG differentials in all-cause mortality among men and women have been increasing since the 1980s. Some of this increase reflects larger falls in cardiovascular causes among advantaged groups, but the trend is largely accounted for by increasing inequalities in mortality in digestive, neoplasm and external causes of deaths.

CONCLUSIONS

These findings are in line with international findings that show that socioeconomic differentials in digestive, neoplasm and external cause deaths are driving general socioeconomic differentials in all-cause mortality. External cause deaths may have been influenced by levels of economic activity, particularly in construction, during the economic boom among manual workers. Furthermore, deaths from digestive diseases during the 1990s and 2000s may well be the result of increases in liver disease associated with excessive alcohol consumption.

Changes in mortality inequalities over two decades: register based study of European countries

OBJECTIVE

To determine whether government efforts in reducing inequalities in health in European countries have actually made a difference to mortality inequalities by socioeconomic group.

DESIGN

Register based study.

DATA SOURCE

Mortality data by level of education and occupational class in the period 1990-2010, usually collected in a census linked longitudinal study design. We compared changes in mortality between the lowest and highest socioeconomic groups, and calculated their effect on absolute and relative inequalities in mortality (measured as rate differences and rate ratios, respectively).

SETTING

All European countries for which data on socioeconomic inequalities in mortality were available for the approximate period between years 1990 and 2010. These included Finland, Norway, Sweden, Scotland, England and Wales (data applied to both together), France, Switzerland, Spain (Barcelona), Italy (Turin), Slovenia, and Lithuania.

RESULTS

Substantial mortality declines occurred in lower socioeconomic groups in most European countries covered by this study. Relative inequalities in mortality widened almost universally, because percentage declines were usually smaller in lower socioeconomic groups. However, as absolute declines were often smaller in higher socioeconomic groups, absolute inequalities narrowed by up to 35%, particularly among men. Narrowing was partly driven by ischaemic heart disease, smoking related causes, and causes amenable to medical intervention. Progress in reducing absolute inequalities was greatest in Spain (Barcelona), Scotland, England and Wales, and Italy (Turin), and absent in Finland and Norway. More detailed studies preferably using individual level data are necessary to identify the causes of these variations.

CONCLUSIONS

Over the past two decades, trends in inequalities in mortality have been more favourable in most European countries than is commonly assumed. Absolute inequalities have decreased in several countries, probably more as a side effect of population wide behavioural changes and improvements in prevention and treatment, than as an effect of policies explicitly aimed at reducing health inequalities.

Is the Mediterranean diet a feasible approach to preserving cognitive function and reducing risk of dementia for older adults in Western countries? New insights and future directions

The rise in the ageing population has resulted in increased incident rates of cognitive impairment and dementia. The subsequent financial and societal burden placed on an already strained public health care system is of increasing concern. Evidence from recent studies has revealed modification of lifestyle and dietary behaviours is, at present, the best means of prevention. Some of the most important findings, in relation to the Mediterranean diet (MedDiet) and the contemporary Western diet, and potential molecular mechanisms underlying the effects of these two diets on age-related cognitive function, are discussed in this review. A major aim of this review was to discuss whether or not a MedDiet intervention would be a feasible preventative approach against cognitive decline for older adults living in Western countries. Critical appraisal of the literature does somewhat support this idea. Demonstrated evidence highlights the MedDiet as a potential strategy to reduce cognitive decline in older age, and suggests the Western diet may play a role in the aetiology of cognitive decline. However, strong intrinsic Western socio-cultural values, traditions and norms may impede on the feasibility of this notion.

Inequalities in Alcohol-Related Mortality in 17 European Countries: A Retrospective Analysis of Mortality Registers

BACKGROUND

Socioeconomic inequalities in alcohol-related mortality have been documented in several European countries, but it is unknown whether the magnitude of these inequalities differs between countries and whether these inequalities increase or decrease over time.

METHODS AND FINDINGS

We collected and harmonized data on mortality from four alcohol-related causes (alcoholic psychosis, dependence, and abuse; alcoholic cardiomyopathy; alcoholic liver cirrhosis; and accidental poisoning by alcohol) by age, sex, education level, and occupational class in 20 European populations from 17 different countries, both for a recent period and for previous points in time, using data from mortality registers. Mortality was age-standardized using the European Standard Population, and measures for both relative and absolute inequality between low and high socioeconomic groups (as measured by educational level and occupational class) were calculated. Rates of alcohol-related mortality are higher in lower educational and occupational groups in all countries. Both relative and absolute inequalities are largest in Eastern Europe, and Finland and Denmark also have very large absolute inequalities in alcohol-related mortality. For example, for educational inequality among Finnish men, the relative index of inequality is 3.6 (95% CI 3.3-4.0) and the slope index of inequality is 112.5 (95% CI 106.2-118.8) deaths per 100,000 person-years. Over time, the relative inequality in alcohol-related mortality has increased in many countries, but the main change is a strong rise of absolute inequality in several countries in Eastern Europe (Hungary, Lithuania, Estonia) and Northern Europe (Finland, Denmark) because of a rapid rise in alcohol-related mortality in lower socioeconomic groups. In some of these countries, alcohol-related causes now account for 10% or more of the socioeconomic inequality in total mortality. Because our study relies on routinely collected underlying causes of death, it is likely that our results underestimate the true extent of the problem.

CONCLUSIONS

Alcohol-related conditions play an important role in generating inequalities in total mortality in many European countries. Countering increases in alcohol-related mortality in lower socioeconomic groups is essential for reducing inequalities in mortality. Studies of why such increases have not occurred in countries like France, Switzerland, Spain, and Italy can help in developing evidence-based policies in other European countries.

Occupational class inequalities in all-cause and cause-specific mortality among middle-aged men in 14 European populations during the early 2000s

This study analyses occupational class inequalities in all-cause mortality and four specific causes of death among men, in Europe in the early 2000s, and is the most extensive comparative analysis of occupational class inequalities in mortality in Europe so far. Longitudinal data, obtained from population censuses and mortality registries in 14 European populations, from around the period 2000–2005, were used. Analyses concerned men aged 30–59 years and included all-cause mortality and mortality from all cancers, all cardiovascular diseases (CVD), all external, and all other causes. Occupational class was analysed according to five categories: upper and lower non-manual workers, skilled and unskilled manual workers, and farmers and self-employed combined. Inequalities were quantified with mortality rate ratios, rate differences, and population attributable fractions (PAF). Relative and absolute inequalities in all-cause mortality were more pronounced in Finland, Denmark, France, and Lithuania than in other populations, and the same countries (except France) also had the highest PAF values for all-cause mortality. The main contributing causes to these larger inequalities differed strongly between countries (e.g., cancer in France, all other causes in Denmark). Relative and absolute inequalities in CVD mortality were markedly lower in Southern European populations. We conclude that relative and absolute occupational class differences in all-cause and cause specific mortality have persisted into the early 2000's, although the magnitude differs strongly between populations. Comparisons with previous studies suggest that the relative gap in mortality between occupational classes has further widened in some Northern and Western European populations.

Trends in socio-economic inequalities in mortality by sex in Ireland from the 1980s to the 2000s

BACKGROUND

It has been recognised for some time that mortality rates vary across social class groups, with lower rates in the higher social classes. Internationally, but particularly in Ireland, many studies on the topic of inequalities in mortality have been confined to men, partly because the most frequently used socioeconomic classification, that based on occupation, can less easily be applied to women. Where research does exist, studies indicate that health inequalities are greater for men than for women. Given the issues around classification, there remains however, little knowledge of the socio-economic inequalities in female mortality in Ireland.

AIMS

Using annual mortality data from the Irish Central Statistics Office over the period 1984-2008 this paper calculates crude and standardised mortality rates per 100,000 population for men and women in different socio-economic groups (SEG) and examines trends in these over time. This means that for the first time, longitudinal comparisons can be made between men and women across an important period of recent Irish history.

RESULTS

There is a significant gradient in mortality rates across SEG for both men and women with the absolute and relative differential between professional and manual occupational groups increasing between the 1980s and 2000s even though the mortality rates were falling over time for all SEG groups for both sexes.

CONCLUSIONS

The results confirm international findings that women generally have smaller gradients than men across SEG with the ratio of male/female differentials (i.e. the ratio of the male SEG rate ratio to the female SEG rate ratio) decreasing between the 1980s and 2000s from 1.25 to 1.07.

All part of the job? The contribution of the psychosocial and physical work environment to health inequalities in Europe and the European health divide

This study is the first to examine the contribution of both psychosocial and physical risk factors to occupational inequalities in self-assessed health in Europe. Data from 27 countries were obtained from the 2010 European Working Conditions Survey for men and women aged 16 to 60 (n = 21,803). Multilevel logistic regression analyses (random intercept) were applied, estimating odds ratios of reporting less than good health. Analyses indicate that physical working conditions account for a substantial proportion of occupational inequalities in health in both Central/Eastern and Western Europe. Physical, rather than psychosocial, working conditions seem to have the largest effect on self-assessed health in manual classes. For example, controlling for physical working conditions reduced the inequalities in the prevalence of"less than good health" between the lowest (semi- and unskilled manual workers) and highest (higher controllers) occupational groups in Europe by almost 50 percent (Odds Ratio 1.87, 95% Confidence Interval 1.62-2.16 to 1.42, 1.23-1.65). Physical working conditions contribute substantially to health inequalities across "post-industrial" Europe, with women in manual occupations being particularly vulnerable, especially those living in Central/Eastern Europe. An increased political and academic focus on physical working conditions is needed to explain and potentially reduce occupational inequalities in health.

Measuring social inequalities in cause-specific mortality in France: comparison between linked and unlinked approaches

BACKGROUND

Monitoring the time trends in socioeconomic inequalities in mortality by cause is a key public health issue. The aim of this study was to compare methods to measure social inequalities in cause-specific mortality in the French population aged 25-55 years. More specifically, it compares bias and precision related to the use of occupational class declared at the last census (linked data) to the one declared at the time of death on the death certificate (unlinked data).

METHODS

We used a representative sample of 1% of the French population. Causes of death were obtained by direct linkage with the French national death registry. Occupational class was classified into eight categories. Taking professionals and managers as the reference, relative risks of mortality by cause and their 95% confidence intervals were estimated using Poisson models for the 1983-1989, 1991-1997, and 2000-2006 periods. The relative risks were calculated with both linked data and exhaustive unlinked data.

RESULTS

Over the 2000-2006 period, occupational classes declared at census and on the death certificate were consistent for half of the deaths. Relative risks for manual workers were found to be similar between the two approaches over the 1983-1989 and 1991-1997 periods, and higher for the unlinked approach over the 2000-2006 period. Over the latter period, the order and magnitude of relative risks varied similarly by occupational class and cause of death for both approaches. Confidence intervals obtained from linked data were wide.

CONCLUSION

Occupational class derived from the death certificate must be used with caution as a measure for epidemiological purposes and the available linked data do not allow accurate estimates of social inequalities in cause-specific mortality. Other solutions should be considered in order to improve the follow-up of social inequalities in mortality. This would require the collection of educational level on the death certificate or the linkage of the cause of death database with other exhaustive and informative databases.

Educational inequalities in mortality in northern, mid and southern Italy and the contribution of smoking

BACKGROUND

Previous studies have shown that mortality inequalities are smaller in Italy than in most European countries. This may be due to the weak association between socioeconomic status and smoking in Italy. However, most published studies were based on data from a single city in northern Italy (Turin). In this study, we aimed to assess the size of mortality inequalities in Italy as a whole, their geographical pattern of variation within Italy, and the contribution of smoking to these inequalities.

METHODS

Participants in the National Health Interview Survey 1999-2000 were followed up for mortality until 31 December 2007. Using Cox regression, we computed the age-adjusted relative index of inequality (RII) for all-cause mortality with and without controlling for smoking status and intensity. Education was used as an indicator of socioeconomic status.

RESULTS

Among 72,762 individuals aged 30-74 years at baseline, 4092 died during the follow-up. The age-adjusted RII of mortality was 1.69 (95% CI 1.44 to 2.00) among men and 1.43 (95% CI 1.13 to 1.82) among women. Among men, inequalities were larger in both northern and southern regions than in the middle of the country, whereas among women they were larger in the south. After controlling for smoking RII decreased to 1.63 (95% CI 1.38 to 1.92) among men and increased to 1.54 (95% CI 1.21 to 1.96) among women. The geographical variation in mortality inequalities was not affected by smoking adjustment.

CONCLUSIONS

Mortality inequalities in Italy are smaller than in most European countries. This is due, among other factors, to the weak socioeconomic pattern of smoking over the past decades in Italy.

Education, household wealth and blood pressure in Albania, Armenia, Azerbaijan and Ukraine: findings from the Demographic Health Surveys, 2005-2009

BACKGROUND

While socioeconomic gradients in cardiovascular disease have been well established in high-income countries, this relationship is not well understood in middle-income countries.

METHODS

Data from Demographic Health Surveys collected in Albania (2008-09), Armenia (2005), Azerbaijan (2006) and Ukraine (2007) were used to estimate age-adjusted differences in systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), hypertension (HTN), elevated blood pressure, and optimal blood pressure across a standardized wealth index, level of educational attainment, and urban versus rural residence.

RESULTS

The wealthiest Albanian females had lower average SBP, DBP, PP (all p<0.01) and HTN status (odds ratio [OR]=0.3, CI: 0.2-0.5, p<0.001) compared to the poorest; similar education gradients were also found. Such disparities also existed for Albanian men. Among Armenian women, urban (OR=1.4, 1.1-1.8, p<0.01), more educated (OR=0.7, CI: 0.6-0.9, p<0.01), and wealthier (OR=1.8, 1.4-2.4, p<0.001) women were more likely to have optimal blood pressure. Urban Armenian men were also more likely to have optimal blood pressure (OR=1.8, 1.2-2.9, p<0.01). Wealthier and urban Azerbaijani had lower risk of elevated blood pressure and Azerbaijani women displayed strong wealth gradients with higher quintiles of wealth associated with lower continuous blood pressure measures. There were no socioeconomic gradients for Ukrainian males or females.

CONCLUSIONS

There is compelling evidence that wealth and education gradients affect the probability of HTN for women in Albania, Armenia, and Azerbaijan, and for men in Albania.

Trends in mortality by labour market position around retirement ages in three European countries with different welfare regimes

OBJECTIVES

In the face of economic downturn and increasing life expectancy, many industrial nations are adopting a policy of postponing the retirement age. However, questions still remain around the consequence of working longer into old age. We examine mortality by work status around retirement ages in countries with different welfare regimes; Finland (social democratic), Turin (Italy; conservative), and England and Wales (liberal).

METHODS

Death rates and rate ratios (RRs) (reference rates = 'in-work'), 1970 s-2000 s, were estimated for those aged 45-64 years using the England and Wales longitudinal study, Turin longitudinal study, and the Finnish linked register study.

RESULTS

Mortality of the not-in-work was consistently higher than the in-work. Death rates for the not-in-work were lowest in Turin and highest in Finland. Rate ratios were smallest in Turin (RR men 1972-76 1.73; 2002-06 1.63; women 1.22; 1.68) and largest in Finland (RR men 1991-95 3.03; 2001-05 3.80; women 3.62; 4.11). Unlike RRs for men, RRs for women increased in every country (greatest in Finland).

CONCLUSIONS

These findings signal that overall, employment in later life is associated with lower mortality, regardless of welfare regime.

Does an immigrant health paradox exist among Asian Americans? Associations of nativity and occupational class with self-rated health and mental disorders

A robust socioeconomic gradient in health is well-documented, with higher socioeconomic status (SES) associated with better health across the SES spectrum. However, recent studies of U.S. racial/ethnic minorities and immigrants show complex SES-health patterns (e.g., flat gradients), with individuals of low SES having similar or better health than their richer, U.S.-born and more acculturated counterparts, a so-called "epidemiological paradox" or "immigrant health paradox". To examine whether this exists among Asian Americans, we investigate how nativity and occupational class (white-collar, blue-collar, service, unemployed) are associated with subjective health (self-rated physical health, self-rated mental health) and 12-month DSM-IV mental disorders (any mental disorder, anxiety, depression). We analyzed data from 1530 Asian respondents to the 2002-2003 National Latino and Asian American Study in the labor force using hierarchical multivariate logistic regression models controlling for confounders, subjective social status (SSS), material and psychosocial factors theorized to explain health inequalities. Compared to U.S.-born Asians, immigrants had worse socioeconomic profiles, and controlling for age and gender, increased odds for reporting fair/poor mental health and decreased odds for any DSM-IV mental disorder and anxiety. No strong occupational class-health gradients were found. The foreign-born health-protective effect persisted after controlling for SSS but became nonsignificant after controlling for material and psychosocial factors. Speaking fair/poor English was strongly associated with all outcomes. Material and psychosocial factors were associated with some outcomes--perceived financial need with subjective health, uninsurance with self-rated mental health and depression, social support, discrimination and acculturative stress with all or most DSM-IV outcomes. Our findings caution against using terms like "immigrant health paradox" which oversimplify complex patterns and mask negative outcomes among underserved sub-groups (e.g., speaking fair/poor English, experiencing acculturative stress). We discuss implications for better measurement of SES and health given the absence of a gradient and seemingly contradictory finding of nativity-related differences in self-rated health and DSM-IV mental disorders.

Inequalities in male mortality by occupational class, perceived status and education in Russia, 1994-2006

BACKGROUND

Russia's market reforms in the early 1990s led to marked social inequalities. We analysed inequalities in risks of dying for Russian men by occupational class and perceived social status in the post-transition era.

METHODS

Cox proportional analysis of the hazard of dying by occupational class, education, household income and perceived social status was performed for 593 deaths that occurred between 1994 and 2006 using a representative sample of Russia's male population (n = 6586 people, 40 046 person-years). Occupational class was coded based on the European Socio-Economic Classification; social status was based on survey questionnaires about people's perceived economic, power and respect status.

RESULTS

Manual occupational class is significantly associated with greater hazards of dying among men, after adjusting for age, education and other potential confounding variables. Groups at highest risk were men who were manual workers, manual supervisors and technicians, and lower sales and service workers. Substantial gaps in life expectancy at age 21 of up to 10 years were observed between male managers and professionals and manual workers.

CONCLUSION

Substantial inequalities in risks of dying exist by both occupational class and perceived status in Russia, with patterns by class differing from those in the west.

The contribution of psychological distress to socio-economic differences in cause-specific mortality: a population-based follow-up of 28 years

BACKGROUND

Psychological factors associated with low social status have been proposed as one possible explanation for the socio-economic gradient in health. The aim of this study is to explore whether different indicators of psychological distress contribute to socio-economic differences in cause-specific mortality.

METHODS

The data source is a nationally representative, repeated cross-sectional survey, "Health Behaviour and Health among the Finnish Adult Population" (AVTK). The survey results were linked with socio-economic register data from Statistics Finland (from the years 1979-2002) and mortality follow-up data up to 2006 from the Finnish National Cause of Death Register. The data included 32,451 men and 35,420 women (response rate 73.5%). Self-reported measures of depression, insomnia and stress were used as indicators of psychological distress. Socio-economic factors included education, employment status and household income. Mortality data consisted of unnatural causes of death (suicide, accidents and violence, and alcohol-related mortality) and coronary heart disease (CHD) mortality. Adjusted hazard ratios were calculated using the Cox regression model.

RESULTS

In unnatural mortality, psychological distress accounted for some of the employment status (11-31%) and income level (4-16%) differences among both men and women, and for the differences related to the educational level (5-12%) among men; the educational level was associated statistically significantly with unnatural mortality only among men. Psychological distress had minor or no contribution to socio-economic differences in CHD mortality.

CONCLUSIONS

Psychological distress partly accounted for socio-economic disparities in unnatural mortality. Further studies are needed to explore the role and mechanisms of psychological distress associated with socio-economic differences in cause-specific mortality.

Comparative mortality ratios of cancer among men in Greece across broad occupational groups

AIM

The purpose of this study was to compare site-specific cancer death rates in male workforce across major occupational groups in Greece.

METHODS

Data on cancer mortality in men aged 25-69 years during the period 2000-2005 were obtained from National Statistical Service of Greece. Age- and site (ICD-10)-specific cancer death rates and the ratio of standardized cancer death rates (i.e. the comparative mortality ratio and 95% confidence interval) across seven major occupational groups (ISCO-88) were calculated.

RESULTS

The proportion of total deaths due to cancer was ranged between 6.6, 24.3, 37.4, and 39.4% for the age groups of 15-39, 40-49, 50-59, and 60-69 years, respectively. Respiratory and gastrointestinal malignancies constituted 70% of the total cancer mortality in our population. Groups of elementary occupations, skilled agricultural workers, and plant workers showed very high mortality ratios of respiratory cancer while low ratios were found for the groups of professionals, legislators, senior officials, and managers and paradoxically for craft and related workers. Compared to the other groups, skilled agricultural and elementary groups showed higher rates of gastrointestinal and other or no determined malignancies in the age groups of 40-49 and 50-59 years old. Plant workers and machine operators/assemblers exhibited high mortality rates for most cancer sites especially in the elders group (60-69 years) and a mortality ratio of genitourinary cancer that differed significantly compared to any other group.

CONCLUSIONS

Up to 3.5-fold variations were found in site-specific cancer mortality ratios among men in Greece across broad occupational groups. The extent of the variation attributed to specific socioeconomic and/or occupational factors could not be estimated in the current study but the observed differences might stimulate thinking and preventive actions as well as point to potential hypotheses to pursue using research methods in which job and life related factors should be directly measured and controlled.

Contribution of material, occupational, and psychosocial factors in the explanation of social inequalities in health in 28 countries in Europe

OBJECTIVES

To analyse the associations between socio-economic status (SES), measured using occupation, and self-reported health, and to examine the contribution of various material, occupational and psychosocial factors to social inequalities in health in Europe.

METHODS

This study was based on data from the European Quality of Life Survey (EQLS) carried out in 2003. The total sample consisted of 6038 and 6383 working men and women in 28 countries in Europe (response rates: 30.3-91.2%). Each set of potential material, occupational and psychosocial mediators included between eight and 11 variables. Statistical analysis was performed using multilevel logistic regression analysis.

RESULTS

Significant social differences were observed for self-reported health, manual workers being more likely to be in poor health (OR=1.89, 95% CI 1.46 to 2.46 for men, OR=2.18, 95% CI 1.71 to 2.77 for women). Strong social gradients were found for almost all potential mediating factors, and almost all displayed significant associations with self-reported health. Social differences in health were substantially reduced after adjustment for material, occupational and psychosocial factors, with material factors playing a major role. The four strongest contributions to reducing these differences were found for material deprivation, social exclusion, financial problems and job reward. Taking all mediators into account led to an explanation of the social differences in health by 78-100% for men and women.

CONCLUSION

The association between SES and poor health may be attributed to differential distributions of several dimensions of material, occupational and psychosocial conditions across occupational groups. Interventions targeting different dimensions might result in a reduction in social inequalities in health.

Marital status, educational level and household income explain part of the excess mortality of survey non-respondents

Survey respondents and non-respondents differ in their demographic and socio-economic position. Many of the health behaviours are also known to be associated with socio-economic differences. We aimed to investigate how much of the excess mortality of survey non-respondents can be explained by the socio-economic differences between respondents and non-respondents. Questionnaire-based adult health behaviour surveys have been conducted in Finland annually since 1978. Data from the 1978 to 2002 surveys, including non-respondents, were linked with mortality data from the Finnish National Cause of Death statistics and with demographic and socio-economic register data (marital status, education and household income) obtained from Statistics Finland. The mortality follow-up lasted until 2006, in which period there were 12,762 deaths (7,994 in men and 4,768 in women) during the follow-up. Total and cause-specific mortality were higher among non-respondents in both men and women. Adjusting results for marital status, educational level and average household income decreased the excess total and cause-specific mortality of non-respondents in both men and women. Of the total excess mortality of non-respondents, 41% in men and 20% in women can be accounted for demographic and socio-economic factors. A part of the excess mortality among non-respondents can be accounted for their demographic and socio-economic characteristics. Based on these results we can assume that non-respondents tend to have more severe health problems, acute illnesses and unhealthy behaviours, such as smoking and excess alcohol use. These can be reasons for persons not taking part in population surveys.

Length of life inequality around the globe

Inequality in the distribution of adult length of life - defined as age at death in the population aged 15 and over - is studied for virtually all countries of the world using a new database with over 9000 life tables covering a period of up to two centuries. The data reveal huge variation among countries and time periods in the degree to which the available years of life are distributed equally among the population. Most length of life inequality (about 90%) is within-country inequality. Our findings make clear that measures of length of life inequality should be adjusted for life expectancy to get a more relevant indicator of length of life differentials across populations. At similar levels of life expectancy, substantial differences in inequality are observed, even among highly developed countries. Expressed as premature mortality, inequality may be 35-70% higher in the most unequal countries compared to the most equal ones. Countries that reached a certain level of life expectancy earlier in time than other countries, and countries that improved their life expectancy more quickly than others, experienced higher levels of inequality.

Inequalities, social ties and health in France

OBJECTIVES

To discuss the evidence of social health inequalities in France and, in this context, to examine the association of social ties and socio-economic status (SES) with self-reported health (SRH).

STUDY DESIGN

A literature search and a nationally representative cross-sectional study of 5046 French adults with data about SRH, socio-economic status and relationships with family and friends etc.

METHODS

SRH was analysed by three measures of SES: income, education and socioprofessional group. The frequency of five single and four composite measures of social ties by SES was calculated. Logistic regression models estimated the association between SRH and the social ties variables.

RESULTS

Compared with other countries in Western Europe, France has large social class health inequalities, particularly in relation to premature male mortality. This study found that 'less than good' SRH was significantly more likely to be reported by people in lower education, lower socioprofessional and lower income groups. Social isolation and weak social relationships were associated with low SES. For eight of the nine variables, weak social ties were associated with 'less than good' SRH even after adjusting for SES.

CONCLUSION

Weak social ties are associated with poor health. In the context of a country with large health inequalities, the effect of social isolation on health is independent of SES.

Social inequalities in mortality by cause among men and women in France

BACKGROUND

The aim of this study was to compare inequalities in mortality (all causes and by cause) by occupational group and educational level between men and women living in France in the 1990s.

METHODS

Data were analysed from a permanent demographic sample currently including about one million people. The French Institute of Statistics (INSEE) follows the subjects and collects demographic, social and occupational information from the census schedules and vital status forms. Causes of death were obtained from the national file of the French Institute of Health and Medical Research (INSERM). A relative index of inequality (RII) was calculated to quantify inequalities as a function of educational level and occupational group. Overall all-cause mortality, mortality due to cancer, mortality due to cardiovascular disease and mortality due to external causes (accident, suicide, violence) were considered.

RESULTS

Overall, social inequalities were found to be wider among men than among women, for all-cause mortality, cancer mortality and external-cause mortality. However, this trend was not observed for cardiovascular mortality, for which the social inequalities were greater for women than for men, particularly for mortality due to ischaemic cardiac diseases.

CONCLUSIONS

This study provides evidence for persistent social inequalities in mortality in France, in both men and women. These findings highlight the need for greater attention to social determinants of health. The reduction of cardiovascular disease mortality in low educational level groups should be treated as a major public health priority.

Socioeconomic inequalities in health in 22 European countries

BACKGROUND

Comparisons among countries can help to identify opportunities for the reduction of inequalities in health. We compared the magnitude of inequalities in mortality and self-assessed health among 22 countries in all parts of Europe.

METHODS

We obtained data on mortality according to education level and occupational class from census-based mortality studies. Deaths were classified according to cause, including common causes, such as cardiovascular disease and cancer; causes related to smoking; causes related to alcohol use; and causes amenable to medical intervention, such as tuberculosis and hypertension. Data on self-assessed health, smoking, and obesity according to education and income were obtained from health or multipurpose surveys. For each country, the association between socioeconomic status and health outcomes was measured with the use of regression-based inequality indexes.

RESULTS

In almost all countries, the rates of death and poorer self-assessments of health were substantially higher in groups of lower socioeconomic status, but the magnitude of the inequalities between groups of higher and lower socioeconomic status was much larger in some countries than in others. Inequalities in mortality were small in some southern European countries and very large in most countries in the eastern and Baltic regions. These variations among countries appeared to be attributable in part to causes of death related to smoking or alcohol use or amenable to medical intervention. The magnitude of inequalities in self-assessed health also varied substantially among countries, but in a different pattern.

CONCLUSIONS

We observed variation across Europe in the magnitude of inequalities in health associated with socioeconomic status. These inequalities might be reduced by improving educational opportunities, income distribution, health-related behavior, or access to health care.

[Changing social disparities and mortality in France (1968-1996): cause of death analysis by educational level]

BACKGROUND

Little information is available on temporal trend in socioeconomic inequalities in cause of death mortality in France. The aim of this paper was to study educational differences in mortality in France by cause of death and their temporal trend.

METHODS

We used a representative sample of 1% of the French population and compared four periods (1968-1974, 1975-1981, 1982-1988, 1990-1996). Causes of death were obtained by direct linkage with the French national death registry. Education was measured at the beginning of each period, and educational disparities in mortality were studied among men and women aged 30-64 at the beginning of each period. Analyses were conducted for all deaths and for the following causes of death: all cancers, lung cancer (among men), upper aerodigestive tract cancers (among men), breast cancer (among women), colorectal cancer, other cancers, cardiovascular diseases, ischaemic heart diseases, cerebrovascular diseases, other cardiovascular diseases, external causes, other causes of death. Socioeconomic inequalities were quantified with relative risks and relative indices of inequality. The relative indices of inequality measures socioeconomic inequalities across the population and can be interpreted as the ratio of mortality rates of those with the lowest to those with the highest socioeconomic status.

RESULTS

Analyses showed an increase in educational differences in all cause mortality among men (the relative indices of inequality increased from 1.96 to 2.77 from the first to the last period) and among women (the relative indices of inequality increased from 1.87 to 2.53). Socioeconomic inequalities increased for all cause of death studied among women, and for cancer and cardiovascular diseases among men. The contribution of cancer mortality to difference in overall mortality between the lowest and the highest levels of education increased strongly over the whole study period, especially among women.

CONCLUSION

This study shows that large socioeconomic inequalities in mortality are observed in France, and that they increase over time among men and women.

Causes of death contributing to educational mortality disparities in Austria

BACKGROUND

Many studies have shown that mortality increases with decreasing level of education. This paper aims to identify those causes of death that contribute most to educational mortality differentials in Austria, and to reveal those causes of death for which the relative differentials are higher-than-average.

METHODS

Individual-level 1991 census and death registry records for the entire Austrian population were linked for a follow-up period of one year. Mortality differentials were measured using the regression-based Relative Index of Inequality (RII).

RESULTS

Causes of death contributing most to educational mortality disparities among men were lung cancer (13%), digestive diseases (13%), ischemic heart disease (12%) and the category 'other circulatory diseases' (11%); among females, corresponding conditions were all circulatory diseases combined (58%) and 'other neoplasms' (14%). Compared to all-cause mortality differential among men (RII = 0.72), larger relative disparities were observed for alcohol-associated deaths (RII = 1.71), followed by digestive and respiratory diseases (RII = 1.21 and 1.07, respectively), stomach and lung cancer (RII = 1.04 and 1.08, respectively), injuries (RII = 1.15) and suicides (RII = 0.97). Among females, disparities that were considerably larger than for all-cause mortality (RII = 0.46) were identified for diabetes (RII = 1.35), injuries (RII = 1.12), cerebrovascular disease (RII = 0.94), respiratory diseases (RII = 0.84) and ischemic heart disease (RII = 0.75). For causes of death combined that are amenable to medical intervention, the differentials were surprisingly large (RII(males) = 0.57; RII(females) = 0.48), given that Austria has a comprehensive, social health-care system.

CONCLUSION

Efforts to reduce high death rates among the less-educated for identified diseases that contribute largely to overall mortality disparity could increase average life expectancy and improve the general health status of the Austrian population.

Mortality risks among heavy-smokers with special reference to women: a long-term follow-up of an urban population

Increased mortality risks associated with smoking are well established among men. There are very few population-based studies comprising a sufficient number of heavily smoking women, measuring the direct effect of smoking on mortality risks. Between 1974 and 1992, 8,499 women and 13,888 men attended a health screening programme including reporting of smoking habits. Individuals were followed for total mortality until 2005. All-cause, cancer, cardiovascular, lung cancer and respiratory mortality were calculated in smoking categories <10 g per day, 10-19 g per day, and > or =20 g per day with never-smokers as a reference group and with adjustments for co-morbidities, socio-economic and marital status. For respiratory mortality and lung cancer adjustments for FEV(1), socio-economic and marital status were performed. Smoking was associated with a two to almost threefold increased mortality risk among women and men. The relative risk (RR) with 95% confidence interval, (CI) for women who smoked 10-19 g per day was 2.44 (2.07-2.87), and for those who smoked 20 g per day or more the RR (95% CI) was 2.42 (2.00-2.92). Smoking was a strong risk factor for cardiovascular mortality among women, the RR (95% CI) for women who smoked 10-19 g per day was 4.52 (3.07-6.64). Ex-smoking women showed increased risks of all-cause mortality; RR (95% CI) 1.26 (1.04-1.52) cancer (excluding lung cancer); RR (95% CI) 1.42 (1.07-1.88) and lung cancer RR (95% CI) 2.71 (1.02-7.23) mortality. However, the cardiovascular; RR (95% CI) 1.18 (0.69-2.00) and respiratory; RR (95% CI) 0.79 (0.16-3.84) mortality risks were not statistically significant. This study confirms that as for men, middle-aged heavily smoking women have a two to threefold increased mortality risk. Adjustments for co-morbidity, socio-economic and marital status did not change these results.

Associations of socio-economic position and disability among older women in Britain and Jyväskylä, Finland

The aim was to compare the pattern of associations in measures of socio-economic position and disability among British and Finnish older women. In Britain data from the British Women's Heart and Health Study was used. Women from 23 towns took part in a nurse-assessed medical examination and postal questionnaire (n = 4286). In Finland, data from the Evergreen study was used. Eight hundred and four women from the city of Jyväskylä were interviewed at home. Socio-economic position was measured according to social class in childhood, education, use of a car, home ownership and previous occupation. Disability measures included questions on difficulties in washing/dressing and climbing stairs. Logistic regression analyses were conducted to examine the relationship between disability and socio-economic position. In the age-adjusted analysis of both samples increasing disability in washing/dressing and climbing stairs was associated with at least one of the measures of deprivation. The relationship between socio-economic position and disability was more distinct in the British than Finnish women. Despite adjustment for a range of confounders, the relationship between socio-economic position and disability was not much attenuated, particularly in the British women. The associations in the measures of socio-economic position and disability showed a slightly different pattern between the British and Finnish women.

Are Mortality Differences and Trends by Education Any Better or Worse in New Zealand? A Comparison Study with Norway, Denmark and Finland, 1980–1990s

During the 1980s and early 1990s New Zealand experienced major social and economic change, decreasing all-cause mortality rates for the majority ethnic group, and high (but falling) cardiovascular disease (CVD) mortality rates. This paper explores whether inequalities in mortality by education were greater, and increased more, in New Zealand than in Nordic countries (Denmark, Finland, Norway), and determines the contribution of CVD to these differences and trends.

METHODS

We used mortality rates for 30-59 year olds by education, and slope (SII) and relative (RII) indices of inequality, calculated from comparable linked census mortality data.

RESULTS

Mortality inequalities in New Zealand were at the high end of the Nordic range when standardised by age only, but were mid-range when also standardised by ethnicity. Over time, relative inequalities in all-cause mortality increased similarly in all countries. In New Zealand a large increase in inequality for cardiovascular disease (CVD) mortality was the major contributor. In contrast both CVD and other causes of death were important drivers of increasing inequalities in Nordic countries. Absolute inequalities in all-cause mortality were stable over time among males across all countries, and increased modestly among females. The contribution of CVD to absolute inequality was stable or decreasing over time in all countries.

CONCLUSION

Overall, inequalities in mortality in New Zealand did not widen more rapidly than in northern European countries. However, rapid social and economic change may have affected trends in CVD mortality among low educated men and women, and especially the ethnic minority groups.

[Health of the unemployed in France: literature review]

BACKGROUND

This paper reviews and analyses the main publications concerning health and mortality of the unemployed in France, in order to formulate research orientations for future studies or secondary data analysis.

METHODS

The conceptual framework was first set up by assembling the different hypotheses concerning the link between health and unemployment (causality versus selection). A review of the different studies was organized by type: health studies based on data from either cross-sectional health surveys at a national or regional scale, or longitudinal surveys, and mortality studies based on data from follow-up of census samples.

RESULTS

Those studies confirm the health disadvantage of the unemployed relative to the employed, in terms of self-perceived health, morbidity, health services utilization and mortality. They provide arguments in favor of both the causality and selection hypotheses.

CONCLUSION

The exact nature of the health conditions and causes of death associated with unemployment needs further clarification, as well as the causal pathways.

A widening health gap in general practice? Socio-economic differences in morbidity between 1975 and 2000 in The Netherlands

BACKGROUND

During the past two decades, socio-economic inequalities in health have been a major research theme in Western Europe. Research has shown that there are persistent differences in health between people with a high socio-economic status (SES) compared with people with a low SES. There are also indications for a widening health gap. The present paper aimed to find out whether this widening health gap exists in The Netherlands using morbidity data from a general practice (GP) registry.

METHODS

Incidence data from a GP registry were used, involving over 12,000 patients. Morbidity data from 1975 to 2000 were grouped into 25 disease categories. SES was based on household occupational status. Poisson regression was used to determine the relationship between morbidity and SES and its changes over time. Separate analyses were performed for men and women.

RESULTS

In most disease categories, a clear SES gradient disadvantageous to the lowest-SES group was identified: 17 out of 22 morbidity categories for men and 17 out of 24 for women. For seven (men) and eight (women) morbidity categories out of 17, the SES gradient increased between 1975 and 2000.

CONCLUSIONS

This study provides new evidence for a widening gap in health between higher and lower SES in The Netherlands, using GP-defined disease data and a wide range of morbidity categories.

Trends in socioeconomic inequalities in self-assessed health in 10 European countries

BACKGROUND

Changes over time in inequalities in self-reported health are studied for increasingly more countries, but a comprehensive overview encompassing several countries is still lacking. The general aim of this article is to determine whether inequalities in self-assessed health in 10 European countries showed a general tendency either to increase or to decrease between the 1980s and the 1990s and whether trends varied among countries.

METHODS

Data were obtained from nationally representative interview surveys held in Finland, Sweden, Norway, Denmark, England, The Netherlands, West Germany, Austria, Italy, and Spain. The proportion of respondents with self-assessed health less than 'good' was measured in relation to educational level and income level. Inequalities were measured by means of age-standardized prevalence rates and odds ratios (ORs).

RESULTS

Socioeconomic inequalities in self-assessed health showed a high degree of stability in European countries. For all countries together, the ORs comparing low with high educational levels remained stable for men (2.61 in the 1980s and 2.54 in the 1990s) but increased slightly for women (from 2.48 to 2.70). The ORs comparing extreme income quintiles increased from 3.13 to 3.37 for men and from 2.43 to 2.86 for women. Increases could be demonstrated most clearly for Italian and Spanish men and women, and for Dutch women, whereas inequalities in health in the Nordic countries showed no tendency to increase.

CONCLUSIONS

The results underscore the persistent nature of socioeconomic inequalities in health in modern societies. The relatively favourable trends in the Nordic countries suggest that these countries' welfare states were able to buffer many of the adverse effects of economic crises on the health of disadvantaged groups.

Socioeconomic status, smoking, and health: a test of competing theories of cumulative advantage

Although both low socioeconomic status and cigarette smoking increase health problems and mortality, their possible combined or interactive influence is less clear On one hand, the health of low status groups may be harmed least by unhealthy behavior such as smoking because, given the substantial health risks produced by limited resources, they have less to lose from damaging lifestyles. On the other hand, the health of low status groups may be harmed most by smoking because lifestyle choices exacerbate the health problems created by deprived material conditions. Alternatively, the harm of low status and smoking may accumulate additively rather than multiplicatively. We test these arguments with data from the 1990 U.S. National Health Interview Survey, and with measures of morbidity and mortality. For ascribed statuses such as gender, race, and ethnicity, and for the outcome measure of mortality, the results favor the additive argument, whereas for achieved status and morbidity, the results support the vulnerability hypothesis--that smoking inflicts greater harm among disadvantaged groups.