Trends in Mortality Due to Malignant Neoplasms of Female Genital Organs in Poland in the Period 2000-2021-A Population-Based Study

The aim of this study is to assess mortality trends due to malignant neoplasms of female genital organs (MNFGOs) in Poland between 2000 and 2021. For the purpose of the study, the authors used data on all deaths of Polish female inhabitants due to MNFGO between 2000 and 2021, obtained from the Statistics Poland database. The standardised death rates (SDR), potential years of life lost (PYLL), annual percentage change (APC) and average annual percentage change (AAPC) were calculated. Between the years 2000 and 2021, 138,000 women died due to MNFGOs in Poland. Of this number, 54,975 (39.8%) deaths were caused by ovarian cancer, 37,487 (27.2%) by cervix uteri cancer, and 26,231 (19.0%) by corpus uteri cancer. A decrease in mortality due to cervix uteri cancer (APC = -2.4%, p < 0.05) was the most favourable change that occurred in the period 2000-2021, while the least favourable change was an increase in mortality due to corpus uteri cancer for the period 2005-2019 (APC = 5.0%, p < 0.05). SDRs due to ovarian cancer showed a decreasing trend between 2007 and 2021 (APC = -0.5%, p < 0.05). The standardised PYLL index due to cervical cancer was 167.7 per 100,000 women in 2000 and decreased to 75.0 in 2021 (AAPC = -3.7, p < 0.05). The number of lost years of life due to ovarian cancer decreased from 143.8 in 2000 to 109.5 in 2021 (AAPC = -1.3, p < 0.05). High values of death rates due to MNFGO in Poland, compared to other European countries, show that there is a need to promote preventive programmes and continue to monitor changes in mortality.

Subnational inequalities in years of life lost and associations with socioeconomic factors in pre-pandemic Europe, 2009-19: an ecological study

BACKGROUND

Health inequalities have been associated with shorter lifespans. We aimed to investigate subnational geographical inequalities in all-cause years of life lost (YLLs) and the association between YLLs and socioeconomic factors, such as household income, risk of poverty, and educational attainment, in countries within the European Economic Area (EEA) before the COVID-19 pandemic.

METHODS

In this ecological study, we extracted demographic and socioeconomic data from Eurostat for 1390 small regions and 285 basic regions for 32 countries in the EEA, which was complemented by a time-trend analysis of subnational regions within the EEA. Age-standardised YLL rates per 100 000 population were estimated from 2009 to 2019 based on methods from the Global Burden of Disease study. Geographical inequalities were assessed using the Gini coefficient and slope index of inequality. Socioeconomic inequalities were assessed by investigating the association between socioeconomic factors (educational attainment, household income, and risk of poverty) and YLLs in 2019 using negative binomial mixed models.

FINDINGS

Between Jan 1, 2009, and Dec 31, 2019, YLLs lowered in almost all subnational regions. The Gini coefficient of YLLs across all EEA regions was 14·2% (95% CI 13·6-14·8) for females and 17·0% (16·3 to 17·7) for males. Relative geographical inequalities in YLLs among women were highest in the UK (Gini coefficient 11·2% [95% CI 10·1-12·3]) and among men were highest in Belgium (10·8% [9·3-12·2]). The highest YLLs were observed in subnational regions with the lowest levels of educational attainment (incident rate ratio [IRR] 1·19 [1·13-1·26] for females; 1·22 [1·16-1·28] for males), household income (1·35 [95% CI 1·19-1·53]), and the highest poverty risk (1·25 [1·18-1·34]).

INTERPRETATION

Differences in YLLs remain within, and between, EEA countries and are associated with socioeconomic factors. This evidence can assist stakeholders in addressing health inequities to improve overall disease burden within the EEA.

FUNDING

Research Council of Norway; Development, and Innovation Fund of Hungary; Norwegian Institute of Public Medicine; and COST Action 18218 European Burden of Disease Network.

The Relationship between Diet and the Occurrence of Depressive Symptoms in a Community Example with High Rates of Social Deprivation: A Cross-Sectional Study

Research suggests that various biological and psychosocial mechanisms are involved in the heterogeneous and complex relationship between dietary patterns and depressive symptoms. The occurrence of depressive symptoms is thought to be related to socioeconomic status (SES), with those with lower SES being more likely to experience persistent depression. The aim of the undertaken study was to investigate whether socioeconomic and health variables are associated with dietary assessment in a population with high rates of social deprivation and whether a relationship exists between dietary assessment and depressive symptoms (DS). The respondents' nutrition was evaluated through a qualitative method, using the Perinumeric Periodic Table questionnaire by Starzyńska. At the same time, the prevalence of DS was assessed employing the Patient Health Questionnaire-9 (PHQ-9). In the DS screening (PHQ-9 ≥ 10), in the entire study population, the risk of DS was 16.1% (n = 605). In our entire study population, up to 61.2% (n = 2297) of the respondents exhibited poor dietary patterns. In the multivariate model, women with almost adequate or poor dietary assessment were 1.62 and 2.18 times more likely to score at least 10 on the PHQ-9 questionnaire, as compared to women whose dietary assessment was good or adequate. In conclusion, it was determined that sociodemographic variables affect nutritional habits. Women who lived in rural areas limited to a vocational education had significantly poorer diets. Moreover, men, younger men, smokers, and those without chronic diseases were characterized by a poorer dietary assessment. Additionally, women who had a better dietary assessment were significantly more likely to have lower scores on the questionnaire assessing the occurrence of DS (PHQ-9 10).

Is area-level socioeconomic deprivation associated with mortality due to circulatory system diseases in Poland?

BACKGROUND

Socioeconomic deprivation (SED) is known to influence cardiovascular health. However, studies analyzing the relationship between deprivation and circulatory system diseases (CSD) in Central and Eastern Europe are limited. This study aimed to assess the relationship between SED and mortality due to CSD at a population level in 66 sub-regions of Poland.

METHODS

The 2010-2014 data regarding mortality and SED components were obtained from the Central Statistical Office. An area-based SED index was calculated based on the higher education rates, employment structure, wages, unemployment, and poverty. The dynamics of changes in mortality due to CSD was expressed by the number of deaths prevented or postponed (DPP) in terciles of the SED index. The associations between the mortality from CSD and SED index were analyzed using multivariate Poisson regression models and generalized estimating equations.

RESULTS

Among men, the percentage of DPP in 2014 was 13.1% for CSD, 23.4% for ischemic heart disease (IHD), and 21.4% for cerebrovascular diseases (CeVD). In the case of women, the proportion of DPP was 12.8, 25.6, and 21.6%, respectively. More deprived sub-regions experienced a greater decrease in CSD-related mortality than less deprived sub-regions. The disparity in mortality reduction between more deprived and less deprived sub-regions was even more pronounced for women. After adjusting for smoking prevalence, average BMI, population density, and changes in mortality over time, it was found that the SED index over the 2010-2014 time period was significantly associated with CSD- and IHD-related mortality for men (respectively 5.3 and 19.5% expected mortality increase per 1-unit increase of SED index), and with IHD- and CeVD-related mortality for women (respectively 30.3 and 23.0% expected mortality increase per 1-unit increase of SED index).

CONCLUSIONS

Significant differences in mortality changes due to CSD in Poland could be observed in relation to socioeconomic deprivation, resulting in reduced health inequalities. To reduce CSD mortality, more comprehensive preventive measures, including approaches addressing the socioeconomic factors, mainly poverty, education and employment, are needed, particularly in less urbanized areas.

The Prevalence of Depression Symptoms and Their Socioeconomic and Health Predictors in a Local Community with a High Deprivation: A Cross-Sectional Studies

Depression is a heterogeneous and etiologically complex psychiatric syndrome thatshows a strong sexual dimorphism and often impacts people with a low socioeconomic status (SES). The aim of the study was to estimate the occurrence of depression symptoms in a local community with a high deprivation rate, the example being the inhabitants of the JanówLubelski County in eastern Poland. A cross-sectional study was carried out on 3752 people aged between 35 and 64. The prevalence of depression symptoms was assessed using the Patient Health Questionnaire-9 (PHQ-9) scale. In the screening for depression symptoms in the entire population we studied, the risk of depression symptoms was 16.1% (n = 605), with women having a significantly higher mean score than men (p < 0.001). Significant predictors associated with the achievement of 10 points and more in the PHQ-9 assessment in the case of women and men were: living alone, education and having comorbidities. Moreover, female participants living in rural areas were significantly more likely to exhibit depression symptoms, whereas smoking was a significant predictor of depressive symptoms in men. It was observed that in the case of obese women, the chance of being in the higher category of the PHQ-9 assessment was 1.41 times higher than in women with normal body weight. However, in the case of men, an increase in age by one year increased the chance of being in a higher category by 1.02 times. Moreover, the odds of falling into a higher category, as assessed by the PHQ-9 questionnaire, among men who drink alcohol more than once a week was 1.7 times higher than in men who do not drink or consume alcohol occasionally. Summarising the results of studies conducted in a local community characterised by a high deprivation rate, socioeconomic and health variables related to SES significantly impacted the incidence of depression, but they differ in terms of gender.

Educational gradients in all-cause mortality in two cohorts in the Czech Republic during the early stage of the postcommunist transition

Objectives

We investigated whether social gradient in all-cause mortality in the Czech Republic changed during the postcommunist transition by comparing two cohorts, recruited before and after the political changes in 1989.

Methods

Participants (aged 25–64 years) in two population surveys (n=2530 in 1985, n=2294 in 1992) were followed up for mortality for 15 years (291 and 281 deaths, respectively). Education was classified into attainment categories and years of schooling (both continuous and in tertiles). Cox regression was used to estimate HR of death by educational indices in each cohort over a 15-year follow-up.

Results

All three educational variables were significantly associated with reduced risk of death in both cohorts when men and women were combined; for example, the adjusted HRs of death in the highest versus lowest tertile of years of schooling were 0.65 (95% CI 0.47 to 0.89) in 1985 and 0.67 (95% CI 0.48 to 0.93) in 1992. Adjustment for covariates attenuated the gradients. In sex-specific analysis, the gradient was more pronounced and statistically significant in men. There were no significant interactions between cohort and educational indices.

Conclusions

The educational gradient in mortality did not differ between the two cohorts (1985 vs 1992), suggesting no major increase in educational inequality during the early stage of postcommunist transition. Further research is needed to understand trends in health inequalities during socioeconomic transitions.

Social Mobility, Health and Wellbeing in Poland

Recently there has been a surge of interest in the consequences of intergenerational social mobility on individuals' health and wellbeing outcomes. However, studies on the effects of social mobility on health, using high-quality panel survey data, have almost exclusively been conducted in Western welfare democracies. To account for this gap, and using empirical data from one of the largest and most eventful post-communist countries, Poland, in this study we investigate how individuals' origin and destination socio-economic position and social mobility are linked to self-rated health and reported psychological wellbeing. We use the Polish Panel Survey (POLPAN) data to construct self-rated health and psychological wellbeing measures, origin, destination and occupational class mobility variables, and account for an extensive set of sociodemographic determinants of health. We employ diagonal reference models to distinguish social mobility effects from origin and destination effects, and account for possible health selection mechanisms. Our results suggest that there is an occupational class gradient in health in Poland and that both parental and own occupational class matter for individual health outcomes. We also find a positive reported psychological wellbeing effect for upward social mobility from the working to the professional class.

Estimation of socioeconomic inequalities in mortality in Japan using national census-linked longitudinal mortality data

BACKGROUND

We aimed to develop census-linked longitudinal mortality data for Japan and assess its validity as a new resource for estimating socioeconomic inequalities in health.

METHODS

Using deterministic linkage, we identified, from national censuses for 2000 and 2010 and national death records, persons and deceased persons who had unique personal identifiers (generated using sex, birth year/month, address, and marital status). For the period 2010-2015, 1 537 337 Japanese men and women aged 30-79 years (1.9% in national census) were extracted to represent the sample population. This population was weighted to adjust for confounding factors. We estimated age-standardized mortality rates (ASMRs) by education level and occupational class. The slope index of inequality (SII) and relative index inequality (RII) by educational level were calculated as inequality measures.

RESULTS

The reweighted sample population's mortality rates were somewhat higher than those of the complete registry, especially in younger age-groups and for external causes. All-cause ASMRs (per 100 000 person-years) for individuals aged 40-79 years with high, middle, and low education levels were 1078 (95% confidence interval: 1051-1105), 1299 (1279-1320), and 1670 (1634-1707) for men, and 561 (536-587), 601 (589-613), and 777 (745-808) for women, respectively, during 2010-2015. SII and RII by educational level increased among both sexes between 2000-2005 and 2010-2015, which indicates mortality inequalities increased.

CONCLUSIONS

The developed census-linked longitudinal mortality data provide new estimates of socioeconomic inequalities in Japan that can be triangulated with estimates obtained with other methods.

Age, Period and Cohort Effects On Alcohol Consumption In Estonia, 1996-2018

AIMS

To analyse the independent effects of age, period and cohort on estimated daily alcohol consumption in Estonia.

METHODS

This study used data from nationally representative repeated cross-sectional surveys from 1996 to 2018 and included 11,717 men and 16,513 women aged 16-64 years in total. The dependent variables were consumption of total alcohol and consumption by types of beverages (beer, wine and strong liquor) presented as average daily consumption in grams of absolute alcohol. Mixed-effects negative binomial models stratified by sex were used for age-period-cohort analysis.

RESULTS

Alcohol consumption was highest at ages 20-29 years for both men and women and declined in older ages. Significant period effects were found indicating that total alcohol consumption and consumption of different types of beverages had increased significantly since the 1990s for both men and women. Cohort trends differed for men and women. Men born in the 1990-2000s had significantly lower daily consumption compared to earlier cohorts, whereas the opposite was found for women.

CONCLUSION

While age-related patterns of alcohol consumption are aligned with life course stages, alcohol use has increased over the study period. Although the total daily consumption among men is nearly four times higher than among women, the cohort trends suggest convergence of alcohol consumption patterns for men and women.

Education and mortality in three Eastern European populations: findings from the PrivMort retrospective cohort study

BACKGROUND

The aim of the study is 2-fold. Firstly, it attempts to investigate the potential impact of major political and economic changes on inequalities in all-cause mortality among men and women with different levels of education in three Eastern European countries. Secondly, to identify changes in contribution of smoking and drinking to educational differences in all-cause mortality. Study covers the period from 1982 to 2013.

METHODS

Data were collected in 2013-14 as a part of the PrivMort retrospective cohort study. Participants in Russia, Belarus and Hungary provided information on their educational attainment, health-related behaviors and vital statistics of their close relatives (N = 179 691). Odds ratios for mortality and relative indices of inequality (RII) were estimated for individuals aged 20-65 years, stratifying by three levels of educational attainment: higher, secondary and less than secondary education.

RESULTS

Those in lower educational groups were significantly more likely to die, through most time periods and sub-groups. The RII increased over time in all countries and both genders, except for Hungarian men. Alcohol consumption and smoking have increasingly contributed to educational inequalities in mortality during this period.

CONCLUSION

Educational inequalities in mortality in these Eastern European countries have increased during recent decades. Smoking and alcohol consumption, two major health-related behaviors, made a significant contribution to these increases in inequality.

Contrasts in alcohol-related mortality in Czechia and Lithuania: Analysis of time trends and educational differences

INTRODUCTION AND AIMS

Globally, Czechia and Lithuania are among the top-ranking countries in terms of high alcohol consumption. This study highlights notable contrasts in temporal trends in alcohol-related mortality and identifies country-specific patterns in educational differences.

DESIGN AND METHODS

The study uses harmonised cause-of-death series from the Human Cause of Death Database. Mortality disparities by education were assessed using census-linked mortality data. Directly standardised death rates were used to estimate levels of national and group-specific mortality. Relative and absolute mortality differences by education were assessed by range-type measures (Poisson regression mortality ratios and rate differences) and Gini-type measures.

RESULTS

Between 1994-1995 and 2016, the absolute difference between Czechia and Lithuania in terms of alcohol-related age-standardised death rates (per 1 000 000) decreased from 450 for males and 130 for females to 76 in males and 11 in females. In both countries, alcohol-related mortality was markedly higher among persons of lower education levels. Lithuanian males experienced the highest absolute inequalities measured by rate difference between the low and high educated (740 per million), while Lithuanian females showed the most pronounced relative inequalities (6.70-fold difference between low and high educated). The corresponding figures were less than half for Czechia.

DISCUSSION AND CONCLUSIONS

Reducing educational disparities in alcohol-related mortality within both countries would have a substantial impact on overall levels. Policies aimed at targeting the lowest priced and illegal alcohols and reducing levels of harmful drinking should be a priority, especially in Lithuania.

The association of social and behavioral factors with dietary risks in adults: Evidence from the Kardiovize Brno 2030 study

BACKGROUND AND AIMS

Uncovering the main determinants of diet quality is one of the greatest challenges for Public Health, since it could guide future strategies and interventions against cardiovascular diseases (CVDs). The present cross-sectional analysis of the Kardiovize cohort evaluates the prevalence of dietary risk factors for CVDs and their association with social and behavioural characteristics in a random sample of 1536 adults (aged 25-64 years) from Brno, Czech Republic.

METHODS AND RESULTS

A face-to-face health interview guided by structured questionnaires was carried out on socio-demographic characteristics (age, sex, educational level, employment, marital status, income, and household size) and behaviours (smoking status, physical activity, and sleep habits). Twelve dietary risk factors covered by the Global Burden of Diseases comparative risk assessment framework were assessed using a Food Frequency Questionnaire. In general, we observed that the consumption of nearly all healthy foods and nutrients was suboptimal, and that it was also aggravated by high intake of foods and nutrients that constituted dietary risk factors. Moreover, we found several associations of social and behavioural characteristics with specific dietary risk factors. Particularly, being male (β = 0.466; SE = 0.079; p < 0.001), increasing household size (β = 0.130; SE = 0.047; p = 0.006), low income (β = 0.192; SE = 0.091; p = 0.035), and decreasing physical activity level (β = 0.172; SE = 0.054; p = 0.002) were associated with increasing number of dietary risk factors.

CONCLUSION

Thus, our study raises an urgent need for Public Health strategies promoting healthy eating in adulthood, which should be based on traditional and novel determinants of dietary risk.

Cancer Incidence Trends in the Oil Shale Industrial Region in Estonia

Large oil shale resources are found in Eastern Estonia, where the mineral resource is mined, excavated, and used for electricity generation and shale oil extraction. During industrial activities in the last 100 years, pollutants have been emitted in large amounts, some of which are toxic and carcinogenic. The current study aims to analyse time trends in cancer incidence in the oil shale industry-affected areas and compare them with overall cancer incidence rates and trends in Estonia. We analysed Estonian Cancer Registry data on selected cancer sites that have been previously indicated to have relationships with industrial activities like oil shale extraction. We included lung cancer, kidney cancer, urinary bladder cancer, leukaemia, breast cancer, and non-Hodgkin's lymphoma. A statistically significantly higher lung cancer age-standardized incidence rate (ASIR) was found during the study period (1992-2015) only in males in the oil shale areas as compared to males in Estonia overall: 133.6 and 95.5 per 100,000, respectively. However, there appeared to be a statistically significant (p < 0.05) decrease in the lung cancer ASIR in males in the oil shale areas (overall decrease 28.9%), whereas at the same time, there was a significant increase (p < 0.05) in non-oil shale areas (13.3%) and in Estonia overall (1.5%). Other cancer sites did not show higher ASIRs in the oil shale industrial areas compared to other areas in Estonia. Possible explanations could be improved environmental quality, socio-economic factors, and other morbidities.

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

OBJECTIVE

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

STUDY DESIGN

This is a record-linked cohort study.

METHODS

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

RESULTS

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

CONCLUSION

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

Socio-Demographic Determinants of Mortality from Chronic Noncommunicable Diseases in Women of Reproductive Age in the Republic of Georgia: Evidence from the National Reproductive Age Mortality Study (2014)

Purpose

Worldwide, noncommunicable diseases (NCDs) are the leading cause of premature death of women, taking the highest toll in developing countries. This study aimed to identify key socio-demographic determinants of NCD mortality in reproductive-aged women (15-49 years) in Georgia.

Materials and Methods

The study employed the verbal autopsy data from the second National Reproductive Age Mortality Survey 2014. Univariate and multivariate logistic regression models were fitted to explore the association between each risk factor and NCD mortality, measured by crude and adjusted odds ratio (AOR) with respective 95% confidence intervals (95% CI).

Results

In the final sample of 843 women, 586 (69.5%) deaths were attributed to NCDs, the majority of which occurred outside a hospital (72.7%) and among women aged 45-49 years (46.8%), ethnic Georgians (85.2%), urban residents (60.1%), those being married (60.6%), unemployed (75.1%) or having secondary and higher education (69.5%), but with nearly equal distribution across the wealth quintiles. After multivariate adjustment, the odds of dying from NCDs were significantly higher in women aged 45-49 years (AOR=17.69, 95% CI= 9.35 to 33.50), those being least educated (AOR=1.55, 95% CI= 1.01 to 2.37) and unemployed (AOR=1.47, 95% CI= 1.01 to 2.14) compared, respectively, to their youngest (15-24 years), more educated and employed counterparts. Strikingly, the adjusted odds were significantly lower in "other" ethnic minorities (AOR=0.29, 95% CI= 0.14 to 0.61) relative to ethnic Georgians. Contrariwise, there were no significant associations between NCD mortality and women's marital or wealth status, place of residence (rural/urban) or place of death.

Conclusion

Age, ethnicity, education, and employment were found to be strong independent predictors of young women's NCD mortality in Georgia. Further research on root causes of inequalities in mortality across the socioeconomic spectrum is warranted to inform equity- and life course-based multisectoral, integrated policy responses that would be conducive to enhancing women's survival during and beyond reproduction.

Progress against inequalities in mortality: register-based study of 15 European countries between 1990 and 2015

Socioeconomic inequalities in mortality are a challenge for public health around the world, but appear to be resistant to policy-making. We aimed to identify European countries which have been more successful than others in narrowing inequalities in mortality, and the factors associated with narrowing inequalities. We collected and harmonised mortality data by educational level in 15 European countries over the last 25 years, and quantified changes in inequalities in mortality using a range of measures capturing different perspectives on inequality (e.g., 'relative' and 'absolute' inequalities, inequalities in 'attainment' and 'shortfall'). We determined which causes of death contributed to narrowing of inequalities, and conducted country- and period-fixed effects analyses to assess which country-level factors were associated with narrowing of inequalities in mortality. Mortality among the low educated has declined rapidly in all European countries, and a narrowing of absolute, but not relative inequalities was seen in many countries. Best performers were Austria, Italy (Turin) and Switzerland among men, and Spain (Barcelona), England and Wales, and Austria among women. Ischemic heart disease, smoking-related causes (men) and amenable causes often contributed to narrowing inequalities. Trends in income inequality, level of democracy and smoking were associated with widening inequalities, but rising health care expenditure was associated with narrowing inequalities. Trends in inequalities in mortality have not been as unfavourable as often claimed. Our results suggest that health care expansion has counteracted the inequalities widening effect of other influences.

Changes in socioeconomic mortality inequalities at adult and old ages in Lithuania, 2001-05 to 2011-15

This article provides evidence about changes in mortality inequalities by education and economic activity status among adults aged 30-64 and older adults aged 65 and over in Lithuania between 2001-05 and 2011-15. The study shows that the overall mortality decline in Lithuania was not homogeneous across socio-economic groups. The inequitable progress resulted in a widening in absolute and relative mortality inequalities among older adults and notable increases in relative mortality inequalities among adults aged 30-64. The total public health burden of mortality inequalities remained very pronounced or even increased further.

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.

Association between educational level and total and cause-specific mortality: a pooled analysis of over 694 000 individuals in the Asia Cohort Consortium

OBJECTIVE

To study the association of educational level and risk of death from all causes, cardiovascular disease (CVD) and cancer among Asian populations.

DESIGN

A pooled analysis of 15 population-based cohort studies.

SETTING AND PARTICIPANTS

694 434 Asian individuals from 15 prospective cohorts within the Asia Cohort Consortium.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

HRs and 95% CIs for all-cause mortality, as well as for CVD-specific mortality and cancer-specific mortality.

RESULTS

A total of 694 434 participants (mean age at baseline=53.2 years) were included in the analysis. During a mean follow-up period of 12.5 years, 103 023 deaths were observed, among which 33 939 were due to cancer and 34 645 were due to CVD. Higher educational levels were significantly associated with lower risk of death from all causes compared with a low educational level (≤primary education); HRs and 95% CIs for secondary education, trade/technical education and ≥university education were 0.88 (0.85 to 0.92), 0.81 (0.73 to 0.90) and 0.71 (0.63 to 0.80), respectively (ptrend=0.002). Similarly, HRs (95% CIs) were 0.93 (0.89 to 0.97), 0.86 (0.78 to 0.94) and 0.81 (0.73 to 0.89) for cancer death, and 0.88 (0.83 to 0.93), 0.77 (0.66 to 0.91) and 0.67 (0.58 to 0.77) for CVD death with increasing levels of education (both ptrend <0.01). The pattern of the association among East Asians and South Asians was similar compared with ≤primary education; HR (95% CI) for all-cause mortality associated with ≥university education was 0.72 (0.63 to 0.81) among 539 724 East Asians (Chinese, Japanese and Korean) and 0.61 (0.54 to 0.69) among 154 710 South Asians (Indians and Bangladeshis).

CONCLUSION

Higher educational level was associated with substantially lower risk of death among Asian populations.

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

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

Towards a Central-Eastern European EQ-5D-3L population norm: comparing data from Hungarian, Polish and Slovenian population studies

BACKGROUND

EQ-5D-3L population data are available only from Hungary, Poland and Slovenia in Central and Eastern Europe (CEE). We aimed to compare the accessible studies and estimate a regional EQ-5D-3L population norm for CEE.

METHODS

A combined dataset using patient-level data of 8850 respondents was created. Based on the European Census of 2011, regional population norm estimates were calibrated by gender, age and education for the joint citizenry of 11 CEE countries.

RESULTS

EQ-5D-3L health states were available for 6926 and EQ VAS scores for 6569 respondents. Demographic characteristics of the samples reflected the recruitment methods (Hungary: online; Slovenia: postal survey, Poland: personal interviews). Occurrence of problems differed significantly by educational level in all the five dimensions (p < 0.001). The inter-country differences persisted after controlling for demographic variables. The estimated EQ-5D-3L index CEE norms with UK tariffs for age groups 18-24, 25-34, 35-44, 45-54, 55-64, 65-74 and 75 + were 0.911, 0.912, 0.871, 0.817, 0.762, 0.743 and 0.636 for males and 0.908, 0.888, 0.867, 0.788, 0.752, 0.68 and 0.584 for females, respectively. Estimates were provided also using Polish, European and Slovenian value sets.

CONCLUSIONS

Besides gender and age, education should be considered during the design and interpretation of quality-of-life studies in CEE. The estimated regional EQ-5D-3L population norm may be used as a benchmark by CEE countries with lack of local dataset. However, the substantial inter-country differences in health status and scarcity of data over age 65 call for harmonized country-specific EQ-5D-3L population norm studies in the CEE region.

Area-Based Socio-Economic Inequalities in Mortality from Lung Cancer and Respiratory Diseases

Background: After political transformation in 1989/1990, Poland experienced a general improvement in living conditions and quality of life, but the benefits did not extend evenly across all segments of the society. We hypothesized that the regional differences in mortality due to diseases of the respiratory system are related to socioeconomic status (SES) and its changes over time. Materials and methods: An ecological study was carried out in 66 sub-regions of Poland using the data from the period of 2010 to 2014. Age-standardized mortality rates (SMRs) were calculated separately for men and women in three age categories: ≥15, 25–64 years, and ≥65 years. An area-based SES index was derived from the characteristics of the sub-regions using the z-score method. Multiple weighted linear regression models were constructed to estimate a real socioeconomic gradient for mortality resulting from lung cancer and respiratory diseases. Results: In the regions studied, the SMRs for respiratory disease varied from 70/100,000 to 215/100,000 in men and from 18/100,000 to 53/100,000 in women. The SMRs for lung cancer varied from 36/100,000 to 110/100,000 among men and from 26/100,000 to 77/100,000 among women. After adjusting for the prevalence of smoking and environmental pollution, the SES index was found to be inversely associated with the SMR for lung cancer in each category of age among men, and in the age group of 25–64 years among women. An increase of the SES index between 2010 and 2014 was associated with a decrease of SMR for respiratory disease both in men and women, but this change was not significantly associated with the SMR for lung cancer. Conclusion: SES appears to be an important correlate of mortality from respiratory diseases and lung cancer at the population level, particularly in men. A lower SES was associated with greater mortality from lung cancer and respiratory diseases. An increase in SES over time was related to a decrease in mortality from respiratory disease, but not from lung cancer.

Mortality in the Visegrad countries from the perspective of socioeconomic inequalities

OBJECTIVES

Large socioeconomic inequalities in health are still present in the Central Europe. The aim was to explore socioeconomic inequalities in mortality in Visegrad countries-the Czech Republic, Hungary, Poland and Slovakia (V4), by three different socioeconomic indicators (unemployment, risk of poverty/social exclusion, education). The study was conducted within the H2020 Euro-Healthy project.

METHODS

The associations between selected socioeconomic indicators and the standardised mortality rates by four main causes (mortality related to cancer, circulatory, respiratory and digestive system) in the economically active population aged 20-64 years in the 35 NUTS 2 level regions of the V4 in the period 2011-2013 were explored, using linear regression models.

RESULTS

Lower education level was the most significant predictor of mortality in the V4. The lowest mortality rates by all causes of death were found in the regions of the Czech Republic, the highest in regions of Hungary.

CONCLUSIONS

Despite the common origin, the pathways of the V4 countries in employment, poverty and education seem to be different, also having impact on health equity. Therefore, where you live in the V4 can significantly influence your health.

Trends in health inequalities in 27 European countries

Unfavorable health trends among the lowly educated have recently been reported from the United States. We analyzed health trends by education in European countries, paying particular attention to the possibility of recent trend interruptions, including interruptions related to the impact of the 2008 financial crisis. We collected and harmonized data on mortality from ca 1980 to ca 2014 for 17 countries covering 9.8 million deaths and data on self-reported morbidity from ca 2002 to ca 2014 for 27 countries covering 350,000 survey respondents. We used interrupted time-series analyses to study changes over time and country-fixed effects analyses to study the impact of crisis-related economic conditions on health outcomes. Recent trends were more favorable than in previous decades, particularly in Eastern Europe, where mortality started to decline among lowly educated men and where the decline in less-than-good self-assessed health accelerated, resulting in some narrowing of health inequalities. In Western Europe, mortality has continued to decline among the lowly and highly educated, and although the decline of less-than-good self-assessed health slowed in countries severely hit by the financial crisis, this affected lowly and highly educated equally. Crisis-related economic conditions were not associated with widening health inequalities. Our results show that the unfavorable trends observed in the United States are not found in Europe. There has also been no discernible short-term impact of the crisis on health inequalities at the population level. Both findings suggest that European countries have been successful in avoiding an aggravation of health inequalities.

Socioeconomic inequalities in suicide in Europe: the widening gap

BACKGROUND

Suicide has been decreasing over the past decade. However, we do not know whether socioeconomic inequality in suicide has been decreasing as well.AimsWe assessed recent trends in socioeconomic inequalities in suicide in 15 European populations.

METHOD

The DEMETRIQ study collected and harmonised register-based data on suicide mortality follow-up of population censuses, from 1991 and 2001, in European populations aged 35-79. Absolute and relative inequalities of suicide according to education were computed on more than 300 million person-years.

RESULTS

In the 1990s, people in the lowest educational group had 1.82 times more suicides than those in the highest group. In the 2000s, this ratio increased to 2.12. Among men, absolute and relative inequalities were substantial in both periods and generally did not decrease over time, whereas among women inequalities were absent in the first period and emerged in the second.

CONCLUSIONS

The World Health Organization (WHO) plan for 'Fair opportunity of mental wellbeing' is not likely to be met.Declaration of interestNone.

Nordic paradox, Southern miracle, Eastern disaster: persistence of inequalities in mortality in Europe

The persistence of socioeconomic inequalities in health, despite all that has been done to reduce social and economic inequalities in many European countries, is one of the great disappointments of public health. In this paper, I summarize the results of a series of studies into the explanation of variations and trends in inequalities in mortality in three European regions: the Nordic countries with their puzzlingly large inequalities in mortality, Southern European countries with their miraculously small inequalities in mortality and Central & Eastern European countries in which inequalities in mortality have disastrously exploded since the early 1990 s. The results of these studies show that inequalities in mortality are remarkably variable and dynamic, which suggests that it may be possible to reduce them if we exploit the entry-points for policy that these studies have also identified, such as poverty, smoking, excessive alcohol consumption and lack of access to health care. At the same time, another lesson is that health inequalities are influenced in sometimes unexpected ways by factors that are not under our control, and that we cannot expect to eliminate these health inequalities soon.

Health inequalities in Germany and in international comparison: trends and developments over time

Social epidemiological research has consistently demonstrated that people with a low socioeconomic status are particularly at risk of diseases, health complaints and functional limitations, and die at younger ages than those with a higher socioeconomic status. Greater stresses and strains in the workplace, family and living environment are under discussion as possible explanations. Health-related behaviours, psycho-social factors and personal resources, which are important in coping with everyday demands, certainly also play a role. From a public health and health policy perspective, reducing these health inequalities is an important goal. Insights into developments and trends in health inequalities over time can contribute towards highlighting new and emerging problems, and can thus help identify possible target groups and settings for relevant interventions. At the same time, these insights provide a basis upon which the success of policies and programmes that have already been implemented can be analysed and measured. Against this background, this review examines how health inequalities in Germany have developed over the last 20 to 30 years and places its findings within the context of the latest international research in this field.

Between 'Pioneers' of the Cardiovascular Revolution and Its 'Late Followers': Mortality Changes in the Czech Republic and Poland Since 1968

After several decades of stagnation, mortality in most Central European countries started to decrease after 1989. The Czech Republic and Poland were the first former Communist countries in this region to experience a rapid and sustained increase in life expectancy. This study focuses on the trends in cause-of-death mortality that have contributed to the recent progress in these two countries. The analysis is based on the cause-of-death time series (1968-2013) reconstructed in accordance with the 10th ICD revision, which makes the data fully comparable over the full period under study. Actual trends in cause-specific mortality are presented, and age, sex and causes of death components of life expectancy changes are disentangled. In both countries, the reduction in cardiovascular mortality at adult and old ages was crucial for the increase in life expectancy after 1991. Results are discussed in the context of institutional changes that occurred after the fall of Communism, such as the reorientation of health policies and the emergence of non-governmental organizations. Changes in health-related attitudes and behaviours as well as structural changes in societies, notably the rising share of persons with tertiary education, are also discussed.

The Trends in Cardiovascular Diseases and Respiratory Diseases Mortality in Urban and Rural China, 1990-2015

With the rapid development of the economy over the past 20 years, the mortality rates from cardiovascular diseases (CVDs) and respiratory diseases (RDs) have changed in China. This study aimed to analyze the trends of mortality rates and years of life lost (YLLs) from CVDs and RDs in the rural and urban population from 1990 to 2015. Using data from Chinese yearbooks, joinpoint regression analysis was employed to estimate the annual percent change (APC) of mortality rates from CVDs and RDs. YLLs due to CVDs and RDs were calculated by a standard method, adopting recommended standard life expectancy at birth values of 80 years for men and 82.5 years for women. Age-standardized mortality rates and YLL rates were calculated by using the direct method based on the Chinese population from the sixth population census of 2010. Age-standardized mortality rates from CVDs for urban residents and from RDs for both urban and rural residents showed decreasing trends in China from 1990 to 2015. Age-standardized mortality rates from CVDs among rural residents remained constant during above period and outstripped those among urban residents gradually. The age-standardized YLL rates of CVDs for urban and rural residents decreased 35.2% and 8.3% respectively. Additionally, the age-standardized YLL rates of RDs for urban and rural residents decreased 64.2% and 79.0% respectively. The age-standardized mortality and YLL rates from CVDs and RDs gradually decreased in China from 1990 to 2015. We observed more substantial declines of the mortality rates from CVDs in urban areas and from RDs in rural areas.

Determinants of the magnitude of socioeconomic inequalities in mortality: A study of 17 European countries

The magnitude of socioeconomic inequalities in mortality differs importantly between countries, but these variations have not been satisfactorily explained. We explored the role of behavioral and structural determinants of these variations, by using a dataset covering 17 European countries in the period 1970-2010, and by conducting multilevel multivariate regression analyses. Our results suggest that between-country variations in inequalities in current mortality can partly be understood from variations in inequalities in smoking, excessive alcohol consumption, and poverty. Also, countries with higher national income, higher quality of government, higher social transfers, higher health care expenditure and more self-expression values have smaller inequalities in mortality. Finally, trends in behavioral risk factors, particularly smoking and excessive alcohol consumption, appear to partly explain variations in inequalities in mortality trends. This study shows that analyses of variations in health inequalities between countries can help to identify entry-points for policy.

Ethnic variation in self-rated health-mortality association: Results from a 17-year follow-up study in Estonia

BACKGROUND AND AIM

Previous research has highlighted the role of self-rated health (SRH) as an important predictor of mortality. With substantial ethnic differences in SRH and mortality reported in Estonia, this study aims to examine the ethnic variation in SRH-mortality association in this setting.

MATERIALS AND METHODS

The baseline data come from the nationally representative 1996 Estonian Health Interview Survey. Individual records of 3983 respondents in the 25-79 age group were linked with mortality data with 17 years follow-up time. The association between SRH and all-cause mortality was analyzed using the Cox regression for two ethnic groups and separately for men and women.

RESULTS

Among ethnic Estonians, both men and women with bad or very bad SRH had about 60% higher mortality compared to those with good or very good SRH even after adjustment for age, socioeconomic and health-related variables. In contrast, SRH did not predict mortality among non-Estonian men and women. A strong and universal inverse association with mortality was found for personal income. Education (among men) and occupation (among women) predicted mortality only among non-Estonians, whereas ever smoking was associated with mortality in Estonian men and women. Overweight women had lower mortality risk compared to women in normal weight category.

CONCLUSIONS

We found considerable ethnic variation in SRH-mortality association and in socioeconomic predictors of mortality. Further research, preferably focusing on cause-specific mortality and reporting heterogeneity of SRH could potentially shed further light on ethnic differences in SRH-mortality association in Estonia and more generally on socioeconomic inequalities in mortality in Eastern Europe.

Trends in educational inequalities in obesity in 15 European countries between 1990 and 2010

BACKGROUND

The prevalence of obesity increased dramatically in many European countries in the past decades. Whether the increase occurred to the same extent in all socioeconomic groups is less known. We systematically assessed and compared the trends in educational inequalities in obesity in 15 different European countries between 1990 and 2010.

METHODS

Nationally representative survey data from 15 European countries were harmonized and used in a meta-regression of trends in prevalence and educational inequalities in obesity between 1990 and 2010. Educational inequalities were estimated by means of absolute rate differences and relative rate ratios in men and women aged 30-64 years.

RESULTS

A statistically significant increase in the prevalence of obesity was found for all countries, except for Ireland (among men) and for France, Hungary, Italy and Poland (among women). Meta-regressions showed a statistically significant overall increase in absolute inequalities of 0.11% points [95% CI 0.03, 0.20] per year among men and 0.12% points [95% CI 0.04, 0.20] per year among women. Relative inequalities did not significantly change over time in most countries. A significant reduction of relative inequalities was found among Austrian and Italian women.

CONCLUSION

The increase in the overall prevalence aligned with a widening of absolute but not of relative inequalities in obesity in many European countries over the past two decades. Our findings urge for a further understanding of the drivers of the increase in obesity in lower education groups particularly, and an equity perspective in population-based obesity prevention strategies.

Large variation in predictors of mortality by levels of self-rated health: Results from an 18-year follow-up study

OBJECTIVES

To analyze the variation in factors associated with mortality risk at different levels of self-rated health (SRH).

STUDY DESIGN

Retrospective cohort study.

METHODS

Cox regression analysis was used to examine the association between mortality and demographic, socioeconomic and health-related predictors for respondents with good, average, and poor SRH in a longitudinal data set from Estonia with up to 18 years of follow-up time.

RESULTS

In respondents with good SRH, male sex, older age, lower income, manual occupation, ever smoking, and heavy alcohol consumption predicted higher mortality. These covariates, together with marital status, illness-related limitations, and underweight predicted mortality in respondents with average SRH. For poor SRH, only being never married and having illness-related limitations predicted mortality risk in addition to older age and male sex.

CONCLUSIONS

The predictors of all-cause mortality are not universal but depend on the level of SRH. The higher mortality of respondents with poor SRH could to a large extent be attributed to health problems, whereas in the case of average or good SRH, factors other than the presence of illness explained outcome mortality.

Long-term trends of inequalities in mortality in 6 European countries

Objectives

We aimed to assess whether trends in inequalities in mortality during the period 1970–2010 differed between Finland, Norway, England and Wales, France, Italy (Turin) and Hungary.

Methods

Total and cause-specific mortality data by educational level and, if available, occupational class were collected and harmonized. Both relative and absolute measures of inequality in mortality were calculated.

Results

In all countries except Hungary, all-cause mortality declined strongly over time in all socioeconomic groups. Relative inequalities in all-cause mortality generally increased, but more so in Hungary and Norway than elsewhere. Absolute inequalities often narrowed, but went up in Hungary and Norway. As a result of these trends, Hungary (where inequalities in mortality where almost absent in the 1970s) and Norway (where inequalities in the 1970s were among the smallest of the six countries in this study) now have larger inequalities in mortality than the other four countries.

Conclusions

While some countries have experienced dramatic setbacks, others have made substantial progress in reducing inequalities in mortality.

Electronic supplementary material

The online version of this article (doi:10.1007/s00038-016-0922-9) contains supplementary material, which is available to authorized users.

Educational inequalities in premature mortality in Poland, 2002-2011: a population-based cross-sectional study

BACKGROUND

The aim of the study is to evaluate the differences in premature mortality between educational groups of Polish inhabitants in 2002 and 2011.

METHODS

The analysis included all deaths among inhabitants of Poland, aged 25-64 years, which occurred in 2002 (N=97 004) and 2011 (N=104 598). We calculated age-standardised death rates (SDRs) and summary measures on inequalities. The relative index of inequality (RII) was calculated with Poisson regression.

RESULTS

The SDR for Poland decreased from 285.7 per 100 000 in 2002 to 246.0 in 2011 among males with higher education and increased from 1141.0 in 2002 to 1183.0 in 2011 among males with lower secondary or less education (the rate ratio increased from 4.0 to 4.8). With regard to females with higher education, the SDR decreased from 127.2 per 100 000 in 2002 to 115.6 in 2011. Among females with lower secondary or less education, the SDR increased from 375.8 per 100 000 in 2002 to 423.1 in 2011 (the rate ratio increased from 3.0 to 3.7). The RII increased from 5.8 to 9.7 in the male group and from 4.4 to 8.3 in the female group. The greatest educational inequalities in 2011 were observed in females who died of cardiovascular diseases (RII=14.9) and lung cancer (RII=6.6) and in males who died of suicides (RII=19.3) and lung cancer (RII=11.9).

CONCLUSIONS

Educational inequalities in premature mortality in Poland are growing. There is a need to implement health education programmes targeted at groups of the most poorly educated Polish inhabitants, especially for diseases resulting from smoking and excessive alcohol consumption.

Trends in major risk factors and mortality from main non-communicable diseases in Lithuania, 1985-2013

Background

This study aimed to assess the trends in the prevalence and levels of risk factors and mortality from main non-communicable diseases in the Lithuanian population aged 45–64 years during 1985 to 2013.

Methods

Data from four general population surveys conducted between 1985 and 2008 were used. All these surveys were carried out in Kaunas city and five randomly selected municipalities of Lithuania. Risk factors measured at each survey included regular smoking, overweight, obesity, arterial hypertension, and high levels of blood lipids. In total, data of 10,719 subjects (4,965 men and 5,754 women) aged 45–64 were analysed. Trends in standardized all-cause mortality and mortality from cardiovascular disease (CVD), coronary heart disease (CHD), and malignant neoplasms were estimated for both sexes by joinpoint regression analysis.

Results

In 1985–2013, some favourable trends were observed in the age-standardized mean levels and prevalence of risk factors and mortality from main non-communicable diseases in the Lithuanian middle-aged population. The mean values of blood lipids (with the exception of triglycerides) and the prevalence of dyslipidemias declined. In women, mean levels of systolic blood pressure and body mass index decreased, while in men, the levels of these factors increased. The prevalence of arterial hypertension and obesity increased in men. The proportion of obese women decreased. Smoking prevalence increased in both men and women. From 2007 to 2008, significant downward trends, which were steeper in women than in men, were observed in all-cause, CVD, and CHD mortality.

Conclusions

Despite the favourable changes in some risk factors and mortality rates, the prevalence of risk factors and mortality from main non-communicable diseases in Lithuania are still high. This indicates the importance of the ongoing primary and secondary prevention and optimal treatment of these diseases.

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.

The Health Effects of Income Inequality: Averages and Disparities

Much research has investigated the association of income inequality with average life expectancy, usually finding negative correlations that are not very robust. A smaller body of work has investigated socioeconomic disparities in life expectancy, which have widened in many countries since 1980. These two lines of work should be seen as complementary because changes in average life expectancy are unlikely to affect all socioeconomic groups equally. Although most theories imply long and variable lags between changes in income inequality and changes in health, empirical evidence is confined largely to short-term effects. Rising income inequality can affect individuals in two ways. Direct effects change individuals' own income. Indirect effects change other people's income, which can then change a society's politics, customs, and ideals, altering the behavior even of those whose own income remains unchanged. Indirect effects can thus change both average health and the slope of the relationship between individual income and health.

Population health and status of epidemiology in Western European, Balkan and Baltic countries

BACKGROUND

This article is part of a series commissioned by the International Epidemiological Association, aimed at describing population health and epidemiological resources in the six World Health Organization (WHO) regions. It covers 32 of the 53 WHO European countries, namely the Western European countries, the Balkan countries and the Baltic countries.

METHODS

The burdens of mortality and morbidity and the patterns of risk factors and inequalities have been reviewed in order to identify health priorities and challenges. Literature and internet searches were conducted to stock-take epidemiological teaching, research activities, funding and scientific productivity.

FINDINGS

These countries have among the highest life expectancies worldwide. However, within- and between-country inequalities persist, which are largely due to inequalities in distribution of main health determinants. There is a long tradition of epidemiological research and teaching in most countries, in particular in the Western European countries. Cross-national networks and collaborations are increasing through the support of the European Union which fosters procedures to standardize educational systems across Europe and provides funding for epidemiological research through framework programmes. The number of Medline-indexed epidemiological research publications per year led by Western European countries has been increasing. The countries accounts for nearly a third of the global epidemiological publication.

CONCLUSIONS

Although population health has improved considerably overall, persistent within- and between-country inequalities continue to challenge national and European health institutions. More research, policy and action on the social determinants of health are required in the region. Epidemiological training, research and workforce in the Baltic and Balkan countries should be strengthened. European epidemiologists can play pivotal roles and must influence legislation concerning production and access to high-quality data.

Socio-economic mortality inequalities in Lithuania during 2001-2009: the record linkage study

OBJECTIVES

To present socio-economic inequalities in mortality and their trends in Lithuania using routinely collected data and record linkage for the years 2001-2009, as related to educational level, occupation, economic activity, marital status and household size.

STUDY DESIGN

Retrospective cohort study.

METHODS

Record linkage was performed using personal identification number between three data sources: 2001 population census, national mortality register for years 2001-2009 and population register, including individuals of age 30 years and older. The linked data set consisted of 2,061,481 records, including 338,652 death cases. Age-standardized mortality rates were calculated for socio-economic groups and compared in terms of rate differences (RD) and rate ratios (RR).

RESULTS

Significant mortality inequalities were found for all socio-economic variables. Both among males and females the highest RR were observed for the occupation (males--3.4, females--2.8) and economic activity status (males--2.7, females--3.1). RR were the highest in mid-ages and declined with ageing. RD increased with the increase in total mortality during 2005-2007, while decline in inequalities was observed in later years.

CONCLUSIONS

Lower education, manual occupations, unemployed, economically inactive and unmarried groups of population appeared in the most unfavourable position in terms of mortality and contributed most to the mortality increase in Lithuania throughout 2005-2007.

Educational differentials in cancer mortality and avoidable deaths in Lithuania, 2001-2009: a census-linked study

OBJECTIVES

We investigate relative mortality inequalities by education for detailed cancer sites and provide estimates of deaths which could have been avoided through the elimination of these inequalities.

METHODS

A census-linked dataset based on a follow-up of all residents registered in the 2001 census was used for the analysis. Mortality rate ratios were estimated by employing multivariate Poisson regression models for count data.

RESULTS

An inverse educational gradient was observed for 11 cancer sites among men and for three cancer sites among women. Substantial shares of these cancer deaths would have been avoided if mortality among less educated groups had been the same as mortality among highly educated groups.

CONCLUSIONS

Cancer control plans must consider socioeconomic inequalities and propose ways to improve prevention measures aimed at disadvantaged groups.

Longevity and Education: A Demographic Perspective

In the second half of the 20th century, the advances in human longevity observed have been accompanied by an increase in the disparities between countries and regions. Education is one of the strongest predictors of life expectancy. Studies have shown that both relative and absolute mortality differences by education within countries have been increasing, even in the most developed and egalitarian countries. It is possible to assume that groups of highly educated people who systematically display life expectancy levels which are higher than the observed best practice (record) life expectancy at the national level are vanguards who are leading the way toward a lengthening of life for the remaining population groups. This evidence based on population-level statistics and exploring an important single factor could inspire further discussion about the possibilities for extending human length of life at the national level. However, more comprehensive and reliable data covering a larger number of countries and more covariates are needed for understanding health effects of education and prospects of human longevity.

The health effects of the global financial crisis: can we reconcile the differing views? A network analysis of literature across disciplines

Why are researchers studying the health effects of economic change reaching markedly varying conclusions? To understand these differences, we first systematically searched Web of Science for the literature on recessions and health yielding 461 articles and 14,401 cited documents. We then undertook a network analysis of co-citation pattern by disciplines, journals and backgrounds of the authors, followed by a chronological review of the literature, to trace the evolution of ideas. We then examined the extent to which earlier literature predicted what has happened in the 2007-2012 crisis. Our analysis finds the literature is dominated by disciplinary silos, with economics studies predominantly citing each other and relative isolation of psychiatry and substance abuse journals. Different philosophical approaches to assessing causality appear to contribute to varying interpretations, a tendency that is unlikely to be resolved without a shift in research norms. We conclude by calling for more inter-disciplinary research that combines empirical findings with a search for plausible mechanisms. This approach would evaluate not only the effects of economic shocks but also the mechanisms that offer protection against them.

Income inequality, life expectancy and cause-specific mortality in 43 European countries, 1987-2008: a fixed effects study

Whether income inequality is related to population health is still open to debate. We aimed to critically assess the relationship between income inequality and mortality in 43 European countries using comparable data between 1987 and 2008, controlling for time-invariant and time-variant country-level confounding factors. Annual data on income inequality, expressed as Gini index based on net household income, were extracted from the Standardizing the World Income Inequality Database. Data on life expectancy at birth and age-standardized mortality by cause of death were obtained from the Human Lifetable Database and the World Health Organization European Health for All Database. Data on infant mortality were obtained from the United Nations World Population Prospects Database. The relationships between income inequality and mortality indicators were studied using country fixed effects models, adjusted for time trends and country characteristics. Significant associations between income inequality and many mortality indicators were found in pooled cross-sectional regressions, indicating higher mortality in countries with larger income inequalities. Once the country fixed effects were added, all associations between income inequality and mortality indicators became insignificant, except for mortality from external causes and homicide among men, and cancers among women. The significant results for homicide and cancers disappeared after further adjustment for indicators of democracy, education, transition to national independence, armed conflicts, and economic freedom. Cross-sectional associations between income inequality and mortality seem to reflect the confounding effects of other country characteristics. In a European context, national levels of income inequality do not have an independent effect on mortality.