Educational Inequalities In Mortality Research Articles

Educational inequalities in cervical cancer mortality: A systematic review and meta-analysis

Abstract Background Educational inequalities in mortality continue to persist. We aimed to systematically analyse the association between level of education and cervical cancer mortality. Methods We conducted a systematic review and meta-analysis. We systematically searched Pub-Med, Web of Science, Scopus, EMBASE and Global Health (CAB), EconLit and Sociology Source Ultimate databases. A protocol has been registered with PROSPERO (CRD42023411757). We included studies that measured the association between level of education and cervical cancer mortality using individual level data. Included articles were assessed for study quality and risk of bias using the Joanna Briggs Institute critical appraisal checklists. A random-effects meta-analysis was conducted to evaluate the overall and stratified effects of education on mortality. Findings Our literature search resulted in over 47,000 articles. 30 studies mentioned cervical cancer as a cause of death, and of these, 11 were eligible for the meta-analysis. Results showed an overall risk ratio of 2.41 (95% CI 1.81-3.20) for low education (ISCED 0-2) and 1.62 (95% CI 1.18-2.24) for medium education (ISCED 3-4). Those aged 25-64 with low education had more than twice the risk of cervical cancer (RR = 5.73; 95% CI 5.04-6.51) compared to those aged 25 and above (RR = 2.11; 95% CI 1.82-2.45). Besides, the impact of an additional level of education on reducing risk of cervical cancer mortality was higher in Northern Europe, compared to the South. Interpretation Lower educational attainment is associated with an increase in the risk of cervical cancer mortality, with an additional level of education greatly reducing this risk in Northern Europe. Younger cohorts with low education have a higher risk of cervical cancer mortality. This study provides important information for evidence-based policy seeking to reduce health inequities and inequalities in both the health and education sector. Key messages • Lower educational attainment is linked to a higher risk of cervical cancer mortality. • Younger cohorts (aged 25-64) with low education are at a particularly heightened risk compared to those aged 25 and above.

Does Inequality Have Momentum? The Implications of Convex Inequality Regimes for Mortality Dynamics

AbstractFor decades, educational inequalities in mortality have widened and mortality among the least educated has stalled, even as overall mortality has improved, and an increasing proportion of young people have completed secondary and tertiary education. While researchers recognize that these trends are in part related to changing selection into education groups, there has been no unifying framework for understanding why the trends may be related. This article provides a unifying framework by introducing a concept called the “convex inequality regime,” a diminishing returns relationship between relative education and mortality. In populations where convex inequality regimes prevail, even without any changes in the institutions governing inequality or any changes in overall mortality conditions, education transitions result in an increase in mortality for the less educated and an increase in mortality inequality between education groups. The model also shows that lifespan variation increases for lower education groups because convex inequality regimes tend to increase relative mortality more rapidly at younger ages during an education transition. Even after an education transition is complete, inequality between education groups will continue to increase for decades due to the momentum of inequality, a cohort replacement phenomenon where younger more unequal cohorts replace older more equal cohorts.

Enabling the examination of long-term mortality trends by educational level for England and Wales in a time-consistent and internationally comparable manner

BackgroundStudying long-term trends in educational inequalities in health is important for monitoring and policy evaluation. Data issues regarding the allocation of people to educational groups hamper the study and international comparison of educational inequalities in mortality. For the UK, this has been acknowledged, but no satisfactory solution has been proposed.ObjectiveTo enable the examination of long-term mortality trends by educational level for England and Wales (E&W) in a time-consistent and internationally comparable manner, we propose and implement an approach to deal with the data issues regarding mortality data by educational level.MethodsWe employed 10-year follow-ups of individuals aged 20+ from the Office for National Statistics Longitudinal Study (ONS-LS), which include education information from each decennial census (1971–2011) linked to individual death records, for a 1% representative sample of the E&W population. We assigned the individual cohort data to single ages and calendar years, and subsequently obtained aggregate all-cause mortality data by education, sex, age (30+), and year (1972–2017). Our data adjustment approach optimised the available education information at the individual level, and adjusts—at the aggregate level—for trend discontinuities related to the identified data issues, and for differences with country-level mortality data for the total population.ResultsThe approach resulted in (1) a time-consistent and internationally comparable categorisation of educational attainment into the low, middle, and high educated; (2) the adjustment of identified data-quality related discontinuities in the trends over time in the share of personyears and deaths by educational level, and in the crude and the age-standardised death rate by and across educational levels; (3) complete mortality data by education for ONS-LS members aged 30+ in 1972–2017 which aligns with country-level mortality data for the total population; and (4) the estimation of inequality measures using established methods. For those aged 30+ , both absolute and relative educational inequalities in mortality first increased and subsequently decreased.ConclusionWe obtained additional insights into long-term trends in educational inequalities in mortality in E&W, and illustrated the potential effects of different data issues. We recommend the use of (part of) the proposed approach in other contexts.

Educational inequalities in all-cause and cause-specific mortality in Japan: national census-linked mortality data for 2010-15.

Due to the lack of a national mortality inequality monitoring framework, the overall picture in Japan remains unclear. Here, we investigated educational inequalities in mortality and their cause-specific contribution in Japan. Data were obtained by linking the 2010 Japanese population census and death records between 1 October 2010 and 30 September 2015. We included 7 984 451 Japanese people aged 30-79 years who had a unique 'matching key' generated by sex, birth year/month, address (municipality), marital status and age of spouse (9.9% of the total census population). We computed population-weighted all-cause and cause-specific age-standardized mortality rates (ASMRs) by education level. In addition, we calculated the slope index of inequality (SII), relative index inequality (RII) by education level, and population attributable fraction (PAF) referenced with the highest education (e.g. university graduation). Individuals with less education had higher all-cause and cause-specific ASMRs than highly educated individuals. All-cause SII (per 100 000 person-years) values were 433 (95% CI: 410-457) for men and 235 (95% CI: 217-252) for women. RII values were 1.48 (95% CI: 1.45-1.51) for men and 1.47 (95% CI: 1.43-1.51) for women. Estimated PAFs, excess premature deaths caused by educational inequalities, were 11.6% for men and 16.3% for women, respectively. Cerebrovascular diseases, ischaemic heart diseases and lung cancer were the major contributors to mortality inequalities for both sexes. This first census-based comprehensive report on cause-specific educational mortality inequalities suggested that differences in unfavourable health risk factors by educational background might be associated with these inequalities in Japan.

Educational inequality in cause-specific mortality among immigrants and their descendants in Sweden

Abstract Introduction Although immigrants in Western countries often face disadvantages and vulnerabilities such as lower socioeconomic status, they tend to exhibit weaker educational gradients in mortality compared to the native majority populations. However, it is unclear how these gradients vary across specific causes of death and whether they persist among second-generation immigrants. Therefore, this study aims to investigate educational inequalities in cause-specific mortality among first- and second-generation immigrants compared to the native ancestral population in Sweden. Data & Methods Individual-level analysis was conducted on Swedish register data from 2004 to 2016, including men and women aged 25 to 64. Poisson regression was used to examine the association between the highest educational degree attained and mortality due to circulatory diseases, neoplasms, external causes, self-harm, drug and alcohol use. Results The findings indicated that first-generation immigrants exhibited significantly lower educational inequality in all causes of death compared to native ancestral Swedes. In contrast, second-generation immigrants showed similar degrees of educational inequality in all-cause mortality and mortality due to neoplasms when compared to ancestral Swedes. However, they displayed more pronounced educational inequalities in mortality from external causes, self-harm, and drug use. Conclusions The results highlight that while first-generation immigrants experience lower educational inequality in the considered causes of death, second-generation immigrants show pronounced educational inequalities in avoidable causes of death. This study emphasizes the importance of considering heterogeneity in educational disparities in immigrant mortality and calls for policy interventions to address educational inequalities in second-generation immigrants. Key messages • When compared to the native majority population, first-generation immigrants in Sweden demonstrate lower educational inequality in mortality, regardless of the underlying cause. • Conversely, second-generation immigrants display larger educational inequalities, particularly for mortality caused by preventable factors.

Educational inequalities in mortality and their mediators among generations across four decades: nationwide, population based, prospective cohort study based on the ChinaHEART project

ObjectivesTo assess the different educational inequalities in mortality among generations born between 1940 and 1979 in China, and to investigate the role of socioeconomic, behavioural, and metabolic factors as potential...

Trends in social inequality in mortality in Denmark 1995–2019: the contribution of smoking- and alcohol-related deaths

BackgroundDuring the past decades, social inequality in mortality has increased in several countries, including Denmark. Modifiable risk factors, such as smoking and harmful alcohol consumption, have been suggested to moderate...

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

BackgroundWe aim to assess the age- and cause-specific contributions to differences in life expectancy and lifespan variation between the high- and low-educated groups in Spain. MethodsWe use sex-, age-, education- and cause-specific mortality and population data for individuals aged 30 and over for 2016-19 in Spain. We estimated life expectancies, and standard deviations of the age-at-death distribution (lifespan variation), and we disentangled the contribution of age-causes of death to educational differences in both indicators. FindingsLife expectancy at age 30 was higher for high-educated groups compared to low-educated groups, 5.5 years for males and 3.0 years for females. Lifespan variation was higher for low-educated groups compared to high-educated groups, 2.9 years for males and 2.2 years for females. The main contributors to the life expectancy gaps in males were lung cancer (0.58 years) and ischaemic heart diseases (0.42 years), and in females were other cardiovascular causes (0.26 years), and ischaemic heart diseases (0.22 years). The main contributors to the lifespan variation gaps were in males lung cancer (−0.25 years) and ischaemic heart diseases (−0.22 years), while in females were other neoplasms and other diseases of the nervous system. InterpretationWhereas behavioural causes are more important in explaining educational inequalities in mortality among men, ageing-related causes of death seem more important among women. Attempts at narrowing socioeconomic gaps in mortality may benefit from applying gender-specific preventive policy measures.

Increase in educational inequalities in alcohol-related mortality in Spain during a period of economic growth.

Alcohol-related mortality risk is almost always greater in lower than higher socio-economic positions (SEPs). There is little information on the evolution of this SEP gradient and its relationship with the economic cycle. Some results suggest that during economic expansions, there is a hypersensitivity of low-SEP people to harmful drinking. The main objective of this study was to measure the evolution of educational inequality in alcohol-related and non-alcohol related mortality by sex and age group in Spain during 2012-19. This is a repeated cross-sectional study. This study includes all residents in Spain aged 25 years and over from 2012 to 2019. (1) We calculated age-standardized mortality rates (ASMRs) from strongly/moderately alcohol-related causes (directly alcohol-attributable, unspecified liver cirrhosis, liver and upper aerodigestive tract cancers and moderately alcohol-related), weakly alcohol-related causes and other causes by educational level. (2) We used age-adjusted relative index of inequality (RII) and slope index of inequality (SII) to measure relative and absolute educational inequality in mortality, respectively. (3) Age-adjusted annual percentage change (APC) was also used to measure linear trends in mortality by educational level. RII, SII and APC were obtained from negative binomial regression. Between 2012-15 and 2016-19, economic growth accelerated, the RII in mortality from strongly/moderately alcohol-related causes increased from 2.0 to 2.2 among men and from 1.1 to 1.3 among women, and the SII in deaths/100 000 person-years from 181.4 to 190.9 among men and from 18.9 to 46.5 among women. It also increased relative and absolute inequality in mortality from weakly alcohol-related and other causes of death in both men and women. These increases in inequality were due primarily to a flattening or even reversal of the downward mortality trend among low- and medium-educated people. During the economic expansion of 2012-19 in Spain, changes in mortality risk from strongly/moderately alcohol-related causes were especially unfavourable among low- and medium-educated people.

Widening educational inequalities in mortality in more recent birth cohorts: a study of 14 European countries

BackgroundStudies of period changes in educational inequalities in mortality have shown important changes over time. It is unknown whether a birth cohort perspective paints the same picture. We compared changes...

Educational inequalities in mortality due to alcoholic liver disease in Poland

Educational inequalities in mortality due to alcoholic liver disease in Poland

Reducing educational inequalities in mortality: a comparative risk assessment approach

Abstract Educational inequalities in mortality are increasingly recognized as one of the main challenges for health policy. Studies comparing European countries have shown that such inequalities are substantial almost everywhere, but that there are important variations between countries, suggesting great scope for reduction. However, identifying this scope is difficult because it requires comparative information about the educational distribution of mortality rates, risk factors and relative risks. In this presentation I show how this can be done, by quantifying the impact of a theoretical equalization of the distribution of several known risk factors for mortality, in a comparative risk assessment approach. Harmonized data set on mortality (from register data) and risk factors (from survey data) by educational level for 21 European populations in the early 2000s were applied. The impact of the risk factors on mortality in each educational group was determined using Population Attributable Fractions (PAF). The impact on inequalities in mortality was estimated applying two counterfactual scenarios: a theoretical upward levelling scenario in which it is assumed that inequalities in the risk factor were completely eliminated, and a more realistic best practice scenario, in which it is assumed that inequalities in a risk factor were to be reduced to those seen in the country with the smallest inequalities for that risk factor. The analysis shows how information on risk factors, mortality rates and relative risks can be combined from different data sources and provide a meaningful analysis of the European mortality burden that can be linked to educational inequalities in risk factors. The analysis also shows that upward levelling scenarios and best practice scenarios demonstrate a theoretical potential for reducing inequalities in mortality.

Comparative study of two birth cohorts: did the explanatory role of behavioural, social and psychological factors in educational inequalities in mortality change over time?

ObjectivesTo investigate the contribution of behavioural, social and psychological factors to inequalities in mortality by educational level between birth cohorts.DesignCohort-sequential design.SettingTwo population-based studies in the Netherlands: the Longitudinal Aging Study...

The Role of Epigenetic Clocks in Explaining Educational Inequalities in Mortality: A Multicohort Study and Meta-analysis.

Educational inequalities in all-cause mortality have been observed for decades. However, the underlying biological mechanisms are not well known. We aimed to assess the role of DNA methylation changes in blood captured by epigenetic clocks in explaining these inequalities. Data were from 8 prospective population-based cohort studies, representing 13 021 participants. First, educational inequalities and their portion explained by Horvath DNAmAge, Hannum DNAmAge, DNAmPhenoAge, and DNAmGrimAge epigenetic clocks were assessed in each cohort via counterfactual-based mediation models, on both absolute (hazard difference) and relative (hazard ratio) scales, and by sex. Second, estimates from each cohort were pooled through a random effect meta-analysis model. Men with low education had excess mortality from all causes of 57 deaths per 10 000 person-years (95% confidence interval [CI]: 38, 76) compared with their more advantaged counterparts. For women, the excess mortality was 4 deaths per 10 000 person-years (95% CI: -11, 19). On the relative scale, educational inequalities corresponded to hazard ratios of 1.33 (95% CI: 1.12, 1.57) for men and 1.15 (95% CI: 0.96, 1.37) for women. DNAmGrimAge accounted for the largest proportion, approximately 50%, of the educational inequalities for men, while the proportion was negligible for women. Most of this mediation was explained by differential effects of unhealthy lifestyles and morbidities of the World Health Organization (WHO) risk factors for premature mortality. These results support DNA methylation-based epigenetic aging as a signature of educational inequalities in life expectancy emphasizing the need for policies to address the unequal social distribution of these WHO risk factors.

Incidence of SARS-CoV-2 Infection and Related Mortality by Education Level during Three Phases of the 2020 Pandemic: A Population-Based Cohort Study in Rome.

Evidence on social determinants of health on the risk of SARS-CoV-2 infection and adverse outcomes is still limited. Therefore, this work investigates educational disparities in the incidence of infection and mortality within 30 days of the onset of infection during 2020 in Rome, with particular attention to changes in socioeconomic inequalities over time. A cohort of 1,538,231 residents in Rome on 1 January 2020, aged 35+, followed from 1 March to 31 December 2020, were considered. Cumulative incidence and mortality rates by education were estimated. Multivariable log-binomial and Cox regression models were used to investigate educational disparities in the incidence of SARS-CoV-2 infection and mortality during the entire study period and in three phases of the pandemic. During 2020, there were 47,736 incident cases and 2281 deaths. The association between education and the incidence of infection changed over time. Till May 2020, low- and medium-educated individuals had a lower risk of infection than that of the highly educated. However, there was no evidence of an association between education and the incidence of SARS-CoV-2 infection during the summer. Lastly, low-educated adults had a 25% higher risk of infection from September to December than that of the highly educated. Similarly, there was substantial evidence of educational inequalities in mortality within 30 days of the onset of infection in the last term of 2020. In Rome, social inequalities in COVID-19 appeared in the last term of 2020, and they strengthen the need for monitoring inequalities emerging from this pandemic.

Alcohol and educational inequalities: Hazardous drinking prevalence and all-cause mortality by hazardous drinking group in people aged 50 and older in Europe

Background We examined educational inequalities in hazardous drinking prevalence among individuals aged 50 or more in 14 European countries, and explored educational inequalities in mortality in hazardous drinkers in European regions. Methods: We analyzed data from waves 4, 5 and 6 of the Survey of Health Ageing and Retirement in Europe (SHARE). We estimated age-standardized hazardous drinking prevalence, and prevalence ratios (PR) of hazardous drinking by country and educational level using Poisson regression models with robust variance. We estimated the relative index of inequality (RII) for all-cause mortality among hazardous drinkers and non-hazardous drinkers using Cox proportional hazards regression models and for each region (North, South, East and West). Results: In men, educational inequalities in hazardous drinking were not observed (PRmedium = 1.09 [95%CI: 0.98–1.21] and PRhigh = 0.99 [95%CI: 0.88–1.10], ref. low), while in they were observed in women, having the highest hazardous drinking prevalence in the highest educational levels (PRmedium = 1.28 [95%CI: 1.15–1.42] and PRhigh = 1.53 [95%CI: 1.36–1.72]). Overall, the Relative Index of Inequality (RII) in all-cause mortality among hazardous drinkers was 1.12 [95%CI: 1.03–1.22] among men and 1.10 [95%CI: 0.97–1.25] among women. Educational inequalities among hazardous drinkers were observed in Eastern Europe for both men (RIIhazardous = 1.21 [95%CI: 1.01–1.45]) and women (RIIhazardous = 1.46 [95%CI: 1.13–1.87]). Educational inequalities in mortality among non-hazardous drinkers were observed in Southern, Western and Eastern Europe among men, and in Eastern Europe among women. Conclusions: Higher educational attainment is positively associated with hazardous drinking prevalence among women, but not among men in most of the analyzed European countries. Clear educational inequalities in mortality among hazardous drinkers were only observed in Eastern Europe. Further research on the associations between alcohol use and inequalities in all-cause mortality in different regions is needed.

Educational inequalities in suicide in the highly volatile economy of Argentina.

Little is known about how economic fluctuations affect educational inequalities in mortality in low- or middle-income countries. The objective of this study is to analyze the temporal variations in educational differentials in suicide in four Argentinian provinces. Data on suicides for ages 25years and over and three age groups (25-44, 45-64, and 65 +) in four Argentinian provinces during the period 1999-2013 were linked to population data and information on the educational level of the deceased. Regression models were estimated using age, sex, year, province of residence, educational level, and economic character of the year (expansion or recession) as explanatory variables. The educational gap in suicide mortality widened since the expansion following the crisis of 1999-2002, and then only decreased in 2005 and 2011. For ages 45-64, the confidence intervals of the suicide rate overlapped each year, and the suicide rate of the middle-high education population exceeded the suicide rate of the low-education population in 2 recession years, 1999 and 2002. Considering the years of economic expansion or recession as a dichotomous variable, at ages 45-64 differences in suicide rates by educational level disappeared during years of recession, while they were present in years of expansion. Suicides rise during economic downturns but these periods could reduce the educational gaps of suicide mortality by increasing the vulnerability of adults of high educational level to changes in the economy.

Widening Educational Differentials in Mortality: Analysis for Austria with International Comparisons

Recent studies have reported a widening in the relative mortality gap between thesocioeconomic classes in several industrialized western countries. The present paper aimsto determine whether or not education-related differentials in mortality have increasedbetween 1981/82 and 1991/92 in Austria, and compares the findings with those from otherEuropean countries, the USA and New Zealand. For the Austrian analysis the source of thedata is based on a one year mortality follow up of the entire Austrian census population,and contains for the examined population aged 30-74 in total 3,805,208 individual recordsfor 1981/82 and 4,064,184 records for 1991/92 of which 34,218 and 29,443 were deceased.The study applies a sophisticated measure of inequality that takes into account the relativeposition of the educational groups, since changing educational compositions over time mayreduce comparability. The findings suggest that educational inequalities in mortality havewidened in Austria, but more among men than among women. The Austrian results aresimilar to patterns observed in the other countries. However, the international trends varywith regard to age groups and sex.

Economic fluctuations and urban-rural differences in educational inequalities in mortality in the Baltic countries and Finland in 2000\u20132015: a register-based study

We examined urban-rural differences in educational inequalities in mortality in the Baltic countries (Estonia, Latvia, Lithuania) and Finland in the context of macroeconomic changes. Educational inequalities among 30–74 year olds were examined in 2000–2003, 2004–2007, 2008–2011 and 2012–2015 using census-linked longitudinal mortality data. We estimated age-standardized mortality rates and the relative and slope index of inequality. Overall mortality rates were larger in rural areas except among Finnish women. Relative educational inequalities in mortality were often larger in urban areas among men but in rural areas among women. Absolute inequalities were mostly larger in rural areas excepting Finnish men. Between 2000–2003 and 2012–2015 relative inequalities increased in most countries while absolute inequalities decreased except in Lithuania. In the Baltic countries the changes in both relative and absolute inequalities tended to be more favorable in urban areas; in Finland they were more favorable in rural areas. The overall pattern changed during the reccessionary period from 2004–2007 to 2008–2011 when relative inequalities often diminished or the increase slowed, while the decrease in absolute inequalities accelerated with larger improvements observed in urban areas. Despite substantial progress in reducing overall mortality rates in both urban and rural areas in all countries, low educated men and women in rural areas in the Baltic countries are becoming increasingly disadvantaged in terms of mortality reduction.

Education and pneumonia mortality: a trend analysis of its inequalities in Colombian adults

ObjectiveTo explore the existence and trends of social inequalities related to pneumonia mortality in Colombian adults using educational level as a proxy of socioeconomic status.MethodsWe obtained individual and anonymised registries...