Educational Inequalities In Mortality Research Articles

Educational inequalities in 28 day and 1-year mortality after hospitalisation for incident acute myocardial infarction — A nationwide cohort study

BackgroundThere is little recent evidence on the impact of comorbidities and access to revascularisation procedures on educational inequalities in mortality after acute myocardial infarction (AMI). The aim of the study was to investigate educational inequalities in mortality among all patients hospitalised for an incident AMI during 2001–2009 in Norway. MethodsData were obtained through the Cardiovascular Disease in Norway (CVDNOR) project. Incident AMI was defined as an AMI-hospitalisation without any AMI-events in the previous 7years. Education was categorised as basic, upper secondary or tertiary (college/university). Cox regression was used to assess educational differences in 28-day and 29–365-day mortality after an incident AMI in terms of hazard ratios and relative index of inequality (RII). RII can be interpreted as the ratio in mortality between the 0th and the 100th percentile of the education distribution. Results111 993 incident AMIs were included (39.4% women). Among patients aged 35–69, RIIs (95% CI) adjusted for age, sex and year were 1.86 (1.59–2.18) and 2.10 (1.69–2.59) for 28-day and 29–365-day mortality respectively. Among patients aged 70–94 the corresponding RIIs were 1.12 (1.06–1.30) and 1.28 (1.19–1.38). Educational inequalities in mortality were attenuated after adjustment for comorbidities and revascularisation, but were still significant. Educational inequalities did not decrease during 2001–2009. ConclusionEducational inequalities in both 28-day and 29–365day mortality were strong and persistent during 2001–2009. Further research is needed to investigate if these disparities are driven by inequalities in the severity of the AMI or by inequitable access to treatment and rehabilitation.

Decreasing educational differences in mortality over 40-years: evidence from the Turin Longitudinal Study (Italy)

Background Recent studies suggest that inequalities in premature mortality have continued to rise over the last decade in most European countries, but not in southern European countries. Methods In this study, we assess long-term trends (1971–2011) in absolute and relative educational inequalities in all-cause and cause-specific mortality in the Turin Longitudinal Study (Turin, Italy), a record-linkage study including all individuals resident in Turin in the 1971, 1981, 1991 and 2001 censuses, and aged 30–99 years (more than 2 million people). We examined mortality for all causes, cardiovascular disease (CVD), all cancers and specific cancers (lung, breast), as well as smoking and alcohol-related mortality. Results Overall mortality substantially decreased in all educational groups over the study period, although cancer rates only slightly declined. Absolute inequalities decreased for both genders (SII=962/694 in men/women in 1972–1976 and SII=531/259 in 2007–2011, p Conclusions Absolute inequalities in mortality strongly declined over the study period in both genders. Relative educational inequalities in mortality were generally stable among men; while they tended to narrow among women. In general, this study supports the hypothesis that educational inequalities in mortality have decreased in southern European countries.

The changing contribution of smoking to educational inequality in female mortality

The negative association between education and mortality is well established in international research. The harmful effect of smoking on health is well known. However, the contribution of smoking to educational inequality in mortality varies across studies, and in some studies, the contribution is negligible. This paper demonstrates the use of an analytical approach to provide one explanation for this phenomenon. Analysing nationally representative survey data for two cohorts of Australian women born in 1920–1928 and 1945–1951 respectively, we found that in the 1994–2006 period, the less educated are subject to higher mortality by 38–50 %. In the total sample, the smoking contribution to excess mortality due to lower education is negligible. However, when the cohorts are analysed independently, the smoking contribution ranges from −13 % among those born in 1920–1928 to +23 % among those born in 1945–1951. The smoking contribution is only seen in the cohort-specific analysis because smoking is more prevalent among tertiary degree holders in the earlier cohort but more prevalent among less educated women in the later cohort. The disaggregated analytical approach taken here deserves further attention in research on inequality.

Why does Spain have smaller inequalities in mortality? An exploration of potential explanations

While educational inequalities in mortality are substantial in most European countries, they are relatively small in Spain. A better understanding of the causes of these smaller inequalities in Spain may help to develop policies to reduce inequalities in mortality elsewhere. The aim of the present study was therefore to identify the specific causes of death and determinants contributing to these smaller inequalities. Data on mortality by education were obtained from longitudinal mortality studies in three Spanish populations (Barcelona, Madrid, the Basque Country), and six other Western European populations. Data on determinants by education were obtained from health interview surveys. The Spanish populations have considerably smaller absolute inequalities in mortality than other Western European populations. This is due mainly to smaller inequalities in mortality from cardiovascular disease (men) and cancer (women). Inequalities in mortality from most other causes are not smaller in Spain than elsewhere. Spain also has smaller inequalities in smoking and sedentary lifestyle and this is due to more smoking and physical inactivity in higher educated groups. Overall, the situation with regard to health inequalities does not appear to be more favourable in Spain than in other Western European populations. Smaller inequalities in mortality from cardiovascular disease and cancer in Spain are likely to be related to its later socio-economic modernization. Although these smaller inequalities in mortality seem to be a historical coincidence rather than the outcome of deliberate policies, the Spanish example does suggest that large inequalities in total mortality are not inevitable.

Smoking and the potential for reduction of inequalities in mortality in Europe

Socioeconomic inequalities in health and mortality remain a widely recognized problem. Countries with smaller inequalities in smoking have smaller inequalities in mortality, and smoking plays an important part in the explanation of inequalities in some countries. We identify the potential for reducing inequalities in all-cause and smoking-related mortality in 19 European populations, by applying different scenarios of smoking exposure. Smoking prevalence information and mortality data come from 19 European populations. Prevalence rates are mostly taken from National Health Surveys conducted around the year 2000. Mortality rates are based on country-specific longitudinal or cross-sectional datasets. Relative risks come from the Cancer Prevention Study II. Besides all-cause mortality we analyze several smoking-related cancers and chronic obstructive pulmonary disease/asthma. We use a newly-developed tool to quantify the changes in population health potentially resulting from modifying the population distribution of exposure to smoking. This tool is based on the epidemiological measure of the population attributable fraction, and estimates the impact of scenario-based distributions of smoking on educational inequalities in mortality. The potential reduction of relative inequality in all-cause mortality between those with high and low education amounts up to 26 % for men and 32 % for women. More than half of the relative inequality may be reduced for some causes of death, often in countries of Northern Europe and in Britain. Patterns of potential reduction in inequality differ by country or region and sex, suggesting that the priority given to smoking as an entry-point for tackling health inequalities should differ between countries.

Educational Inequalities in Three Smoking-Related Causes of Death in 18 European Populations

Smoking is an important determinant of socioeconomic inequalities in mortality in many countries. As the smoking epidemic progresses, updates on the development of mortality inequalities attributable to smoking are needed. We provide estimates of relative and absolute educational inequalities in mortality from lung cancer, aerodigestive cancers, and chronic obstructive pulmonary disease (COPD)/asthma in Europe and assess the contribution of these smoking-related diseases to inequalities in all-cause mortality. We use data from 18 European populations covering the time period 1998-2007. We present age-adjusted mortality rates, relative indices of inequality, and slope indices of inequality. We also calculate the contribution of inequalities in smoking-related mortality to inequalities in overall mortality. Among men, relative inequalities in mortality from the 3 smoking-related causes of death combined are largest in the Czech Republic and Hungary and smallest in Spain, Sweden, and Denmark. Among women, these inequalities are largest in Scotland and Norway and smallest in Italy and Spain. They are often larger among men and tend to be larger for COPD/asthma than for lung and aerodigestive cancers. Relative inequalities in mortality from these conditions are often larger in younger age groups, particularly among women, suggesting a possible further widening of inequalities in mortality in the coming decades. The combined contribution of these diseases to inequality in all-cause mortality varies between 13% and 32% among men and between -5% and 30% among women. Our results underline the continuing need for tobacco control policies, which take into account socioeconomic position.

Evolution of educational inequalities in mortality among young adults in an urban setting

To gain insight into the evolution in educational inequalities in adolescent and young adult all-cause and cause-specific mortality in the urban setting of the Brussels-Capital Region. Data were derived from record linkage between the censuses of 1991 and 2001 and register data on all-cause and cause-specific mortality and emigration in the respective periods of 1st October 1991 to 1st January 1996 and 1st October 2001 to 1st January 2006. Both directly and indirectly standardised mortality rates and the relative index of inequality (RII) were computed. Mortality rates among adolescents and young adults have dropped significantly, especially infections and traffic accidents. However, educational inequalities among men have slightly increased: men with a maximum primary education are four times more likely to die than those who are higher educated [RII = 4.09 (2.78-6.03)]. Among women, no social gradient is observed in either period, but a clear split between the lowest educated and other educational groups is apparent in the 2000s. There is a positive evolution towards lower mortality among adolescents and young adults, but educational inequalities remain a public health concern.

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

BackgroundPrevious studies have shown that mortality inequalities are smaller in Italy than in most European countries. This may be due to the weak association between socioeconomic status and smoking in...

Trends in educational inequalities in mortality, seven types of cancers, Norway 1971-2002

Knowledge about educational disparities in deaths from specific cancer sites is incomplete. Even more scant is information about time trends in educational patterns in specific cancer mortality. This study examines educational inequalities in Norway 1971-2002 for mortality in lung and larynx, colorectal, stomach, melanoma, prostate, breast and cervix uteri cancer. A data file encompassing all Norwegian inhabitants registered some time during 1971-2002 while aged 45-74 was constructed with linked information from administrative registers. During an exposure of more than 40 millions person-years, about 87,000 deaths in the analysed cancer types were registered. Absolute and relative inequalities during three periods were analysed by age-standardized deaths rates, hazard regression odds ratios and Relative Index of Inequality. Educational inequalities in lung and related cancer mortality widened considerably from the 1970s to the 1990s for both sexes. The moderate educational gradient for stomach and cervix uteri cancer persisted, as did the weak gradient for colorectal cancer. No educational differences in prostate cancer were observed in any of the time periods. The modest inverse educational gradients in deaths from breast cancer and melanoma remained at the same level. Among the seven cancer types examined in this study, only lung cancer mortality showed a clear widening in educational disparities. As lung cancer mortality constitutes a large proportion of all cancer deaths, this increase may result in larger disparities for overall cancer mortality. Some explanations for the observed patterns in cancer mortality are suggested.

Educational inequalities in mortality and associated risk factors: German- versus French-speaking Switzerland

BackgroundBetween the French- and German-speaking areas of Switzerland, there are distinct differences in mortality, similar to those between Germany and France. Assessing corresponding inequalities may elucidate variations in mortality and risk factors, thereby uncovering public health potential. Our aim was to analyze educational inequalities in all-cause and cause-specific mortality in the two Swiss regions and to compare this with inequalities in behavioural risk factors and self-rated health.MethodsThe Swiss National Cohort, a longitudinal census-based record linkage study, provided mortality and survival time data (3.5 million individuals, 40-79 years, 261,314 deaths, 1990-2000). The Swiss Health Survey 1992/93 provided cross-sectional data on risk factors. Inequalities were calculated as percentage of change in mortality rate (survival time, hazard ratio) or risk factor prevalence (odds ratio) per year of additional education using multivariable Cox and logistic regression.ResultsSignificant inequalities in mortality were found for all causes of death in men and for most causes in women. Inequalities were largest in men for causes related to smoking and alcohol use and in women for circulatory diseases. Gradients in all-cause mortality were more pronounced in younger and middle-aged men, especially in German-speaking Switzerland. Mortality inequalities tended to be larger in German-speaking Switzerland whereas inequalities in associated risk factors were generally more pronounced in French-speaking Switzerland.ConclusionsWith respect to inequalities in mortality and associated risk factors, we found characteristic differences between German- and French-speaking Switzerland, some of which followed gradients described in Europe. These differences only partially reflected inequalities in associated risk factors.

Does Educational Status Impact Adult Mortality in Denmark? A Twin Approach

To disentangle an independent effect of educational status on mortality risk from direct and indirect selection mechanisms, the authors used a discordant twin pair design, which allowed them to isolate the effect of education by means of adjustment for genetic and environmental confounding per design. The study is based on data from the Danish Twin Registry and Statistics Denmark. Using Cox regression, they estimated hazard ratios for mortality according to the highest attained education among 5,260 monozygotic and 11,088 dizygotic same-sex twin pairs born during 1921–1950 and followed during 1980–2008. Both standard cohort and intrapair analyses were conducted separately for zygosity, gender, and birth cohort. Educational differences in mortality were demonstrated in the standard cohort analyses but attenuated in the intrapair analyses in all subgroups but men born during 1921–1935, and no effect modification by zygosity was observed. Hence, the results are most compatible with an effect of early family environment in explaining the educational inequality in mortality. However, large educational differences were still reflected in mortality risk differences within twin pairs, thus supporting some degree of independent effect of education. In addition, the effect of education may be more pronounced in older cohorts of Danish men.

Socioeconomic inequalities in cause specific mortality among older people in France

BackgroundEuropean comparative studies documented a clear North-South divide in socioeconomic inequalities with cancer being the most important contributor to inequalities in total mortality among middle aged men in Latin Europe (France, Spain, Portugal, Italy). The aim of this paper is to investigate educational inequalities in mortality by gender, age and causes of death in France, with a special emphasis on people aged 75 years and more.MethodsWe used data from a longitudinal population sample that includes 1% of the French population. Risk of death (total and cause specific) in the period 1990-1999 according to education was analysed using Cox regression models by age group (45-59, 60-74, and 75+). Inequalities were quantified using both relative (ratio) and absolute (difference) measures.ResultsRelative inequalities decreased with age but were still observed in the oldest age group. Absolute inequalities increased with age. This increase was particularly pronounced for cardiovascular diseases. The contribution of different causes of death to absolute inequalities in total mortality differed between age groups. In particular, the contribution of cancer deaths decreased substantially between the age groups 60-74 years and 75 years and more, both in men and in women.ConclusionsThis study suggests that the large contribution of cancer deaths to the excess mortality among low educated people that was observed among middle aged men in Latin Europe is not observed among French people aged 75 years and more. This should be confirmed among other Latin Europe countries.

Educational inequalities in mortality over four decades in Norway: prospective study of middle aged men and women followed for cause specific mortality, 1960-2000

Objectives To determine the extent to which educational inequalities in relation to mortality widened in Norway during 1960-2000 and which causes of death were the main drivers of this disparity.Design...

Educational inequalities in avoidable mortality in Europe

BackgroundThe magnitude of educational inequalities in mortality avoidable by medical care in 16 European populations was compared, and the contribution of inequalities in avoidable mortality to educational inequalities in life...

Educational inequalities in mortality in four Eastern European countries: divergence in trends during the post-communist transition from 1990 to 2000

Post-communist transition has had a huge impact on mortality in Eastern Europe. We examined how educational inequalities in mortality changed between 1990 and 2000 in Estonia, Lithuania, Poland and Hungary. Cross-sectional data for the years around 1990 and 2000 were used. Age-standardized mortality rates and mortality rate ratios (for total mortality only) were calculated for men and women aged 35-64 in three educational categories, for five broad cause-of-death groups and for five (seven among women) specific causes of death. Educational inequalities in mortality increased in all four countries but in two completely different ways. In Poland and Hungary, mortality rates decreased or remained the same in all educational groups. In Estonia and Lithuania, mortality rates decreased among the highly educated, but increased among those of low education. In Estonia and Lithuania, for men and women combined, external causes and circulatory diseases contributed most to the increasing educational gap in total mortality. Different trends were observed between the two former Soviet republics and the two Central Eastern European countries. This divergence can be related to differences in socioeconomic development during the 1990s and in particular, to the spread of poverty, deprivation and marginalization. Alcohol and psychosocial stress may also have been important mediating factors.

Commentary: Why are we biased against bias?

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Cause-of-Death Contributions to Educational Inequalities in Mortality in Austria between 1981/1982 and 1991/1992

This article uses census records and deaths records to analyze trends in educational inequalities in mortality for Austrian women and men aged 35–64 years between 1981/1982 and 1991/1992. We find an increasing gradient in mortality by education for circulatory diseases and especially ischaemic heart disease. Respiratory diseases and, in addition for women, cancers showed the opposite trend. Using decomposition analysis, we give evidence that in many cases changes in the age-structure within the 10-year interval had a bigger effect than direct improvements in mortality on the analyzed subpopulations.

Educational inequalities in mortality among Israeli Jews: Changes over time in a dynamic population

Changes in educational inequalities in mortality in a country that underwent a sudden population growth were examined using two census-based longitudinal studies from Israel (I, 1983–1992, n=152,150 and II, 1995–2004, n=209,125). Relative changes in educational inequalities in mortality were assessed using mortality rates and odds ratios and their corresponding 95% confidence intervals. Decreases in mortality rates and widening relative educational inequalities in mortality were seen over time. Among recent immigrants, educational inequalities in mortality existed but to a lesser degree than for residents. The widening gap (2.5-fold) in cardiovascular disease mortality risks observed for low versus high educated middle-aged women, was particularly alarming. The observed decreasing mortality rates, indicative of a healthier society, alongside widening educational inequalities in mortality indicates uneven changes within the population.

The contribution of smoking to inequalities in mortality by education varies over time and by sex: two national cohort studies, 1981–84 and 1996–99

The contributions of tobacco smoking to overall mortality and socioeconomic inequalities in mortality vary between populations and over time. We determined how these contributions varied by sex and over time in two national New Zealand cohort studies. Poisson regression and modelling were conducted on linked census-mortality cohorts for people aged 45-74 years in 1981-84 and 1996-99 (2.0 and 2.7 million person-years, respectively). Contribution to socioeconomic inequalities in mortality. Adjusting for current and former smoking reduced the all-cause mortality rate ratios for men with nil educational qualifications compared with men with post-school qualifications from 1.34 to 1.29 in 1981-84 and from 1.31 to 1.25 in 1996-99, or 16 and 21% reductions in relative inequalities. Equivalent results for women were 1.42-1.41 in 1981-84 and 1.42-1.37 in 1996-99, or 3 and 11% reductions in relative inequalities. Contribution to overall mortality. Using 1996-99 data, we estimated that if all current smokers quit and became ex-smokers, mortality rates would reduce by 11% for men and 5% for women. If everyone was a never smoker (i.e. a historically smoke-free society), mortality rates would have been 26% lower for men and 25% lower for women. The contribution of smoking to educational inequalities in mortality was greater for males, and increased over time for both males and females, reflecting the historically differential phasing of the tobacco epidemic by sex and socioeconomic position. Complete cessation of smoking in contemporary New Zealand would reduce both overall mortality and educational inequalities in mortality.

Health inequalities in Korea: age- and sex-specific educational differences in the 10 leading causes of death

An ideological climate has persisted in Korea that has discouraged public discussion of social inequalities. Thus studies on inequalities in mortality remain undeveloped. This study is to examine age- and cause-specific socioeconomic mortality differentials for both men and women representative of the Korean population. Using Korea's 1995 Census and 1995-2000 Death Certificate data, age-, sex-, and education-specific mortality rates were measured, after which education-specific rate ratios, and relative indices of inequality were calculated. Graded educational differentials in mortality were observed among both sexes with higher mortality rates related to lower educational attainment in most causes of death. However, positive associations were identified between education levels and mortality rates with respect to ischaemic heart disease among older males and breast cancer among older females. The magnitude of educational inequality in mortality was not constant across causes and in some cases differed by sex. The changing relation between educational attainment and mortality rates from ischaemic heart disease and breast cancer likely reflects changes in the social distribution of risk factors that emerged in the process of Korea's rapid economic development. Studies on specific exposures over the life course influencing the occurrence of and survival after specific diseases would help provide a more complete understanding of patterns and trends in socioeconomic mortality differentials in Korea.