Inequalities In Cause-specific Mortality Research Articles

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.

Health inequalities in cause-specific mortality in Costa Rica: a population-based cohort study.

To analyze health inequalities in cause-specific mortality in Costa Rica from 2010 to 2018, observing the main causes for inequality in the country. The National Electoral Rolls were used to follow-up all Costa Rican adults aged 20 years or older from 2010 to 2018 (n = 2,739,733) in an ecological study. A parametric survival model based on the Gompertz distribution was performed and the event death was classified according to the ICD-10. After adjustment for urbanicity, the poorest districts had a higher mortality than the wealthier districts for most causes of death except neoplasms, mental and behavioral disorders, and diseases of the nervous system. Urban districts showed significantly higher mortality than mixed and rural districts after adjustment for wealth for most causes except mental and behavioral disorders, diseases of the nervous system, and diseases of the respiratory system. Differences according to wealth were more frequent in women than men, whereas differences according to urbanicity were more frequent in men than in women. The study's findings were consistent, but not fully similar, to the international literature.

Long-term trends in urban-neighbourhood inequalities in cause-specific mortality and hospitalisation – multilevel analyses among individuals nested in Finnish post-code areas, 1991–2018

BackgroundHigh-income countries yield mixed evidence concerning the long-term trends of neighbourhood inequalities in health outcomes. The reasons why these inequalities persist and the factors driving any changes over time remain unclear. We analysed trends in general neighbourhood differences in mortality and hospitalisation, compared specific area-level and individual-level income effects, and assessed whether area-level effects were attributable to the neighbourhood population composition. MethodsThis prospective cohort study used individual-level register-linked information on sociodemographic factors covering the total population of 20–64-year-olds living in Finnish cities at the beginning of seven four-year periods in 1991–2018 (N = 952,493–1,200,431). We used random-effects Poisson models to assess all-cause and external mortality and hospitalisations among individuals nested in postal-code areas. ResultsThe general contextual effect of the neighbourhood on all-cause mortality and hospitalisation was stable across time, with a median incidence-rate ratio of around 1.20–1.30, and it was mainly attributable to the population's composition. The association between area-level income and both mortality and hospitalisation was also robust and increased slightly even after accounting for population composition. The lowest neighbourhood income quintile in 2015–2018 had 15% (95% CI:5–26%) and 30% (95% CI:15–47%) excess mortality among men and women, respectively. These differentials were particularly large for external causes, but all area-level income associations were much smaller than the corresponding individual-level associations. ConclusionThe overall relevance of the neighbourhood context to mortality and hospitalisation was stable across time, and generally attributable to population composition. However, there were substantial relative area-level income disparities between neighbourhoods, which had grown over time.

Maternal socioeconomic position and inequity in child deaths: An analysis of 2012 South Korean birth cohort of 466,636 children

BackgroundInequalities in child mortality occur via interactions between socio-environmental factors and their constituents. Through childhood developmental stages, we can observe changing patterns of mortality. By investigating these patterns and social inequalities by cause and developmental stage, we aim to gain insights into health policies to reduce and equalize childhood mortality. MethodsUsing vital statistics, we examined the Korean birth cohort of 2012, including all children born in 2012 up to five years of age (N = 466,636). The dependent variables were all-cause and cause-specific mortality by developmental stage (i.e., neonatal, post-neonatal, and childhood). A Cox proportional hazard regression model was built to compare child mortality according to maternal education. The distribution of inequalities in cause-specific mortality by child age was calculated using the slope index of inequality (SII). ResultsInequalities in child mortality due to maternal education occur during the neonatal period and increase over time. After adjusting for covariates, the Cox proportional hazard models showed that “injury and external causes” (HR = 2.178; 95% CI = [1.283–3.697]) and “unknown causes” (HR = 2.299; 95% CI = [1.572–3.363]) in the post-neonatal period, and “injury and external causes” (HR = 2.153; 95% CI = [1.347–3.440]) in the childhood period significantly contributed to socioeconomic inequalities in child mortality. For each period, the leading causes of inequality were identified as follows: “congenital” (96.7%) for the neonatal period, “unknown causes” (58.2%) and “injury and external causes” (28.4%) for the post-neonatal period, and “injury and external causes” (56.5%) for the childhood period. ConclusionWe confirmed that the main causes of death in mortality inequality vary according to child age, in accordance with the distinctive context of child development. Strengthening the health system and multisectoral efforts that consider families' and children's needs according to spatial contexts (e.g., home, community) may be necessary to address the social inequalities in child health.

Impact of COVID-19 pandemic on inequalities in mortality: an analysis in Piedmont and Emilia-Romagna

Abstract Background Italy was heavily hit by the COVID-19 pandemic. According to official statistics, during 2020 there were more than 75,000 excess deaths compared to the average expected mortality in 2015-2019. General mortality (GM) is a good measure of both the direct and indirect effects of the pandemic because it's exempt from potential bias due to misclassification of events. Evidence shows a greater burden of disease and mortality attributable to COVID-19 among disadvantaged populations, with the risk of an exacerbation of existing health inequalities. We aim to analyse the trend of social inequalities in mortality during the first pandemic year in two Italian regions (Piedmont and Emilia-Romagna) using data from Administrative Population Registries (APR) and statistical databases. Methods Data on deaths occurred between Jan 2015 and Jan 2021 in subjects ≥65, stratified by educational level, were obtained from Regional APR and the Census. Using a time series approach, we computed Standardized Mortality Rates (SMR), Relative Index of Inequalities (RII) and Slope Index of Inequalities (SII), adjusted by age, gender, month and region. SMR, RII and SII from March 2020 were forecasted using Holt-Winters method and compared to the observed values in the same period. Results SMRs were higher than expected during the two 2020 epidemic waves (Mar-Apr, Oct-Dec) in both regions. RII didn't increase significantly. Absolute inequalities instead rose in Piedmont during both pandemic waves, mostly among women, and in Emilia-Romagna in March among men. Conclusions The impact of the pandemic on inequalities in GM has been at least of the same size of the impact of other mechanisms of unequal mortality. APR coupled with sociodemographic data are a quick and reliable source for assessing the unequal impact of the COVID-19 pandemic on health. Further research is needed to explore mechanisms underlying these effects e.g. inequalities in cause-specific mortality and access to health services. Key messages

Education-related inequalities in cause-specific mortality: first estimates for Australia using individual-level linked census and mortality data.

BackgroundSocioeconomic inequalities in mortality are evident in all high-income countries, and ongoing monitoring is recommended using linked census-mortality data. Using such data, we provide the first estimates of education-related inequalities in cause-specific mortality in Australia, suitable for international comparisons.MethodsWe used Australian Census (2016) linked to 13 months of Death Registrations (2016–17). We estimated relative rates (RR) and rate differences (RD, per 100 000 person-years), comparing rates in low (no qualifications) and intermediate (secondary school) with high (tertiary) education for individual causes of death (among those aged 25–84 years) and grouped according to preventability (25–74 years), separately by sex and age group, adjusting for age, using negative binomial regression.ResultsAmong 13.9 M people contributing 14 452 732 person-years, 84 743 deaths occurred. All-cause mortality rates among men and women aged 25–84 years with low education were 2.76 [95% confidence interval (CI): 2.61–2.91] and 2.13 (2.01–2.26) times the rates of those with high education, respectively. We observed inequalities in most causes of death in each age-sex group. Among men aged 25–44 years, relative and absolute inequalities were largest for injuries, e.g. transport accidents [RR = 10.1 (5.4–18.7), RD = 21.2 (14.5–27.9)]). Among those aged 45–64 years, inequalities were greatest for chronic diseases, e.g. lung cancer [men RR = 6.6 (4.9–8.9), RD = 57.7 (49.7–65.8)] and ischaemic heart disease [women RR = 5.8 (3.7–9.1), RD = 20.2 (15.8–24.6)], with similar patterns for people aged 65–84 years. When grouped according to preventability, inequalities were large for causes amenable to behaviour change and medical intervention for all ages and causes amenable to injury prevention among young men.ConclusionsAustralian education-related inequalities in mortality are substantial, generally higher than international estimates, and related to preventability. Findings highlight opportunities to reduce them and the potential to improve the health of the population.

Using Linked Whole-Of-Population Data to Estimate Education-Related Inequalities in Cause-Specific Mortality in Australia

IntroductionOfficial Australian estimates of socioeconomic inequalities in cause-specific mortality have been based on area-level socioeconomic measures. Using area-level measures is known to underestimate inequalities.
 Objectives and ApproachUsing recently released census linked to mortality data, we estimate education-related inequalities in cause-specific mortality for Australia. We used 2016 Australian Census and Death Registration data (2016-17) linked via a Person Linkage Spine (linkage rates: 92% and 97%, respectively) from the Multi-Agency Data Integration Project (MADIP). Education, from the Census, was categorised as low (no secondary school graduation or other qualification), intermediate (secondary graduation with/without other non-tertiary qualifications) and high (tertiary qualification). Cause of death was coded according to the underlying cause of death using the ICD-10. We used negative binomial regression to estimate relative rates (RR) for cause-specific mortality at ages 25-84 years, in the 12-months following Census, comparing low vs high education, separately by sex and 20-year age group, adjusting for age.
 Results80,317 deaths occurred among 13,856,202 people. For those aged 25-44 years, relative inequalities were large for causes related to injury and smaller for lesspreventable deaths (e.g. for men, suicide RR=5.6, 95%CI: 4.1-7.5 and brain cancer RR=1.3, 0.6-3.1). For those aged 45-64, inequalities were large for causes related to health behaviours and amenable to medical intervention, e.g. lung cancer (men RR= 6.4, 4.7-8.8) and ischaemic heart disease (women RR=5.0, 3.2-7.7), and were small for less preventable causes e.g. brain cancer (women RR=0.9, 0.6-1.3). Patterns among those aged 65-84years were similar to those aged 45-64 years.
 Conclusion / ImplicationsIn Australia, inequalities in mortality are substantial. Our findings highlight the health burden from inequalities, opportunities for prevention and provide insights on targets to effectively reduce them.

Deaths of despair: cause-specific mortality and socioeconomic inequalities in cause-specific mortality among young men in Scotland

BackgroundIncreasing mortality among men from drugs, alcohol and suicides is a growing public health concern in many countries. Collectively known as “deaths of despair”, they are seen to stem from unprecedented economic pressures and a breakdown in social support structures.MethodsWe use high-quality population wide Scottish data to calculate directly age-standardized mortality rates for men aged 15–44 between 1980 and 2018 for 15 leading causes of mortality. Absolute and relative inequalities in mortality by cause are calculated using small-area deprivation and the slope and relative indices of inequality (SII and RIIL) for the years 2001–2018.ResultsSince 1980 there have been only small reductions in mortality among men aged 15–44 in Scotland. In that period drug-related deaths have increased from 1.2 (95% CI 0.7–1.4) to 44.9 (95% CI 42.5–47.4) deaths per 100,000 and are now the leading cause of mortality. Between 2001 and 2018 there have been small reductions in absolute but not in relative inequalities in all-cause mortality. However, absolute inequalities in mortality from drugs have doubled from SII = 66.6 (95% CI 61.5–70.9) in 2001–2003 to SII = 120.0 (95% CI 113.3–126.8) in 2016–2018. Drugs are the main contributor to inequalities in mortality, and together with alcohol harm and suicides make up 65% of absolute inequalities in mortality.ConclusionsContrary to the substantial reductions in mortality across all ages in the past decades, deaths among young men are increasing from preventable causes. Attempts to reduce external causes of mortality have focused on a single cause of death and not been effective in reducing mortality or inequalities in mortality from external causes in the long-run. To reduce deaths of despair, action should be taken to address social determinants of health and reduce socioeconomic inequalities.

Inequalities in cause-specific mortality in children and adolescents in the Moramanga health survey, Madagascar.

One child or young adolescent dies every 10min in Madagascar and large disparities in survival persist. We estimated cause-specific mortality in a cohort of children aged 0-14 in the Moramanga district and explored how causes of death shape these inequalities. Children were followed prospectively between 2012 and 2017. Causes of death were established based on verbal autopsies. Incidence rate ratios were estimated in Poisson regression models. The risk of dying before age 15 was 68.1 per thousand live births. Risks of dying were highest in the first year of life (31.2‰) and lowest in children aged 10-14 (6.4‰). The male-to-female sex ratios of mortality increased with age and reached 2.3 among adolescents aged 10-14. Communicable, nutritional and neonatal causes accounted for 79.5% of deaths below age 5 and 47.0% above age 5. Mortality was positively associated with household poverty, lack of education of the household head, and rural residence. Interventions should be designed with an equity lens to reduce large disparities in survival and be tailored to the needs of each age-group.

A Social History of Disease: Contextualizing the Rise and Fall of Social Inequalities in Cause-Specific Mortality.

Fundamental cause theory posits that social inequalities in health arise because of unequal access to flexible resources, including knowledge, money, power, prestige, and beneficial social connections, which allow people to avoid risk factors and adopt protective factors relevant in a particular place. In this study, we posit that diseases should also be put into temporal context. We characterize diseases as transitioning through four stages at a given time: (1) natural mortality, characterized by no knowledge about risk factors, preventions, or treatments for a disease in a population; (2) producing inequalities, characterized by unequal diffusion of innovations; (3) reducing inequalities, characterized by increased access to health knowledge; and (4) reduced mortality/disease elimination, characterized by widely available prevention and effective treatment. For illustration, we pair an ideal-types analysis with mortality data to explore hypothesized incidence rates of diseases. Although social inequalities exist in incidence rates of many diseases, the cause, extent, and direction of inequalities change systematically in relation to human intervention. This article highlights opportunities for further development, specifically highlighting the role of stage duration in maintaining social inequalities in cause-specific mortality.

The arithmetic of reducing relative and absolute inequalities in health: a theoretical analysis illustrated with European mortality data

BackgroundReducing inequalities in health is a great challenge for public health, but how relative and absolute inequalities in mortality respond to changes in mortality by socioeconomic group is not well...

Mortality rates by occupation in Korea: a nationwide, 13-year follow-up study

ObjectiveThe present study sought to identify inequalities in cause-specific mortality across different occupational groups in Korea.MethodsThe cohort included Korean workers enrolled in the national employment insurance programme between 1995 and...

Socioeconomic inequalities in cause-specific mortality in 15 European cities

BackgroundSocioeconomic inequalities are increasingly recognised as an important public health issue, although their role in the leading causes of mortality in urban areas in Europe has not been fully evaluated....

Socioeconomic inequalities in cause-specific mortality after disability retirement due to different diseases

Socioeconomic inequalities in both disability retirement and mortality are large. The aim of this study was to examine socioeconomic differences in cause-specific mortality after disability retirement due to different diseases. We used administrative register data from various sources linked together by Statistics Finland and included an 11% sample of the Finnish population between the years 1987 and 2007. The data also include an 80% oversample of the deceased during the follow-up. The study included men and women aged 30-64 years at baseline and those who turned 30 during the follow-up. We used Cox regression analysis to examine socioeconomic differences in mortality after disability retirement. Socioeconomic differences in mortality after disability retirement were smaller than in the population in general. However, manual workers had a higher risk of mortality than upper non-manual employees after disability retirement due to mental disorders and cardiovascular diseases, and among men also diseases of the nervous system. After all-cause disability retirement, manual workers ran a higher risk of cardiovascular and alcohol-related death. However, among men who retired due to mental disorders or cardiovascular diseases, differences in social class were found for all causes of death examined. For women, an opposite socioeconomic gradient in mortality after disability retirement from neoplasms was found. Conclusions: The disability retirement process leads to smaller socioeconomic differences in mortality compared with those generally found in the population. This suggests that the disability retirement system is likely to accurately identify chronic health problems with regard to socioeconomic status.

Trends in educational inequalities in cause specific mortality in Norway from 1960 to 2010: a turning point for educational inequalities in cause specific mortality of Norwegian men after the millennium?

BackgroundEducational inequalities in total mortality in Norway have widened during 1960–2000. We wanted to investigate if inequalities have continued to increase in the post millennium decade, and which causes of deaths were the main drivers.MethodsAll deaths (total and cause specific) in the adult Norwegian population aged 45–74 years over five decades, until 2010 were included; in all 708,449 deaths and over 62 million person years. Two indices of inequalities were used to measure inequality and changes in inequalities over time, on the relative scale (Relative Index of Inequality, RII) and on the absolute scale (Slope Index of Inequality, SII).ResultsRelative inequalities in total mortality increased over the five decades in both genders. Among men absolute inequalities stabilized during 2000–2010, after steady, significant increases each decade back to the 1960s, while in women, absolute inequalities continued to increase significantly during the last decade. The stabilization in absolute inequalities among men in the last decade was mostly due to a fall in inequalities in cardiovascular disease (CVD) mortality and lung cancer and respiratory disease mortality. Still, in this last decade, the absolute inequalities in cause-specific mortality among men were mostly due to cardiovascular diseases (CVD) (34% of total mortality inequality), lung cancer and respiratory diseases (21%). Among women the absolute inequalities in mortality were mostly due to lung cancer and chronic lower respiratory tract diseases (30%) and CVD (27%).ConclusionsIn men, absolute inequalities in mortality have stopped increasing, seemingly due to reduction in inequalities in CVD mortality. Absolute inequality in mortality continues to widen among women, mostly due to death from lung cancer and chronic lung disease. Relative educational inequalities in mortality are still on the rise for Norwegian men and women.

Socio-economic Inequalities in Cause-specific Mortality: A 16-year Follow-up Study

To examine socio-economic inequalities in cause-specific mortality by examining the independent effects of education, occupation and income in a population-based study of working-age Canadian adults. This is a secondary analysis of data from the 1991-2006 Canadian Census mortality and cancer follow-up study (n=2.7 million persons). For this analysis, the cohort was restricted to 2.3 million persons aged 25 to 64 at cohort inception, of whom 164,332 died during the follow-up period. Hazard ratios were calculated by educational attainment (4 levels), occupational skill (6 categories) and income adequacy (5 quintiles) for all-cause mortality and major causes of death. Models were run separately for men and women, controlled for multiple variables simultaneously, and some were stratified by 10-year age cohorts. The magnitude of socio-economic inequalities in mortality differed by indicator of socio-economic position (education, occupation, or income), age group, sex, and cause of death. Compared to age-adjusted models, hazard ratios were attenuated but remained significant in models that adjusted for both age and all three indicators of socio-economic position simultaneously. Socio-economic inequalities in mortality were evident for most of the major causes of death examined. This study demonstrates that education, occupation and income were each independently associated with mortality and were not simply proxies for each other. When evaluating socio-economic inequalities in mortality, it is important to use different indicators of socio-economic position to provide a more complete picture.

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

BackgroundMonitoring the time trends in socioeconomic inequalities in mortality by cause is a key public health issue. The aim of this study was to compare methods to measure social inequalities in cause-specific mortality in the French population aged 25–55years. More specifically, it compares bias and precision related to the use of occupational class declared at the last census (linked data) to the one declared at the time of death on the death certificate (unlinked data). MethodsWe used a representative sample of 1% of the French population. Causes of death were obtained by direct linkage with the French national death registry. Occupational class was classified into eight categories. Taking professionals and managers as the reference, relative risks of mortality by cause and their 95% confidence intervals were estimated using Poisson models for the 1983–1989, 1991–1997, and 2000–2006 periods. The relative risks were calculated with both linked data and exhaustive unlinked data. ResultsOver the 2000–2006 period, occupational classes declared at census and on the death certificate were consistent for half of the deaths. Relative risks for manual workers were found to be similar between the two approaches over the 1983–1989 and 1991–1997 periods, and higher for the unlinked approach over the 2000–2006 period. Over the latter period, the order and magnitude of relative risks varied similarly by occupational class and cause of death for both approaches. Confidence intervals obtained from linked data were wide. ConclusionOccupational class derived from the death certificate must be used with caution as a measure for epidemiological purposes and the available linked data do not allow accurate estimates of social inequalities in cause-specific mortality. Other solutions should be considered in order to improve the follow-up of social inequalities in mortality. This would require the collection of educational level on the death certificate or the linkage of the cause of death database with other exhaustive and informative databases.

Social Inequalities and Mortality in Europe – Results from a Large Multi-National Cohort

BackgroundSocio-economic inequalities in mortality are observed at the country level in both North America and Europe. The purpose of this work is to investigate the contribution of specific risk factors to social inequalities in cause-specific mortality using a large multi-country cohort of Europeans.MethodsA total of 3,456,689 person/years follow-up of the European Prospective Investigation into Cancer and Nutrition (EPIC) was analysed. Educational level of subjects coming from 9 European countries was recorded as proxy for socio-economic status (SES). Cox proportional hazard model's with a step-wise inclusion of explanatory variables were used to explore the association between SES and mortality; a Relative Index of Inequality (RII) was calculated as measure of relative inequality.ResultsTotal mortality among men with the highest education level is reduced by 43% compared to men with the lowest (HR 0.57, 95% C.I. 0.52–0.61); among women by 29% (HR 0.71, 95% C.I. 0.64–0.78). The risk reduction was attenuated by 7% in men and 3% in women by the introduction of smoking and to a lesser extent (2% in men and 3% in women) by introducing body mass index and additional explanatory variables (alcohol consumption, leisure physical activity, fruit and vegetable intake) (3% in men and 5% in women). Social inequalities were highly statistically significant for all causes of death examined in men. In women, social inequalities were less strong, but statistically significant for all causes of death except for cancer-related mortality and injuries.DiscussionIn this European study, substantial social inequalities in mortality among European men and women which cannot be fully explained away by accounting for known common risk factors for chronic diseases are reported.

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.

Heterogeneity by age in educational inequalities in cause-specific mortality in women in the Region of Madrid

Background:Within Europe, women in the southern regions have the lowest inequalities in mortality. This study evaluates inequalities in mortality from different causes by educational level and their contribution to total...