Social Class Differences In Mortality Research Articles

Life course research: new opportunities for establishing social and biological plausibility

Life course research on health and disease has reached a new stage in exploring the social-to-biological transition. Large longitudinal datasets containing sociodemographic and socioeconomic characteristics, self-reported health assessments, psychological and biological data are coming into maturation and being made available to researchers. Some examples are the Survey of Health, Ageing and Retirement in Europe (SHARE), the UK Household longitudinal study (Understanding Society), The Longitudinal Aging Study Amsterdam (LASA), and linked registry data sets (particularly in Scandinavia). Consequently, questions around how environmental factors (in the broadest sense including social, psychosocial, behavioural, physical, etc.) lead to biological alterations over time can now be investigated on a wider scale, and in a variety of contexts and disciplines. Such work might also lead to a better understanding of the social structure of such social-to-biological mechanisms across the life course. The field of life course research is interdisciplinary by construction, stemming from different traditions. Since the 1990s, life course research on health topics developed in parallel within the fields of demography, such as in Wunch et al.’s (1996) work on unfavourable life course states and mortality; in epidemiology, where the importance of childhood circumstances for future health was highlighted by Mann et al. (1992); and in sociology via pivotal research on intergenerational social mobility and transmission (Erikson and Goldthorpe 1992, 2002). An interdisciplinary field of life course research has emerged from collaborations between these disciplines and others (Richter and Blane 2013). Given these strong traditions, life course research is well placed to establish both social and biological plausibility in hypothesis testing (Mayer 2009). While the literature has now established the associations between measures of the socioeconomic environment and subsequent morbidity and mortality, the specific pathways along which these associations are likely to operate need to be disentangled. A growing body of research hypotheses on the specific pathways that may operate between different environmental factors and biological embodiment can be identified and tested, informing deductive methods and the rejection of hypotheses or formulation of new ones (Blane et al. 2013). Recent examples of this type of research can be found in a previous issue of this journal. Hypotheses were put forward on central-nervous-system-mediated (or psychosocial) mechanisms around the development of cancers from early Michelle Kelly-Irving is a social epidemiologist working for the French institute for health and medical research (INSERM). She is based at a research unit in Toulouse, in the South West of France and her main research focus is on the social determinants of health inequalities from early life onwards. Silke Tophoven is a sociologist and research associate at the Institute for Employment Research in Nuremberg, Germany. She is interested in research on the relationship between work and health, with a special focus on women and ageing societies. David Blane has a background in medicine and sociology. He is professor emeritus of Imperial College London and professorial research associate of University College London. His research interests include social class differences in mortality, life course studies and social gerontology.

Time Trends in Social Class Mortality Differentials in the Netherlands, 1820-1920: An Assessment Based on Indirect Estimation Techniques

The question whether socioeconomic status gradients in adult mortality have changed over a broad historical period has become an important political and theoretical issue but is hard to test. In this article we study long-term trends in social inequality in adult mortality by using data for 2 (of the 11) provinces of the Netherlands for the period 1812–1922. We apply indirect estimation techniques, which have been developed for the analysis of mortality patterns in countries with deficient data. Our article shows that indeed there was a clear social class gradient in mortality, with the elite having higher survival chances between ages 35 and 55 than the middle class and farmers. Differences were even more apparent in comparison with workers. Over time there was a strong convergence among social classes in mortality levels. The implications of our results for the dominant views on the change in living standards in the past are discussed.

Time Trends in Social Class Mortality Differentials in the Netherlands, 1820–1920

The question whether socioeconomic status gradients in adult mortality have changed over a broad historical period has become an important political and theoretical issue but is hard to test. In this article we study long-term trends in social inequality in adult mortality by using data for 2 (of the 11) provinces of the Netherlands for the period 1812–1922. We apply indirect estimation techniques, which have been developed for the analysis of mortality patterns in countries with deficient data. Our article shows that indeed there was a clear social class gradient in mortality, with the elite having higher survival chances between ages 35 and 55 than the middle class and farmers. Differences were even more apparent in comparison with workers. Over time there was a strong convergence among social classes in mortality levels. The implications of our results for the dominant views on the change in living standards in the past are discussed.

Effect of living conditions in the parental home and youth paths on the social class differences in mortality among women

A longitudinal study was undertaken to assess the effects of parental home and youth paths on the adult social class differences in mortality among women. The study used population registration data on all Finnish women aged 30-34 in 1990 for whom information on their childhood characteristics and youth paths were available from the 1970, 1975, 1980, 1985, and 1990 censuses. Cause of death follow-up was for the period 1991-98 (1185 deaths). Adjusting for parental social class, family type, and number of siblings attenuated the effects of adult social class on cardiovascular disease mortality by 27%; for all external causes this attenuation was negligible. Educational, marital, and employment paths accounted for a substantial part (30-85%) of the social class differences in mortality for all specific causes of death. Although living conditions in the parental home were associated with mediating life trajectories in youth their effect on adult social class differences in mortality was moderate. Youth paths have a pervasive influence on mortality risks and social class differences in mortality in middle adulthood.

Life-course experiences and mortality by adult social class among young men

Circumstances over the life-course may contribute to adult social class differences in mortality. However, it is only rarely that the life-course approach has been applied to mortality studies among young adults. The aim of this study is to determine to what extent social class differences in mortality among young Finnish men are explained by living conditions in the parental home and life paths related to transitions in youth. The data for males born in 1956–60 based on the 1990 census records are linked with death records (3184 deaths) by cause of death for 1991–98, and with information on life-course circumstances from the 1970, 1975, 1980, and 1985 censuses. Controlling for living conditions in the parental home—social class, family type, number of siblings, language and region of residence—reduced the high excess mortality of the lower non-manual (RR 1.51, 95% CI: 1.28–1.79), skilled manual (RR 2.94, 2.54–3.40), and unskilled manual class (RR 4.08, 3.51–4.73) by 10% in all-cause mortality. The equivalent reduction for cardiovascular disease was 28% and for alcohol-related causes 16%. The effect of parental home on mortality differences was mainly mediated through its effect on youth paths (pathway model). Educational, marital, and employment paths had a substantial effect—independent of parental home—on social class differences from various causes of death. When all these variables were controlled for adult social class differences in cause specific mortality were reduced by 75–86%. Most of this reduction in mortality differences can be attributed to educational path. However, marital and employment paths had their independent effects, particularly on the excess mortality of unskilled manual workers with disproportionately common exposure to long-term unemployment and living without a partner. In summary, social class differences in total mortality among men in their middle adulthood were only partly determined by parental home but they were mainly attributable to educational, marital, and employment paths in youth.

From past to present. Effect of lifecourse on mortality, and social class differences in mortality in middle adulthood

Social class differences in mortality are larger in middle adulthood than at any other time of life. Circumstances over the lifecourse may contribute to these adult social class differences. However, it is only rarely that the lifecourse approach has been applied to mortality studies among persons in their middle adulthood. The aim of this thesis is to disentangle the effects of the living conditions in the parental home and major transition in youth on social class differences in mortality from various causes of death among women and men aged 31-42 at death, and to evaluate whether the effect of the past circumstances on mortality is through latency, accumulation or pathway mechanisms. This thesis (papers II-V) is based on the 1990 census data for all Finnish persons born in 1956-60 linked with death records (4369 deaths) for 1991-98 and with information on lifecourse circumstances from the 1970, 1975, 1980 and 1985 censuses. These aggregated cross-tables are analysed by means of Poisson regression. Parental home had an association with disease mortality from age 20 onwards, indicating a latency effect. However, the direct effect of the parental home on mortality was minor, and therefore the contribution of latency model to differential mortality remained small. An indication for the accumulative effect of disadvantageous social class was found for cardiovascular diseases and alcohol-related causes. The living conditions in the parental home, i.e. the manual class and one-parent family, had an effect on the transitions a person experienced in youth, and thus contributed to the effect youth paths exerted on adult social class differences in mortality from various causes of death. Youth paths had a substantial effect (about 60-90%) over and above the preceding effect of living conditions in the parental home on mortality. The higher mortality in the lower social classes was mainly attributable to disadvantageous educational path. Moreover, both family formation, particularly early marriage in women and staying single in men, and experience of unemployment in youth, had independent effects on class differences in mortality. These results strongly suggest that youth is a ‘sensitive period’ affecting social class differences in mortality in middle adulthood.

Changes in socioeconomic inequalities in mortality during an economic boom and recession among middle-aged men and women in Finland

Background: Socioeconomic inequalities in mortality increased in several countries in the 1980s, but little is known about more recent trends. This study looks at how social class differences in mortality changed in Finland during 1981–1995, a period which saw drastic economic fluctuations. Methods: The study is based on the person records of the Finnish censuses of 1980, 1985 and 1990, to which the death records for 1981–1985, 1986–1990 and 1991–1995 respectively were linked. Men and women aged 35–64 years were classified into manual and non-manual classes on the basis of current or former occupation or the occupation of head of household. Results: Class differences in mortality Increased during the 1980s among both men and women due to a more rapid decrease in cardiovascular mortality in the non-manual class and to a more rapid increase in mortality from alcohol-related causes of death, accidents and suicide in the manual class. In the 1990s, a period of severe economic recession, the increase in the relative mortality gap was clearly smaller than in the 1980s. This was due to the convergence between classes of trends for cardiovascular mortality and for mortality from alcohol-related causes, accidents and suicide. Conclusion: In Finland, economic recession slowed down rather than sped up the growth of relative inequalities among middle-aged men and women. Changes in mortality and socioeconomic inequalities in mortality result from a complex combination of different and even opposite trends in mortality from various causes of death. In the light of this complexity it seems unlikely that there exists any major single explanation for changes in inequalities in mortality.

Social class differences in mortality using the National Statistics Socio-economic Classification — too little, too soon: a reply to Chandola

Chandola’s (2000; Social Science and Medicine, 50(5), 641–649) claims that the UK National Statistics Socio-economic Classification (NS-SEC) is not significantly related to mortality are examined. It is shown that this result is likely to be an artefact of the data and methods he uses. Other findings and interpretations in his paper are also critically discussed. In the process, various theoretical, measurement and analysis issues relating to the use of classifications such as the NS-SEC in health research are reviewed.

Social class differences in mortality using the National Statistics Socio-economic Classification: a reply to Rose and Pevalin

Social class differences in mortality using the National Statistics Socio-economic Classification: a reply to Rose and Pevalin

Social class differences in mortality using the new UK National Statistics Socio-Economic Classification

Social class differences in health in the UK have usually been demonstrated by the Registrar General's social classification (RGSC). It is being replaced by the new UK National Statistics Socio-Economic Classification (NS-SEC). The NS-SEC is explicitly based on differences between employment relations and conditions. The mechanisms underlying social class differences in health remain debatable. Some studies have hypothesised that class differences in work characteristics and employment conditions may explain part of the observed class differences in health. This study investigates the associations of the NS-SEC and other measures of socio-economic status (SES) with mortality outcomes in a 7-year panel study representative of British private households and their members (the British Household Panel Survey, n=10264). The NS-SEC was neither significantly associated with mortality for respondents of all ages nor with mortality for a younger subsample who were under 65 years at the initial survey. Other measures of SES, especially income and housing tenure showed significant patterns of inequalities in mortality. It may be useful to use other measures of SES along with the NS-SEC when analysing social inequalities in health and mortality.

Inequality in health: socioeconomic differentials in mortality in Rome, 1990-95.

STUDY OBJECTIVE: Population groups with a lower socioeconomic status (SES) have a greater risk of disease and mortality. The aim of this study was to investigate the relation between SES...

Social class differences in health until the age of seven years among the Finnish 1987 birth cohort

Studies on social class differences in childhood health are controversial partly because of different data collection methods, limited sample sizes and the use of limited numbers of health indicators. The increasing collection of health register data enables the use of such data in social class studies. Our purpose was to investigate social class differences in mortality and morbidity among all children born in Finland in 1987 ( N=59,865 liveborns) until the age of seven by using several national health registers, and to study whether perinatal health explains these differences. The follow-up was based on data linkage with six national health registers, with 18 regional registers of mentally disabled children, covering the whole country, and with 38 educational registers of the largest county. Morbidity was measured in terms of a cumulative disease index, the cumulative incidence of asthma, diabetes, epilepsy and intellectual disability, hospitalisations, disease-related welfare benefits and special education. Social class, divided in four groups (I–III, Others) was defined by using the mother's occupation at the time the child was seven years old. Our study showed that register-based data collection is a feasible method for studying social class differences in health. In the unadjusted analysis, social class differences were found for all indicators except mortality after the age of one year and for the cumulative incidence of asthma and diabetes. After adjusting for confounders, the children in the lowest social class had the highest risk for poor health outcome both in the perinatal period and in childhood, and had the most intellectual disabilities, the highest mean of hospitalisation days, and received the most special education. The differences were not explained by perinatal health. The health of the children in the lowest social class was poorer, especially regarding mental indicators.

Socioeconomic differentials in mortality among men within Great Britain: time trends and contributory causes.

STUDY OBJECTIVE: To assess the size of mortality differentials in men by social class in Scotland as compared with England and Wales, and to analyse the time trends in these...

Cause specific social class mortality differentials for child injury and poisoning in England and Wales.

We examined social class injury mortality differentials [among children in England and Wales] for [the] period 1985-92....Despite the overall decline in child injury mortality steep social class mortality differentials persist....

Socioeconomic differences in mortality among diabetic people in Finland: five year follow up.

To compare socioeconomic differences in mortality (by cause of death) among diabetic people with those in the rest of the population. Five year follow up of mortality in the population of Finland, comparing people with diabetes and those without diabetes. Finland. All residents of Finland aged 30 to 74 included in the 1980 census. Subjects were classified as diabetic (230,000 person years) or other (12,400,000 person years) according to whether they were exempted from charges for medication for diabetes. During 1981-5 there were 114,058 deaths, of which 11,215 were in people with diabetes. Age standardised mortality by sex, social class, and cause of death for the diabetic and non-diabetic populations. No significant social class differences in mortality were found among women with diabetes. Among diabetic men there was a slight increasing trend in mortality from the upper while collar group to the unskilled blue collar workers but it was much less steep than that of non-diabetic men. Among people with diabetes in Finland the quality of treatment and compliance with treatment probably do not vary by socioeconomic status. Health education for diabetic people seems to be effective in all socioeconomic strata; in people from the lower strata this leads to greater changes because their health behavior was originally less good.

The social patterning of mortality in a cohort of elderly Swedes

Social class differences in mortality among the elderly have received only limited interest. In this paper we analyze the impact of social class on mortality from mid-life onwards. In 1968 1,860 persons born between 1892 and 1915 were interviewed and followed in the national cause of death registry for the period 1968-1991. In addition. 537 of the 563 survivors were fe-interviewed in 1992. We employ proportional hazard regressions to analyze the impact of social class on death risks over time. There are fairly small class differences in the probability of reaching old age. However, it appears that mortality differentials were steeper before retirement age than after. Still, the size of class differences in mortality seem smaller than expected on the basis of other studies. At the same time steep class gradients in illness and functional abilities exist among survivors. Some possible explanations for these somewhat contradictory findings are discussed.

Must the gap widen before it can be narrowed? Long-term trends in social class mortality differentials

Les auteurs s'attachent aux variations de la mortalité suivant les classes sociales, à l'occasion d'un réexamen systématique de l'œuvre de Aaron Antonovsky, publiée dans les années 1965. S'appuyant sur des séries concernant l'Amérique et l'Europe, ils retracent les tendances à long terme de la mortalité masculine (infantile et adulte) au cours des sept derniers siècles. II ressort qu'il est important de considérer les différences en fonction de paramètres multiples, et qu'il faut aborder avec la plus grande prudence tous les problèmes associés aux définitions des diverses classes sociales. L'article souligne enfin à quel point l'environnement pouvait influencer les modèles de mortalite differentielle, insistant sur les ecarts constates entre sites urbains et sites ruraux.

Social class gradients in years of potential life lost in Switzerland

Analysis of the official Swiss mortality data have shown considerable social differences. In an earlier study of Swiss men aged 15–74 for the period 1979–1982 the social class mortality differentials have been analysed using standardized mortality ratios (SMR). The present study extends this previous work by calculating years of potential life lost (YPLL) before age 75, an additional indicator of mortality that puts more importance on deaths at younger ages. Emphasis is given on causes contributing to most years of life lost, especially to accidents and violent deaths, which result in more than 30% of total years of life lost. The distribution of years of life lost of the most important causes to social classes is illustrated also for age-specific groups. Additionally, this article presents all causes which account for more than 3% of total years of life lost. The social inequalities are shown as ratios between the social class with the highest (skilled manual workers) and the lowest risk (professionals). Most years of life are lost by skilled manual workers not only in general but also cause-specific. While the SMR from all causes of death showed a 2-fold difference between professionals and skilled manual workers, the social gradient in YPLL rate was even larger (2.5). Hence, the measure of years of potential life lost emphasizes the disadvantage of skilled manual workers to die earlier than professionals. The concept of YPLL proved to be a useful additional indicator not only of mortality in general, but also especially for monitoring causes, related to the lower social classes.

Epidemiological approach to the explanation of social differentiation in mortality: the Whitehall studies.

A consistent feature of mortality statistics in England and Wales are the social class differences which have even widened in the decade from 1971 to 1981. Two large studies of British Civil Servants, the Whitehall and Whitehall II studies, add to the understanding of social class differences in mortality and morbidity. Some of their results are presented to illustrate current concepts of social class differences in health. There is no evidence for an effect of health selection. The magnitude of social class differences vary for different causes of death, presumably as a sign of the effect of specific factors for specific disease. The observation that social class differences apply to most causes of death, however, suggest that factors like early life experience, difference in behaviour, material and psychosocial conditions act in an unspecific way.

Social class differences in child mortality, Sweden 1981-1986.

The aim was to analyse social class differences in mortality among Swedish children, 1-19 years old, during the period 1981-86. In order to study the development of these differences, mortality differences during the study period were compared with those 20 years earlier, ie, 1961-66. The study used data from two census linked death registries (CDR80 and CDR60). These were constructed by linkages between the 1980 and 1960 population censuses, respectively, and the corresponding national cause of death registries. Age specific and age standardised death rates, for total and cause specific mortality, were calculated for each social class and for the genders separately. To compare the death rates of social classes, relative risks with approximately 95% confidence limits were calculated. The study included children younger than 16 years at the time of the censuses and all deaths in the age range 1-19 years. The children were followed up for a period of six years after the censuses with respect to mortality. During the period 1981-86, children in families of both manual workers and self employed persons had a significantly higher mortality than children in families of non-manual workers. Although there has been a marked decrease in child mortality during the last decades the study shows that social class differences in child mortality still exist and show little tendency to disappear.