Socioeconomic Gradient In Mortality Research Articles

Mortality gradient by education: differences between natives and immigrants in Italian Census cohort

Abstract Background A socioeconomic mortality gradient, favourable to the most advantaged social groups, has been documented in both high migratory pressure (HMPCs) and highly developed Countries, including Italy. However, little is known on how this association differs between natives and immigrants. This study aimed at comparing the mortality gradient by education among these population groups, evaluating differences for macro-area of origin or citizenship. Methods Using a longitudinal design, the 2011 Census population was followed up to 2019. All-cause mortality was retrieved by record linkage with the Causes of Death register. The association of education (as the main exposure) and social class (based on the Erikson and Goldthorpe classification) with mortality was evaluated in subject aged 30-64, separately by sex, citizenship/macro-area of origin. Mortality rate ratios (MRR) and 95% confidence intervals were estimated using negative binomial regression models, adjusted for age and area of residence. Results 23,572,516 subjects (7% immigrants from HMPCs) and 410,746 deaths (3% from HMPCs) were analysed. Among natives, a mortality gradient by education was observed (low/high MRR: 2.37[2.16-2.60] males; 1.79[1.64-1.96] females), whereas a weaker association without trend was found for HMPCs immigrants (MRR: 1.12 [1.00-1.25] males; 1.12[1.00-1.26] females). A higher mortality for less educated was observed for males from Romania, India, China, and for females from Central-Eastern Europe, Sub-Saharan Africa and Central and South America. A lower mortality was found for the least educated from Morocco. Conclusions The higher mortality among less educated subjects is confirmed among natives, while it is less evident in immigrants from HMPCs. However, differences observed between citizenships, macro-areas of origin, and sex, highlight the need for social policies accounting for specific risk factors and cultural specificities affecting correct lifestyles and health services access. Key messages • A mortality gradient by education was found among natives in Italy, whereas a weaker association without trend was observed for immigrants from high migratory pressure Countries. • The differences observed between citizenships or macro-areas of origin, and sex, highlight the need for social and health policies culturally oriented to specific target population.

Socioeconomic gradient in mortality of working age and older adults with multiple long-term conditions in England and Ontario, Canada

BackgroundThere is currently mixed evidence on the influence of long-term conditions and deprivation on mortality. We aimed to explore whether number of long-term conditions contribute to socioeconomic inequalities in mortality, whether the influence of number of conditions on mortality is consistent across socioeconomic groups and whether these associations vary by working age (18–64 years) and older adults (65 + years). We provide a cross-jurisdiction comparison between England and Ontario, by replicating the analysis using comparable representative datasets.MethodsParticipants were randomly selected from Clinical Practice Research Datalink in England and health administrative data in Ontario. They were followed from 1 January 2015 to 31 December 2019 or death or deregistration. Number of conditions was counted at baseline. Deprivation was measured according to the participant’s area of residence. Cox regression models were used to estimate hazards of mortality by number of conditions, deprivation and their interaction, with adjustment for age and sex and stratified between working age and older adults in England (N = 599,487) and Ontario (N = 594,546).FindingsThere is a deprivation gradient in mortality between those living in the most deprived areas compared to the least deprived areas in England and Ontario. Number of conditions at baseline was associated with increasing mortality. The association was stronger in working age compared with older adults respectively in England (HR = 1.60, 95% CI 1.56,1.64 and HR = 1.26, 95% CI 1.25,1.27) and Ontario (HR = 1.69, 95% CI 1.66,1.72 and HR = 1.39, 95% CI 1.38,1.40). Number of conditions moderated the socioeconomic gradient in mortality: a shallower gradient was seen for persons with more long-term conditions.ConclusionsNumber of conditions contributes to higher mortality rate and socioeconomic inequalities in mortality in England and Ontario. Current health care systems are fragmented and do not compensate for socioeconomic disadvantages, contributing to poor outcomes particularly for those managing multiple long-term conditions. Further work should identify how health systems can better support patients and clinicians who are working to prevent the development and improve the management of multiple long-term conditions, especially for individuals living in socioeconomically deprived areas.

Effects of socioeconomic status on excess mortality in patients with multiple sclerosis in France: A retrospective observational cohort study.

The effects of socio-economic status on mortality in patients with multiple sclerosis is not well known. The objective was to examine mortality due to multiple sclerosis according to socio-economic status. A retrospective observational cohort design was used with recruitment from 18 French multiple sclerosis expert centers participating in the Observatoire Français de la Sclérose en Plaques. All patients lived in metropolitan France and had a definite or probable diagnosis of multiple sclerosis according to either Poser or McDonald criteria with an onset of disease between 1960 and 2015. Initial phenotype was either relapsing-onset or primary progressive onset. Vital status was updated on January 1st 2016. Socio-economic status was measured by an ecological index, the European Deprivation Index and was attributed to each patient according to their home address. Excess death rates were studied according to socio-economic status using additive excess hazard models with multidimensional penalised splines. The initial hypothesis was a potential socio-economic gradient in excess mortality. A total of 34,169 multiple sclerosis patients were included (88% relapsing onset (n=30,083), 12% progressive onset (n=4086)), female/male sex ratio 2.7 for relapsing-onset and 1.3 for progressive-onset). Mean age at disease onset was 31.6 (SD=9.8) for relapsing-onset and 42.7 (SD=10.8) for progressive-onset. At the end of follow-up, 1849 patients had died (4.4% for relapsing-onset (n=1311) and 13.2% for progressive-onset (n=538)). A socio-economic gradient was found for relapsing-onset patients; more deprived patients had a greater excess death rate. At thirty years of disease duration and a year of onset of symptoms of 1980, survival probability difference (or deprivation gap) between less deprived relapsing-onset patients (EDI=-6) and more deprived relapsing-onset patients (EDI=12) was 16.6% (95% confidence interval (CI) [10.3%-22.9%]) for men and 12.3% (95%CI [7.6%-17.0%]) for women. No clear socio-economic mortality gradient was found in progressive-onset patients. Socio-economic status was associated with mortality due to multiple sclerosis in relapsing-onset patients. Improvements in overall care of more socio-economically deprived patients with multiple sclerosis could help reduce these socio-economic inequalities in multiple sclerosis-related mortality. This study was funded by the ARSEP foundation "Fondation pour l'aide à la recherche sur la Sclérose en Plaques" (Grant Reference Number 1122). Data collection has been supported by a grant provided by the French State and handled by the "Agence Nationale de la Recherche," within the framework of the "Investments for the Future" programme, under the reference ANR-10-COHO-002, Observatoire Français de la Sclérose en Plaques (OFSEP).

Socioeconomic gradient in mortality of working age and older adults with multiple long-term conditions in England and Ontario, Canada.

ObjectivesThere is mixed evidence on the influence of number of conditions on inequalities in mortality, we explored the association between number of conditions and deprivation on mortality whilst assessing the difference between working age and older adults. We replicated the analysis in England and Ontario, to provide a cross-jurisdiction comparison. ApproachWe used individual level-linked data from primary care activity, secondary care and mortality data in England and Ontario. For both jurisdictions, we took a random sample of 600,000 adults from 1 January 2015 and followed them up till 31 December 2019. We used cox proportional hazard to test the influence of deprivation (measured using area-level deprivation in deciles) and number of conditions (measured at baseline and capped at six conditions) on survival. Age and sex were also measured at baseline. Analyses were stratified by working age (18-64 years) and older adults (65+ years) and were repeated for England and Ontario. ResultsDeprivation gradient in mortality rate was steeper in working age than older adults in both jurisdictions. Number of conditions was associated with increased mortality rate, this was stronger for working age than older adults, in England (working age HR = 1.60, 95% CI 1.56,1.64 and older adults HR= 1.26, 95% CI 1.25,1.27) and Canada (working age HR=1.69, 95% CI 1.66,1.72 and older adults HR= 1.39, 95% CI 1.38,1.40). After accounting for number of conditions, the mortality rate associated with deprivation decreased but remained significant. The interaction between number of conditions and deprivation showed that adults with more conditions have a higher mortality rate and those living in deprived areas also have a higher mortality rate but having more conditions attenuates the deprivation gradient in mortality. ConclusionNumber of conditions contribute to higher mortality rate and inequalities in morality, this is stronger for working age than older adults in England and Ontario. The fragmented health-care system may be contributing to poorer outcomes, further research should help identify which part of the pathway is driving these inequalities further.

The socioeconomic gradient in mortality from ovarian, cervical, and endometrial cancer in Australian women, 2001-2018: A population-based study.

Socio-economic (SE) status is closely linked to health status and the mechanisms of this association are complex. One important adverse effect of SE disadvantage is vulnerability to cancer and cancer is a major cause of morbidity and mortality in Australia. We aimed to estimate the effect of SE status on mortality rates from ovarian, cervical, and endometrial cancer. National mortality data were obtained from the Australian Bureau of Statistics (ABS) for the calendar years from 2001 to 2018, inclusive. Individual deaths were grouped by the ABS Index of Relative Socio-economic Advantage and Disadvantage. Population data were obtained to provided denominators allowing calculation of mortality rates (deaths per 100 000 women aged 30-79 years). Statistical analyses performed included tabulating point-estimates of mortality rates and their changes over time and modelling the trends of rates using maximum likelihood method. Age-standardised mortality rates for ovarian and cervical cancer fell over the study period but increased for endometrial cancer. There was clear evidence of a SE gradient in the mortality rate for all three cancers. This SE gradient increased over the study period for ovarian and cervical cancer but remained unchanged for endometrial cancer. Women at greater SE disadvantage have higher rates of death from the commonest gynaecological cancers and this gradient has not reduced over the last two decades. After the COVID-19 pandemic efforts must be redoubled to ensure that Australians already at risk of ill health do not face even greater risks because of their circumstances.

Educational Gradients Behind Medical Adverse Event Deaths in the US-A Time Series Analysis of Nationwide Mortality Data 2010-2019.

BackgroundDeaths due to medical care appear common. Individuals with low socioeconomic position seem to be at a higher risk for sustaining a medical adverse event and premature death. This time series analysis aimed to assess educational gradients behind adverse event deaths in the US over the period 2010–2019.MethodsPublicly available mortality and census data were retrieved from official sources. The data included age, sex, educational attainment, and underlying cause of death. Adverse event deaths were identified by ICD-10 codes Y40—Y84 and Y88. Four education categories were created in accordance with the International Standard Classification of Education 2011 coding scheme [No high school or General Educational Development (GED); High school or GED; Some college; Bachelor's degeree or higher]. To capture also highly educated individuals, the analysis was delimited to ≥30-year-olds. Age-adjusted mortality rates (AMRs) were compared between education categories by means of mortality plots and linear mixed models.ResultsA total of 25,897,334 certified deaths occurred among ≥30-year-olds during the study period. The underlying cause of death was an adverse event in a rarity of cases (0.12%, n = 31,997). Individuals with Bachelor's degeree or higher had the lowest adverse event AMRs (6.1–12.4 per million per year), followed by the Some college category (9.6–18.6), the High school or GED category (17.1–35.4), and finally the No high school or GED category (20.0–36.0). AMRs showed a gradual increase as education level decreased (p ≤ 0.001 against those with Bachelor's degeree or higher). Moreover, the temporal increase in adverse event AMRs was more pronounced among individuals with low than high education; the contrasts between categories were greatest toward the end of the study period.ConclusionThe findings of this study suggest that the widening socioeconomic gradients in mortality extend also to fatal adverse events. Future studies should aim to analyze whether access to care, severity of the condition at presentation, quality of care, and social determinants of health may drive the gradients.

The Association between Material Deprivation and Avoidable Mortality in Lisbon, Portugal.

There is considerable evidence pointing to the existence of a socioeconomic gradient in mortality, which tends to be steeper in urban areas. Similar to other European cities, Lisbon is far from homogeneous since considerable geographical inequalities exist between the more advantaged and the more deprived neighborhoods. The main goals of this study are to describe the geographical pattern of premature deaths (before 65 years old), avoidable deaths (preventable and amenable to healthcare) and cause-specific mortality (HIV/AIDS and suicide) in Lisbon, at the lower administrative level (civil parish, in Portuguese: Freguesia), and analyze the statistical association between mortality risk and deprivation, before (1999–2003) and during the economic crisis (2008–2012). Smoothed Standardized Mortality Ratios (sSMR) and Relative Risk (RR) with 95% credible intervals were calculated to identify the association between mortality and deprivation. The analysis of the geographical distribution of cause-specific mortality reveals that civil parishes with high sSMR in the first period continued to present higher mortality rates in the second. Moreover, a significant statistical association was found between all the causes of death and deprivation, except suicide. These findings contribute to understanding how social conditions influence health outcomes and can offer insights about potential policy directions for local government.

Socioeconomic Gradients in Mortality Following HF Hospitalization in a Country With Universal Health Care Coverage

ObjectivesThis study explored the association between socioeconomic position (SEP) and long-term mortality following first heart failure (HF) hospitalization. BackgroundIt is not clear to what extent education and income—individually or combined—influence mortality among patients with HF. MethodsThis study included 49,895 patients, age 35+ years, with a first HF hospitalization in Norway during 2000 to 2014 and followed them until death or December 31, 2014. The association between education, income, and mortality was explored using Cox regression models, stratified by sex and age group (35 to 69 years and 70+ years). ResultsCompared with patients with primary education, those with tertiary education had lower mortality (adjusted hazard ratio [HR]: 0.89; 95% confidence interval [CI]: 0.78 to 0.99 in younger men; HR: 0.57; 95% CI: 0.43 to 0.75 in younger women; HR: 0.90; 95% CI: 0.84 to 0.97 in older men, and HR: 0.87; 95% CI: 0.81 to 0.93 in older women). After adjusting for educational differences, younger and older men and younger women in the highest income quintile had lower mortality compared with those in the lowest income quintile (HR: 0.63; 95% CI: 0.55 to 0.72; HR: 0.78; 95% CI: 0.63 to 0.96, and HR: 0.91; 95% CI: 0.86 to 0.97, respectively). The association between income and mortality was almost linear. No association between income and mortality was observed in older women. ConclusionsDespite the well-organized universal health care system in Norway, education and income were independently associated with mortality in patients with HF in a clear sex- and age group-specific pattern.

Height and health in late eighteenth-century England

Adult stature has become a widely used indicator of childhood nutritional status in historical populations and may provide insights into health inequalities that are not discernible in mortality rates. However, most pre-twentieth-century British data on heights suffer from selection biases. Here we present unique evidence on heights of adult males by occupation from an unbiased sample of adult males in Dorset in 1798–99. The mean height of fully grown (married) men was very similar to that of older military recruits, and our sample therefore confirms the taller stature of English males relative to males of other European countries in the same period. In contrast to previous evidence of negligible or U-shaped socio-economic gradients in mortality in this period, we found a fairly linear gradient in height by socio-economic status, that is similar in magnitude to class differences in adult height among English males born in the mid-twentieth century. Supplementary material for this article is available at: https://doi.org/10.1080/00324728.2020.1823011

Does having highly educated adult children reduce mortality risks for parents with low educational attainment in Europe?

AbstractIt is known that the education of significant others may affect an individual's mortality. This paper extends an emerging body of research by investigating the effect of having highly educated adult children on the longevity of older parents in Europe, especially parents with low educational attainment. Using a sample of 15,015 individuals (6,620 fathers and 8,395 mothers) aged 50 and above, with 1,847 recorded deaths, over a mean follow-up period of 10.9 years from the Survey of Health, Ageing and Retirement in Europe (SHARE), we examine whether the well-established socio-economic gradient in mortality among parents is modified when their adult children have higher educational attainment than their parents. We find that having highly educated adult children is associated with reduced mortality risks for fathers and mothers with low educational attainment, compared to their counterparts whose adult children have only compulsory education. The association is stronger in early older age (ages 50–74) than in later older age (ages 75 and over). Part of the association appears to be explained by health behaviours (physical (in)activity) and health status (self-rated health). Our findings suggest that the socio-economic–mortality gradient among older parents might be better captured using an intergenerational approach that recognises the advantage of having highly educated adult children, especially for fathers and mothers with only compulsory education.

Objective and subjective financial status and mortality among older adults in China

The association between financial status and mortality in older adults is well documented. However, it is unclear whether the association may vary by objective and subjective indicators of financial status. To examine this issue, we used the latest four waves (2005, 2008/2009, 2011/2012, and 2014) of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) of community-residing adults aged 65 and older (n = 25,954). Financial status was assessed using eight objective, subjective, and culturally-oriented measures to capture various dimensions of financial resources at older ages. Multivariate hazard models were used to examine how different indicators of financial status were associated with subsequent mortality in all older adults and by age, gender, and urban-rural residence. Results showed that higher financial status—either objective or subjective—was associated with lower risks of mortality. Subjective assessments of financial status had stronger associations with mortality than objective assessments. The patterns were generally similar between young-old (aged 65–79) and the oldest-old (aged 80+), between women and men, and between rural and urban areas. Together, the findings offer new evidence to help improve the socioeconomic gradient in mortality among older adults in China.

Does selective migration alter socioeconomic inequalities in mortality in Wales?: a record-linked total population e-cohort study

Recent studies found evidence of health selective migration whereby healthy people move to less deprived areas and less healthy people move to or stay in more deprived areas. There is no consensus, however, on whether this influences health inequalities. Measures of socio-economic inequalities in mortality and life expectancy are widely used by government and health services to track changes over time but do not consider the effect of migration. This study aims to investigate whether and to what extent migration altered the observed socioeconomic gradient in mortality. Data for the population of Wales (3,136,881) registered with the National Health Service on 01/01/2006 and follow-up for 24 quarters were individually record-linked to ONS mortality files. This included moves between lower super output areas (LSOAs), deprivation quintiles and rural-urban class at each quarter, age, sex, and date of death. Cox regression models were used to estimate the hazard ratios for the deprivation quintiles in all-cause mortality, as well as deprivation change between the start and end of the study. We found evidence of health selective migration in some groups, for example people aged under 75 leaving the most deprived areas having a higher mortality risk than those they left behind, suggesting widening inequalities, but also found the opposite pattern for other migration groups. For all ages, those who lived in the most deprived quintile had a 57% higher risk of death than those in the least deprived quintile, allowing deprivation to vary with moves over time. There was little change in this risk when people were artificially kept in their deprivation quintile of origin (54% higher). Overall, migration during the six year window did not substantially alter the deprivation gradient in mortality in Wales between 2006 and 2011.

Are the Poor Dying Younger in Malaysia? An Examination of the Socioeconomic Gradient in Mortality.

IntroductionSocioeconomic inequalities in health represent unfairness in the health distribution of a population. Efforts to produce information on mortality distributions in many low and middle income countries (LMICs) are mostly hampered by lack of data disaggregated by socioeconomic groups. In this paper we describe how mortality statistics obtained from multiple data sources were combined to provide an evaluation of the socioeconomic distribution of mortality in Malaysia, a LMIC located in the Asia Pacific region.MethodsThis study has an ecological design. As a measure of socioeconomic status, we used principal component analysis to construct a socioeconomic index using census data. Districts were ranked according to the standardised median index of households and assigned to each individual in the 5-year mortality data. The mortality indicators of interest were potential years of life lost (PYLL), standardised mortality ratio (SMR), infant mortality rate (IMR) and under-5 mortality rate (U5MR). Both socioeconomic status and mortality outcomes were used compute the concentration index which provided the summary measure of the magnitude of inequality.ResultsSocially disadvantaged districts were found to have worse mortality outcomes compared to more advantaged districts. The values of the concentration index for the overall population of the Peninsula are C = -0.1334 (95% CI: -0.1605 to -0.1063) for the PYLL, C = -0.0685 (95% CI: -0.0928 to -0.0441) for the SMR, C = -0.0997 (95% CI: -0.1343 to -0.0652) for the IMR and C = -0.1207 (95% CI: -0.1523 to -0.0891) for the U5MR. Mortality outcomes within ethnic groups were also found to be less favourable among the poor.ConclusionThe findings of this study suggest that socioeconomic inequalities disfavouring the poor exist in Malaysia.

Inequality in the Face of Death: The Socioeconomic Gradient in Mortality of the Spanish Working-Age Population

The purpose of this paper is to evaluate the association between income and mortality over a three year period for working-age Spaniards. Method Data on 693,994 individuals was taken from a social security sampling using a logit model to estimate the probabilities of death for each income decile and the mortality rate ratios (MRR) in three different models: 1) using only income, controlled by age and sex,2) adding socio-economic and geographic variables and, 3) adding level of education. Results: A gradient appears in the mortality rate over income deciles with a maximum MRR of 3.41 in men and 1.68 in women. The shape of the adjustment is clearly non-linear and levels out as income increases. The gradient attenuates for both sexes when variables are introduced that try to capture the inverse causality (2.4 and 1.3). Controlling by level of education reduces the gradient for men (2.2) and intensifies it for women (1.5). Conclusion: The association of the relationship between income and mortality is verified, as well as its non-linear nature, the greater intensity for men than for women, and its persistence when controlling for variables that try to capture causality.

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.

Assessing the impact of selective migration and care homes on geographical inequalities in health – A total population cohort study in Sheffield

Selective migration and moves to care homes may potentially contribute to observed socioeconomic gradients in mortality across cities and regions. Sheffield has striking socioeconomic gradients in area-level mortality across the city. We examined for evidence of selective migration and assessed the contribution of migration to observed mortality gradients. We used a total population cohort (539737 in 2001), linked mortality data (2001–2010) and linked data from a health survey carried out in 2000 (66% response rate yielding 10185 responses). We used lower super-output areas and electoral wards as the spatial units of analysis. We found clear evidence of selective migration. In the 25–44 age band, relative risks of mortality were 1.71 (95% CI 1.37–2.12) in migrants from low to high deprivation areas compared with people remaining in low deprivation areas, and 0.53 (0.42–0.65) in migrants from high to low deprivation areas compared with people remaining in high deprivation areas. Relative risks shrank towards unity with increasing age. Characteristics of migrants and non-migrants (illness prevalence, indicators of socioeconomic status, smoking prevalence) ascertained before migration were largely consistent with the relative risks for mortality and indicated that people carried their risks with them. There was also a clear care homes effect, with higher mortality in electoral wards with higher care home bed provision rates. Overall, however, adjustment for selective migration, which included moves to care homes, made little difference to gradients in inequality across the city. Our results suggest that selective migration, including moves to care homes, do not explain existing socioeconomic gradients in area level mortality across Sheffield.

Commentary

Commentary

Increasing Area Deprivation and Socioeconomic Inequalities in Heart Disease, Stroke, and Cardiovascular Disease Mortality Among Working Age Populations, United States, 1969-2011

We examined the extent to which area- and individual-level socioeconomic inequalities in cardiovascular-disease (CVD), heart disease, and stroke mortality among United States men and women aged 25-64 years changed between 1969 and 2011. National vital statistics data and the National Longitudinal Mortality Study were used to estimate area- and individual-level socioeconomic gradients in mortality over time. Rate ratios and log-linear and Cox regression were used to model mortality trends and differentials. Area socioeconomic gradients in mortality from CVD, heart disease, and stroke increased substantially during the study period. Compared to those in the most affluent group, individuals in the most deprived area group had, respectively 35%, 29%, and 73% higher CVD, heart disease, and stroke mortality in 1969, but 120-121% higher mortality in 2007-2011. Gradients were steeper for women than for men. Education, income, and occupation were inversely associated with CVD, heart disease, and stroke mortality, with individual-level socioeconomic gradients being steeper during 1990-2002 than in 1979-1989. Individuals with low education and incomes had 2.7 to 3.7 times higher CVD, heart disease, and stroke mortality risks than their counterparts with high education and income levels. Although mortality declined for all US groups during 1969-2011, socioeconomic disparities in mortality from CVD, heart disease and stroke remained marked and increased over time because of faster declines in mortality among higher socioeconomic groups. Widening disparities in mortality may reflect increasing temporal areal inequalities in living conditions, behavioral risk factors such as smoking, obesity and physical inactivity, and access to and use of health services. With social inequalities and prevalence of smoking, obesity, and physical inactivity on the rise, most segments of the working-age population in low- and middle-income countries will likely experience increased cardiovascular-disease burden in terms of higher morbidity and mortality rates.

Mortality in South Africa: Socio-economic profile and association with self-reported health

This paper exploits the first two waves of the National Income Dynamics Study (NIDS) to describe the socio-economic profile of mortality and to assess whether self-rated health status is predictive of mortality between waves. Mortality rates in NIDS are in line with estimates from official death notification data and display the expected hump of excess mortality in early and middle adulthood due to AIDS, with the excess peaking earlier for women than for men. We find evidence of a socio-economic gradient in mortality, with higher rates of mortality for individuals from asset-poor households and with lower levels of education. Consistent with evidence from many industrialised countries and a few developing countries, we find self-rated health to be a significant predictor of two-year mortality, an association that remains after controlling for socio-economic status and several other subjective and objective measures of health.

Association of socioeconomic position with smoking and mortality: the contribution of early life circumstances in the 1946 birth cohort

BackgroundA large part of the socioeconomic mortality gradient can be statistically accounted for by social patterning of adult health behaviours. However, this statistical explanation does not consider the early life...