Inequalities in women's health: looking at mortality differentials using an alternative approach

Data obtained from follow up of the 1971 census sample in the Office of Population Censuses and Surveys longitudinal study of England and Wales were used to look at women''s mortality differentials at ages 15-59. Women were grouped by combining information on marital state, own occupation, husband''s occupation (if married), economic activity, and indicators of household wealth (housing tenure and access to a car). Large groups were found with considerable differences in mortality. High mortality was associated with working in manual occupations and living in rented housing with no car in the household. In contrast, low mortality was associated with non-manual occupations and living in owner occupied housing with a car. Among married housewives and single women these extreme groups contributed 44% of expected deaths, the disadvantaged group experiencing death rates two and a half times that of the advantaged group. Smaller differences were found among married women with an occupational class.These findings are further evidence of the “health divide” in England and Wales and show that accurately to reflect the relation between a woman''s life circumstances and mortality it is necessary to utilise other measures than those based solely on occupation.     

Social class differences in years of potential life lost: size,trends, and principal causes.

British social class differences in mortality are examined in terms of years of potential life lost, a measure that gives more weight to deaths that take place at younger ages. It shows wider class differences during the years of working life than those found when mortality is expressed in terms of standardised mortality ratios. Examination of the change in class differences between 1971 and 1981 for all causes of death combined and for the three categories of death which during these ages make a major contribution to total years of potential life lost shows complex changes. Inequalities in years of potential life lost have increased between 1971 and 1981, during which all the principal causes of death have shown stationary or rising rates among the manual classes. The use of years of potential life lost as a measure of population health trends focuses attention on the major contribution of violent death, which occurs mainly in younger men, to widening class differences in mortality.     

Mortality in young offenders: retrospective cohort study

Objectives To estimate overall and cause specific standardised mortality ratios in young offenders.Design Comparison of mortality data in cohort of young offenders.Settings State of Victoria, Australia.Subjects Cohort of young offenders aged 10-20 years with a first custodial sentence from 1 January 1988 to 31 December 1999.Main outcome measures Deaths ascertained by matching with the national death index, a database containing records of all deaths in Australia since 1980. Death rates in the reference Victorian population used to calculate standardised mortality ratios.Results The offender cohort comprised 2621 men and 228 women with 11 333 person years of observation. The median age of first detention was 17.9 years for men and 18.4 years for women. Median follow up was 3.3 years for men and 1.4 years for women. Overall standardised mortality ratio adjusted for age (expressed as a ratio) was 9.4 (95% confidence interval 7.4 to 11.9) for men and 41.3 (20.2 to 84.7) for women. Cause specific standardised mortality ratios for men were 25.7 (17.9 to 36.9) for drug related causes, 9.2 (5.8 to 15) for suicide, and 5.7 (3.6 to 9.2) for non-intentional injury. A quarter of drug related deaths in men aged 15-19 years were in offenders.Conclusions Social policies for young offenders should address both the prevalent drug and mental health problems as well the high levels of social disadvantage.     

Ethnic differences in general practitioner consultations.

OBJECTIVE--To examine the levels of general practitioner consultations among the different ethnic groups resident in Britain. DESIGN--The study was based on the British general household surveys of 1983-5 and included 63,966 people aged 0-64. Odds ratios were derived for consultation by ethnic group by using logistic regression analysis adjusting for age and socioeconomic group. SETTING--The results relate to people living in private households in England, Scotland, and Wales. RESULTS--After adjustment for age and socioeconomic class, consultation among adults aged 16-64 was highest among people of Pakistani origin with odds ratios of 2.82 (95% confidence interval 1.86 to 4.28) for men and 1.85 (1.22 to 2.81) for women. Significantly higher consultations were also seen for men of West Indian and Indian origin (odds ratios 1.65 and 1.53 respectively). Ethnic differences were greatest at ages 45-64, when consultation rates in people of Pakistani, Indian, and West Indian origin were much higher in both sexes compared with white people. CONCLUSIONS--The ethnic composition of inner cities is likely to influence the workload and case mix of general practitioners working in these areas.     

Outlook for survivors of childhood in sub-Saharan Africa: adult mortality in Tanzania. Adult Morbidity and Mortality Project.

OBJECTIVE--To measure age and sex specific mortality in adults (15-59 years) in one urban and two rural areas of Tanzania. DESIGN--Reporting of all deaths occurring between 1 June 1992 and 31 May 1995. SETTING--Eight branches in Dar es Salaam (Tanzania''s largest city), 59 villages in Morogoro rural district (a poor rural area), and 47 villages in Hai district (a more prosperous rural area). SUBJECTS--40,304 adults in Dar es Salaam, 69,964 in Hai, 50,465 in Morogoro rural. MAIN OUTCOME MEASURES--Mortality and probability of death between 15 and 59 years of age (45Q15). RESULTS--During the three year observation period a total of 4929 deaths were recorded in adults aged 15-59 years in all areas. Crude mortalities ranged from 6.1/1000/year for women in Hai to 15.9/1000/year for men in Morogoro rural. Age specific mortalities were up to 43 times higher than rates in England and Wales. Rates were higher in men at all ages in the two rural areas except in the age group 25 to 29 years in Hai and 20 to 34 years in Morogoro rural. In Dar es Salaam rates in men were higher only in the 40 to 59 year age group. The probability of death before age 60 of a 15 year old man (45Q15) was 47% in Dar es Salaam, 37% in Hai, and 58% in Morogoro; for women these figures were 45%, 26%, and 48%, respectively. (The average 45Q15s for men and women in established market economies are 15% and 7%, respectively.) CONCLUSION--Survivors of childhood in Tanzania continue to show high rates of mortality throughout adult life. As the health of adults is essential for the wellbeing of young and old there is an urgent need to develop policies that deal with the causes of adult mortality.     

Widening inequality of health in northern England, 1981-91.

OBJECTIVE--To identify relative and absolute changes in mortality in the Northern region of England between 1981 and 1991. DESIGN--1981 and 1991 census data were used to rank 678 wards on an index of material deprivation composed of four variables (unemployment, car ownership, housing tenure, household overcrowding). Standardised mortality ratios (all causes) were calculated for various periods between 1981 and 1991 and for different age categories. SETTING--Counties of Cleveland, Cumbria, Durham, Northumberland, and Tyne and Wear. RESULTS--During 1981-91 mortality differentials widened between the most affluent and deprived fifths of wards in all age categories under 75 years. The decline in the relative position of the poorest areas was particularly great, and there was no narrowing of inequalities across the remainder of the socioeconomic spectrum. In absolute terms, there were improvements in mortality in all age categories in the most affluent areas. In the poorest areas improvements in the 55-64 age group were balanced by increased mortality among men aged 15-44, a slight rise among women aged 65-74, and static rates among men aged 45-54. CONCLUSIONS--These results re-emphasise the case for linking mortality patterns with material conditions rather than individual behaviour.     

Mortality in men admitted to hospital with acute urinary retention: database analysis

Objectives To investigate mortality in men admitted to hospital with acute urinary retention and to report on the effects of comorbidity on mortality.Design Analysis of the hospital episode statistics database linked to the mortality database of the Office for National Statistics.Setting NHS hospital trusts in England, 1998-2005.Participants All men aged over 45 who were admitted to NHS hospitals in England with a first episode of acute urinary retention.Main outcome measures Mortality in the first year after acute urinary retention and standardised mortality ratio against the general population.Results During the study period, 176 046 men aged over 45 were admitted to hospital with a first episode of acute urinary retention. In 100 067 men with spontaneous acute urinary retention, the one year mortality was 4.1% in men aged 45-54 and 32.8% in those aged 85 and over. In 75 979 men with precipitated acute urinary retention, mortality was 9.5% and 45.4%, respectively. In men with spontaneous acute urinary retention aged 75-84, the most prevalent age group, the one year mortality was 12.5% in men without comorbidity and 28.8% in men with comorbidity. The corresponding figures for men with precipitated acute urinary retention were 18.1% and 40.5%. Compared with the general population, the highest relative increase in mortality was in men aged 45-54 (standardised mortality ratio 10.0 for spontaneous and 23.6 for precipitated acute urinary retention) and the lowest for men 85 and over (1.7 and 2.4, respectively).Conclusions Mortality in men admitted to hospital with acute urinary retention is high and increases strongly with age and comorbidity. Patients might benefit from multi-disciplinary care to identify and treat comorbid conditions.     

Alcohol consumption and mortality: modelling risks for men and women at different ages

ObjectiveTo estimate the relation between alcohol consumption and risk of death, the level of alcohol consumption at which risk is least, and how these vary with age and sex.DesignAnalysis using published systematic reviews and population data.SettingEngland and Wales in 1997.ResultsA direct dose-response relation exists between alcohol consumption and risk of death in women aged 16-54 and in men aged 16-34. At older ages the relation is U shaped. The level at which the risk is lowest increases with age, reaching 3 units a week in women aged over 65 and 8 units a week in men aged over 65. The level at which the risk is increased by 5% above this minimum is 8 units a week in women aged 16-24 and 5 units a week in men aged 16-24, increasing to 20 and 34 units a week in women and men aged over 65, respectively.ConclusionsSubstantially increased risks of all cause mortality can occur even in people drinking lower than recommended limits, and especially among younger people.

What is already known on this topic

Non-drinkers and heavy drinkers have higher all cause mortality rates than light drinkers—the U shaped curveThe precise shape and location of the U are likely to depend on age and sex, but this has not been quantified

What this study adds

The level of alcohol consumption that carries the lowest mortality ranges from 0 in men and women aged under 35 to 3 units a week in women aged over 65 and 8 units a week in men aged over 65The level of alcohol consumption that carries a 5% increase in mortality increases with age from 8 to 20 units a week in women and from 5 to 34 units a week in menOur calculations were for England and Wales in 1997: nadirs are likely to be lower in the future and in countries with less ischaemic heart disease     

Gonorrhoea in inner London: results of a cross sectional study.

OBJECTIVES: To estimate population based incidence rates of gonorrhoea in an inner London area and examine relations with age, ethnic group, and socioeconomic deprivation. DESIGN: Cross sectional study. SETTING: 11 departments of genitourinary medicine in south and central London. SUBJECTS: 1978 first episodes of gonorrhoea diagnosed in 1994 and 1995 in residents of 73 electoral wards in the boroughs of Lambeth, Southwark, and Lewisham who attended any of the departments of genitourinary medicine. MAIN OUTCOME MEASURES: Yearly age, sex, and ethnic group specific rates of gonorrhoea per 100,000 population aged 15-59 years; rate ratios for the effects of age and ethnic group on gonorrhoea rates in women and men before and after adjustment for confounding factors. RESULTS: Overall incidence rates of gonorrhoea in residents of Lambeth, Southwark, and Lewisham were 138.3 cases yearly per 100,000 women and 291.9 cases yearly per 100,000 men aged 15-59 years. At all ages gonorrhoea rates were higher in non-white minority ethnic groups. Rate ratios for the effect of age adjusted for ethnic group and underprivilege were 15.2 (95% confidence interval 11.6 to 19.7) for women and 2.0 (1.7 to 2.5) for men aged 15-19 years compared with those over 30. After deprivation score and age were taken into account, women from black minority groups were 10.5 (8.6 to 12.8) times as likely and men 11.0 (9.7 to 12.6) times as likely as white people to experience gonorrhoea. CONCLUSIONS: Gonorrhoea rates in Lambeth, Southwark, and Lewisham in 1994-5 were six to seven times higher than for England and Wales one year earlier. The presentation of national trends thus hides the disproportionate contribution of ongoing endemic transmission in the study area. Teenage women and young adult men, particularly those from black minority ethnic groups, are the most heavily affected, even when socioeconomic underprivilege is taken into account. There is urgent need for resources for culturally appropriate research and effective intervention to prevent gonococcal infections and their long term sequelae in this population.     

Reproductive mortality.

The transfer from traditional to modern methods of contraception in recent decades has been accompanied by a transfer of deaths from complications of pregnancy to deaths from complications of the modern contraceptive methods. In 1975, for example, it is estimated that there were more deaths at ages 25-44 years in England and Wales from adverse effects of oral contraceptive use than from all complications of pregnancy, delivery, and the puerperium combined. Thus maternal mortality is no longer an adequate indicator of the deaths associated with reproduction in the community. An alternative measure, the reproductive mortality rate should be used, which includes deaths from complications of contraceptive use as well as those from complications of pregnancy or abortion. The reproductive mortality rate in England and Wales seems to have declined continuously since 1950 for women aged 25-34. But after 1960 it increased for women aged 35-44, because of the higher mortality associated with oral contraceptive use in this age group.     

Higher mortality in deprived areas: community or personal disadvantage?

OBJECTIVE--To investigate the association between level of social deprivation in electoral wards and premature mortality among residents, before and after allowing for levels of personal deprivation. DESIGN--Longitudinal study of the Office of Population Censuses and Surveys. SETTING--England. SUBJECTS--Random sample of nearly 300,000 people aged between 16 and 65 at the 1981 census and followed up for nearly nine years. MAIN OUTCOME MEASURE--Death from all causes between ages of 16 and 70. RESULTS--Without allowance for personal disadvantage, both sexes showed a clear, significant, and roughly linear positive relation between degree of deprivation of the ward of residence in 1981 and premature death before 1990. For men, this association was effectively explained away once allowance was made for individual socioeconomic circumstances. For women living in wards of above average deprivation, the association was also effectively removed, but the situation for other women was less clear. CONCLUSION--The excess mortality associated with residence in areas designated as deprived by census based indicators is wholly explained by the concentration in those areas of people with adverse personal or household socioeconomic factors. Health policy needs to target people as well as places.     

Paget's disease of bone in 14 British towns.

The radiological prevalence of Paget''s disease was studied in 14 towns. Routine radiographs showed that the disease was present in 5.4% of people aged 55 years and over. The disease was more prevalent in men than in women at all ages, and the prevalence increased with age. The three Lancashire towns studied (Preston, Bolton, and Blackburn) had higher rates than elsewhere. This probably reflects a real geographical variation in the prevalence of Paget''s disease in England and Wales.     

Bereavement and cancer: some data on deaths of spouses from the longitudinal study of Office of Population Censuses and Surveys.

Registration of cancer and mortality after the death of a spouse were assessed using data from the longitudinal study of the Office of Population Censuses and Surveys (OPCS). The study population comprised 1% of the people counted in England and Wales in the 1971 census, for whom data on subsequent vital events were linked with their census records. There was little evidence of an increase in registrations of cancer after the death of a spouse and only a slight suggestion of increased mortality from cancer. For other causes of death there was some evidence of increases in mortality during widow(er)hood. In so far as the death of a spouse is often a very stressful event, these data may be interpreted as providing little support for the hypothesis that stress is implicated in the aetiology of cancer.     

Mortality of employees of the United Kingdom Atomic Energy Authority, 1946-1979.

An analysis was conducted of 3373 deaths among 39 546 people employed by the United Kingdom Atomic Energy Authority between 1946 and 1979, the population having been followed up for an average of 16 years. Overall the death rates were below those prevailing in England and Wales but consistent with those expected in a normal workforce. At ages 15-74 years the standardised mortality ratios (SMRs) were 74 for deaths from all causes and 79 for deaths from all cancers. Mortality from only four causes was above the national average--namely, testicular cancer (SMR 153; 10 deaths), leukaemia (SMR 123; 35 deaths), thyroid cancer (SMR 122; three deaths), non-Hodgkin''s lymphoma (SMR 107; 20 deaths)--but in none was the increase significant at the 5% level. Half of the authority''s employees were recorded as having been monitored for exposure to radiation, their collective recorded exposure being 660 Sv (65 954 rem). Among these prostatic cancer was the only condition with a clearly increased mortality in relation to exposure. Of the 19 men who had a radiation record and died from prostatic cancer at ages 15-74 years, nine had been monitored for several different sources of exposure to radiation. The standardised mortality ratios were 889 (six deaths) in employees monitored for contamination by tritium, 254 (nine deaths) in those monitored for contamination by other radionuclides, and 385 (nine deaths) in those with dosimeter readings totalling more than 50 mSv (5 rem); but the same nine subjects tended to account for each of these significantly raised ratios. Because multiple exposures were common and other relevant information was not available the reason for the increased mortality from prostatic cancer in this population could not be determined and requires further investigation. Excess mortality rates of 2.2 and 12.5 deaths per million person years per 10 mSv (1 rem) were estimated for leukaemia and all cancers, respectively. The confidence limits around these estimates were wide, included zero, and made it unlikely that the International Commission on Radiological Protection''s cancer risk coefficients were underestimated by more than 15-fold. Thus despite this being the largest British workforce whose mortality has been reported in relation to low level ionising radiation exposure, even larger populations will need to be followed up over longer periods before narrower ranges of risk estimates can be derived.     

Why Londoners have low death rates from ischaemic heart disease and stroke.

OBJECTIVE--To explain the low death rates from cardiovascular disease in London. SETTING--London and the other counties of England and Wales. SUBJECTS--Women living in London during 1901-10 and people in London dying during 1968-78. RESULTS--At the beginning of the twentieth century young women aged 15-34 in London had remarkably low death rates, largely because of low rates for tuberculosis and other infectious diseases and low mortality during childbirth. Their low death rates contrasted with the high rates in girls under 15 years. CONCLUSIONS--Large numbers of young women had migrated into London from agricultural counties in southern England and went into domestic service, where the diet was usually very good. Recent findings suggest that a mother''s nutrition and health has a major effect on the risk of cardiovascular disease in the next generation. The low cardiovascular mortality in London is consistent with this, and contrasts with the high mortality from other common diseases.     

Contribution of deaths related to alcohol use of socioeconomic variation in mortality: register based follow up study.

OBJECTIVE: To estimate the contribution of excessive alcohol use to socioeconomic variation in mortality among men and women in Finland. DESIGN: Register based follow up study. SUBJECTS: The population covered by the 1985 and 1990 censuses, aged > or = 20 in the follow up period 1987-93. MAIN OUTCOME MEASURES: Total mortality and alcohol related mortality from all causes, from diseases, and from accidents and violence according to socioeconomic position. The excess mortality among other classes compared with upper non-manual employees and differences in life expectancy between the classes were used to measure mortality differentials. RESULTS: Alcohol related mortality constituted 11% of all mortality among men aged > or = 20 and 2% among women and was higher among manual workers than among other classes. It accounted for 14% of the excess all cause mortality among manual workers over upper non-manual employees among men and 4% among women and for 24% and 9% of the differences in life expectancy, respectively. Half of the excess mortality from accidents and violence among male manual workers and 38% among female manual workers was accounted for by alcohol related deaths, whereas in diseases the role of alcohol was modest. The contribution of alcohol related deaths to relative mortality differentials weakened with age. CONCLUSIONS: Class differentials in alcohol related mortality are an important factor in the socioeconomic mortality differentials in Finland, especially among men, among younger age groups, and in mortality from accidents and violence.     

Mortality in women in relation to their childbearing history.

With data from the Office of Population Censuses and Surveys'' longitudinal study the mortality of currently married women aged under 60 in 1971 was investigated in relation to the number of liveborn children reported at the 1971 census, adjusting for their husbands'' social class. Women who had never had children experienced a higher mortality from many causes of death than the parous women, and this was probably due, at least in part, to selective factors. When the analysis was confined to parous women mortality from diabetes mellitus and cervical cancer increased significantly and oesophageal cancer decreased significantly with increasing number of liveborn children. Mortality from all circulatory diseases and from hypertensive disease, ischaemic heart disease, and subarachnoid haemorrhage tended to rise with parity, though the trends were not statistically significant. Mortality from breast cancer decreased significantly with the number of liveborn children, but only when nullipara were included in the analyses. These data suggest that there may be residual and cumulative effects of childbearing which influence patterns of disease in the long term.     

Mortality from cardiovascular disease among interregional migrants in England and Wales.

OBJECTIVE--To investigate the extent to which geographical variations in mortality from ischaemic heart disease and stroke in Britain are influenced by factors in early life or in adulthood. DESIGN--Longitudinal study of migrants. SUBJECTS--1% sample of residents in England and Wales born before October 1939 and enumerated at the 1971 census (the Office of Population Censuses and Surveys'' longitudinal study). MAIN OUTCOME MEASURE--18,221 deaths from ischaemic heart disease and 9899 deaths from stroke during 1971-88 were analysed by areas of residence in 1939 and 1971. These included 2928 deaths from ischaemic heart disease and 1608 deaths from stroke among individuals moving between 14 areas defined by the major conurbations and nine standard administrative regions of England and Wales. RESULTS--The southeast to northwest gradient in mortality from ischaemic heart disease was related significantly to both the 1939 area (chi 2 = 6.09, df = 1) and area in 1971 (chi 2 = 5.05, df = 1). Geographical variations in mortality from stroke were related significantly to the 1939 area (chi 2 = 4.09, df = 1) but the effect of area in 1971 was greater (chi 2 = 8.07, df = 1). The effect of 1971 area on mortality from stroke was largely due to a lower risk of death from stroke among individuals moving into Greater London compared with migrants to the rest of the South East region (chi 2 = 4.54, df = 1). CONCLUSIONS--Geographical variations in mortality from cardiovascular disease in Britain may be partly determined by genetic factors, environmental exposures, or lifestyle acquired early in life, but the risk of fatal ischaemic heart disease and stroke changes on migration between areas with differing mortality. The low risk of death from stroke associated with residence in Greater London is acquired by individuals who move there.     

Mortality and age differences in marriage.

Data from the 1971 census population were used to evaluate the effects of age differences of married partners on mortality rates. Different age groups were isolated to highlight the association between mortality and age of spouse for specific ages of married men and women. Men married to much younger or to older women exhibited a higher mortality rate than men married to women who were only a few years younger than themselves. A similar trend was observed among women married to much younger or much older men compared with those whose spouses were a few years older or of similar ages as themselves. Trends for other age groups (women aged 60-69 years, men below 40, and women below 30) did not exhibit a clear pattern. Although statistical biases within age groups may in part account for the differences in the findings, the trend which emerged from the analysis suggests that lower morbidity is associated with the most common age combinations (husbands same age or slightly older than wives). Other factors could also account for the differences (e.g., selection of healthy partners in 1st marriages, differences in lifestyles between married and single).