Inequalities in Alcohol-Related Mortality in 17 European Countries: A Retrospective Analysis of Mortality Registers

Background

Socioeconomic inequalities in alcohol-related mortality have been documented in several European countries, but it is unknown whether the magnitude of these inequalities differs between countries and whether these inequalities increase or decrease over time.

Methods and Findings

We collected and harmonized data on mortality from four alcohol-related causes (alcoholic psychosis, dependence, and abuse; alcoholic cardiomyopathy; alcoholic liver cirrhosis; and accidental poisoning by alcohol) by age, sex, education level, and occupational class in 20 European populations from 17 different countries, both for a recent period and for previous points in time, using data from mortality registers. Mortality was age-standardized using the European Standard Population, and measures for both relative and absolute inequality between low and high socioeconomic groups (as measured by educational level and occupational class) were calculated.Rates of alcohol-related mortality are higher in lower educational and occupational groups in all countries. Both relative and absolute inequalities are largest in Eastern Europe, and Finland and Denmark also have very large absolute inequalities in alcohol-related mortality. For example, for educational inequality among Finnish men, the relative index of inequality is 3.6 (95% CI 3.3–4.0) and the slope index of inequality is 112.5 (95% CI 106.2–118.8) deaths per 100,000 person-years. Over time, the relative inequality in alcohol-related mortality has increased in many countries, but the main change is a strong rise of absolute inequality in several countries in Eastern Europe (Hungary, Lithuania, Estonia) and Northern Europe (Finland, Denmark) because of a rapid rise in alcohol-related mortality in lower socioeconomic groups. In some of these countries, alcohol-related causes now account for 10% or more of the socioeconomic inequality in total mortality.Because our study relies on routinely collected underlying causes of death, it is likely that our results underestimate the true extent of the problem.

Conclusions

Alcohol-related conditions play an important role in generating inequalities in total mortality in many European countries. Countering increases in alcohol-related mortality in lower socioeconomic groups is essential for reducing inequalities in mortality. Studies of why such increases have not occurred in countries like France, Switzerland, Spain, and Italy can help in developing evidence-based policies in other European countries.     

Socioeconomic differences in the associations between diabetes and hospital admission and mortality among older adults in Europe

The aim of this study is to explain the trends in socioeconomic inequality and diabetes outcomes in terms of hospital admission and death in old European people. The sample includes 73,301 individuals, across 16 European countries taken from the Survey of Health, Ageing and Retirement in Europe (SHARE). People being diagnosed of diabetes were more likely to be admitted to hospital than those without diabetes, although its effect dropped after controlling for clinical and functional complications. Largest asscociations were observed in women, people aged 50–65 years old, with medium educational level and medium household income. Diabetes was significant and positively related to mortality in the whole sample. Diabetes is significantly associated with mortality risk especially in males, oldest old people, low education and medium income people. These findings have important implications for public policies to reduce socioeconomic-related health inequalities.     

Do socioeconomic differences in mortality persist after retirement? 25 year follow up of civil servants from the first Whitehall study.

OBJECTIVE: To assess the risk of death associated with work based and non-work based measures of socioeconomic status before and after retirement age. DESIGN: Follow up study of mortality in relation to employment grade and car ownership over 25 years. SETTING: The first Whitehall study. SUBJECTS: 18,133 male civil servants aged 40-69 years who attended a screening examination between 1967 and 1970. MAIN OUTCOME MEASURE: Death. RESULTS: Grade of employment was a strong predictor of mortality before retirement. For men dying at ages 40-64 the lowest employment grade had 3.12 times the mortality of the highest grade (95% confidence interval 2.4 to 4.1). After retirement the ability of grade to predict mortality declined (rate ratio 1.86; 1.6 to 2.2). A non-work based measure of socioeconomic status (car ownership) predicted mortality less well than employment grade before retirement but its ability to predict mortality declined less after retirement. Using a relative index of inequality that was sensitive to the distribution among socioeconomic groups showed employment grade and car ownership to have independent associations with mortality that were of equal magnitude after retirement. The absolute difference in death rates between the lowest and highest employment grades increased with age from 12.9 per 1000 person years at ages 40-64 to 38.3 per 1000 at ages 70-89. CONCLUSIONS: Socioeconomic differences in mortality persist beyond retirement age and in magnitude increase with age. Social differentials in mortality based on an occupational status measure seem to decrease to a greater degree after retirement than those based on a non-work measure. This suggests that alongside other socioeconomic factors work itself may play an important part in generating social inequalities in health in men of working age.     

Health and social inequality in Europe.

In most European countries health has been shown to be linked to social circumstances--gradients in health status have persisted for decades, despite major changes in the principal causes of death. In central and eastern Europe life expectancy has stagnated since the mid-60s, whereas in the West it has increased; but even in the West it is related to income distribution. Social differences in mortality in men are three times as large in some countries as in others, and are influenced by factors other than conventional risk factors. Substantial declines in mortality and morbidity could result from a narrowing of health inequalities even when differences in health risk between social groups are comparatively small. Policies to reduce health inequalities can be introduced in smaller communities and organisations such as the school and workplace. National policies are variable; factors generating inequalities require action across several policy areas.     

Occupational Class Inequalities in All-Cause and Cause-Specific Mortality among Middle-Aged Men in 14 European Populations during the Early 2000s

This study analyses occupational class inequalities in all-cause mortality and four specific causes of death among men, in Europe in the early 2000s, and is the most extensive comparative analysis of occupational class inequalities in mortality in Europe so far. Longitudinal data, obtained from population censuses and mortality registries in 14 European populations, from around the period 2000–2005, were used. Analyses concerned men aged 30–59 years and included all-cause mortality and mortality from all cancers, all cardiovascular diseases (CVD), all external, and all other causes. Occupational class was analysed according to five categories: upper and lower non-manual workers, skilled and unskilled manual workers, and farmers and self-employed combined. Inequalities were quantified with mortality rate ratios, rate differences, and population attributable fractions (PAF). Relative and absolute inequalities in all-cause mortality were more pronounced in Finland, Denmark, France, and Lithuania than in other populations, and the same countries (except France) also had the highest PAF values for all-cause mortality. The main contributing causes to these larger inequalities differed strongly between countries (e.g., cancer in France, all other causes in Denmark). Relative and absolute inequalities in CVD mortality were markedly lower in Southern European populations. We conclude that relative and absolute occupational class differences in all-cause and cause specific mortality have persisted into the early 2000''s, although the magnitude differs strongly between populations. Comparisons with previous studies suggest that the relative gap in mortality between occupational classes has further widened in some Northern and Western European populations.     

Social inequalities and mortality in europe - results from a large multi-national cohort

Background

Socio-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.

Methods

A 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.

Results

Total 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.

Discussion

In 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.     

East-West mortality divide and its potential explanations: proposed research agenda.

There is a sharp divide in mortality between eastern and western Europe, which has largely developed over the past three decades and is caused mainly by chronic diseases in adulthood. The difference in life expectancy at birth between the best and worst European countries in this respect is more than 10 years for both sexes. The reasons for these differences in mortality are not clear and data currently available permit only speculation. The contributions of medical care and pollution are likely to be modest; health behaviour, diet, and alcohol consumption seem to be more important; smoking seems to have the largest impact. There is also evidence that psychosocial factors are less favourable in eastern Europe. Available data show socioeconomic gradients in all cause mortality within eastern European countries similar to those in the West. Determinants of the mortality gap between eastern and western Europe are probably related to the contrast in their social environments and may be similar to those underlying the social gradients in mortality within countries.     

Socio-economic transition, inequality, and mortality in Lithuania.

The study assessed inequalities in mortality of Lithuanian urban and rural populations throughout the period of socio-economic transition (1990-2000). Mortality from major causes of death, except cancers in females, was higher among the rural population. Inequality in mortality increased during the period of transition, especially among males, mainly due to more rapidly improving health of the urban population. Cardiovascular diseases and external causes made the largest contribution to the inequality. Differences in mortality of urban and rural populations point to greater social and psychological stress affecting the rural population, unhealthy life styles, inequities in accessibility of health care and lack of preventive programs in rural areas.     

Cancer mortality 1981–2016 and contribution of specific cancers to current socioeconomic inequalities in all cancer mortality: A population-based study

BackgroundIn many high-income countries cancer mortality rates have declined, however, socioeconomic inequalities in cancer mortality have widened over time with those in the most deprived areas bearing the greatest burden. Less is known about the contribution of specific cancers to inequalities in total cancer mortality.MethodsUsing high-quality routinely collected population and mortality records we examine long-term trends in cancer mortality rates in Scotland by age group, sex, and area deprivation. We use the decomposed slope and relative indices of inequality to identify the specific cancers that contribute most to absolute and relative inequalities, respectively, in total cancer mortality.ResultsCancer mortality rates fell by 24 % for males and 10 % for females over the last 35 years; declining across all age groups except females aged 75+ where rates rose by 14 %. Lung cancer remains the most common cause of cancer death. Mortality rates of lung cancer have more than halved for males since 1981, while rates among females have almost doubled over the same period.ConclusionCurrent relative inequalities in total cancer mortality are dominated by inequalities in lung cancer mortality, but with contributions from other cancer sites including liver, and head and neck (males); and breast (females), stomach and cervical (younger females). An understanding of which cancer sites contribute most to inequalities in total cancer mortality is crucial for improving cancer health and care, and for reducing preventable cancer deaths.     

Stagnant Neonatal Mortality and Persistent Health Inequality in Middle-Income Countries: A Case Study of the Philippines

Background

The probability of survival through childhood continues to be unequal in middle-income countries. This study uses data from the Philippines to assess trends in the prevalence and distribution of child mortality and to evaluate the country’s socioeconomic-related child health inequality.

Methodology

Using data from four Demographic and Health Surveys we estimated levels and trends of neonatal, infant, and under-five mortality from 1990 to 2007. Mortality estimates at national and subnational levels were produced using both direct and indirect methods. Concentration indices were computed to measure child health inequality by wealth status. Multivariate regression analyses were used to assess the contribution of interventions and socioeconomic factors to wealth-related inequality.

Findings

Despite substantial reductions in national under-five and infant mortality rates in the early 1990s, the rates of declines have slowed in recent years and neonatal mortality rates remain stubbornly high. Substantial variations across urban-rural, regional, and wealth equity-markers are evident, and suggest that the gaps between the best and worst performing sub-populations will either be maintained or widen in the future. Of the variables tested, recent wealth-related inequalities are found to be strongly associated with social factors (e.g. maternal education), regional location, and access to health services, such as facility-based delivery.

Conclusion

The Philippines has achieved substantial progress towards Millennium Development Goal 4, but this success masks substantial inequalities and stagnating neonatal mortality trends. This analysis supports a focus on health interventions of high quality – that is, not just facility-based delivery, but delivery by trained staff at well-functioning facilities and supported by a strong referral system – to re-start the long term decline in neonatal mortality and to reduce persistent within-country inequalities in child health.     

The relationship between socioeconomic status and infant mortality in metropolitan Ohio, 1999-2001

Empirical evidence has consistently documented the direct relationship between infant mortality and socioeconomic inequality in the United States and numerous other countries. While the majority of these studies reveal an inverse relationship between socioeconomic level and infant mortality, not even this finding is free from disagreement. Furthermore, the specific nature and magnitude of this relationship has varied over time. This study will examine the relationship between socioeconomic status and infant mortality in metropolitan Ohio by using birth and infant death data centered on the 2000 Census. The analyses presented herein will describe and analyze the relationship between infant mortality and socioeconomic status in metropolitan Ohio in the year 2000. The key finding is that in spite of remarkable declines in infant mortality during the past several decades, most notably in neonatal mortality, there continues to be a pronounced inverse association between the infant death rate and the economic status of a population.     

Social epidemiology of chronic liver disease and cirrhosis mortality in the United States, 1935-1997: trends and differentials by ethnicity, socioeconomic status, and alcohol consumption

This study examines trends and ethnic and socioeconomic differentials in chronic liver disease and cirrhosis mortality in the United States. Age-adjusted death rates from the National Vital Statistics System were used to analyze race and sex-specific mortality trends from 1968 through 1997. Age-adjusted liver cirrhosis mortality and per capita alcohol consumption data from 1935 through 1996 were modeled using time-series regression. Moreover, the Cox hazards regression was applied to the National Longitudinal Mortality Study, 1979-1989, to examine socioeconomic differentials at the individual level, whereas multivariate ordinary least squares regression was used to model state-specific cirrhosis mortality from 1990 to 1992 as a function of socioeconomic variables and alcohol consumption at the ecological level. Chronic liver disease and cirrhosis continues to be an important cause of death in the United States, even after three decades of consistently declining mortality rates. For both men and women aged 25 years and older, significant mortality differentials were found by age, race/ethnicity, marital status, family income, and employment status. For men, marked differentials were also found by nativity, rural-urban residence, and education. Unemployment, minority concentration, and alcohol consumption were major predictors of state-specific cirrhosis mortality. Both time-series and cross-sectional data indicate a strong correlation between alcohol consumption and US cirrhosis mortality. Substantial ethnic and socioeconomic differences in cirrhosis mortality suggest the need for social and public health policies and interventions that target such high-risk groups as American Indians, Hispanic Americans, the socially isolated, and the poor.     

Low fertility increases descendant socioeconomic position but reduces long-term fitness in a modern post-industrial society

Adaptive accounts of modern low human fertility argue that small family size maximizes the inheritance of socioeconomic resources across generations and may consequently increase long-term fitness. This study explores the long-term impacts of fertility and socioeconomic position (SEP) on multiple dimensions of descendant success in a unique Swedish cohort of 14 000 individuals born during 1915–1929. We show that low fertility and high SEP predict increased descendant socioeconomic success across four generations. Furthermore, these effects are multiplicative, with the greatest benefits of low fertility observed when SEP is high. Low fertility and high SEP do not, however, predict increased descendant reproductive success. Our results are therefore consistent with the idea that modern fertility limitation represents a strategic response to the local costs of rearing socioeconomically competitive offspring, but contradict adaptive models suggesting that it maximizes long-term fitness. This indicates a conflict in modern societies between behaviours promoting socioeconomic versus biological success. This study also makes a methodological contribution, demonstrating that the number of offspring strongly predicts long-term fitness and thereby validating use of fertility data to estimate current selective pressures in modern populations. Finally, our findings highlight that differences in fertility and SEP can have important long-term effects on the persistence of social inequalities across generations.     

Socioeconomic Inequalities in Smoking and Smoking Cessation Due to a Smoking Ban: General Population-Based Cross-Sectional Study in Luxembourg

This study aimed to measure changes in socioeconomic inequalities in smoking and smoking cessation due to the 2006 smoking ban in Luxembourg. Data were derived from the PSELL3/EU-SILC (Panel Socio-Economique Liewen Zu Letzebuerg/European Union—Statistic on Income and Living Conditions) survey, which was a representative survey of the general population aged ≥16 years conducted in Luxembourg in 2005, 2007, and 2008. Smoking prevalence and smoking cessation due to the 2006 smoking ban were used as the main smoking outcomes. Two inequality measures were calculated to assess the magnitude and temporal trends of socioeconomic inequalities in smoking: the prevalence ratio and the disparity index. Smoking cessation due to the smoking ban was considered as a positive outcome. Three multiple logistic regression models were used to assess social inequalities in smoking cessation due to the 2006 smoking ban. Education level, income, and employment status served as proxies for socioeconomic status. The prevalence of smoking decreased by 22.5% between 2005 and 2008 (from 23.1% in 2005 to 17.9% in 2008), but socioeconomic inequalities in smoking persisted. Smoking prevalence decreased by 24.2% and 20.2% in men and women, respectively; this difference was not statistically significant. Smoking cessation in daily smokers due to the 2006 smoking ban was associated with education level, employment status, and income, with higher percentages of quitters among those with a lower socioeconomic status. The decrease in smoking prevalence after the 2006 law was also associated with a reduction in socioeconomic inequalities, including differences in education level, income, and employment status. Although the smoking ban contributed to a reduction of such inequalities, they still persist, indicating the need for a more targeted approach of smoke-free policies directed toward lower socioeconomic groups.     

Entrenched Geographical and Socioeconomic Disparities in Child Mortality: Trends in Absolute and Relative Inequalities in Cambodia

Background

Cambodia has made considerable improvements in mortality rates for children under the age of five and neonates. These improvements may, however, mask considerable disparities between subnational populations. In this paper, we examine the extent of the country''s child mortality inequalities.

Methods

Mortality rates for children under-five and neonates were directly estimated using the 2000, 2005 and 2010 waves of the Cambodian Demographic Health Survey. Disparities were measured on both absolute and relative scales using rate differences and ratios, and where applicable, slope and relative indices of inequality by levels of rural/urban location, regions and household wealth.

Findings

Since 2000, considerable reductions in under-five and to a lesser extent in neonatal mortality rates have been observed. This mortality decline has, however, been accompanied by an increase in relative inequality in both rates of child mortality for geography-related stratifying markers. For absolute inequality amongst regions, most trends are increasing, particularly for neonatal mortality, but are not statistically significant. The only exception to this general pattern is the statistically significant positive trend in absolute inequality for under-five mortality in the Coastal region. For wealth, some evidence for increases in both relative and absolute inequality for neonates is observed.

Conclusion

Despite considerable gains in reducing under-five and neonatal mortality at a national level, entrenched and increased geographical and wealth-based inequality in mortality, at least on a relative scale, remain. As expected, national progress seems to be associated with the period of political and macroeconomic stability that started in the early 2000s. However, issues of quality of care and potential non-inclusive economic growth might explain remaining disparities, particularly across wealth and geography markers. A focus on further addressing key supply and demand side barriers to accessing maternal and child health care and on the social determinants of health will be essential in narrowing inequalities.     

Socioeconomic Factors and All Cause and Cause-Specific Mortality among Older People in Latin America,India, and China: A Population-Based Cohort Study

Background

Even in low and middle income countries most deaths occur in older adults. In Europe, the effects of better education and home ownership upon mortality seem to persist into old age, but these effects may not generalise to LMICs. Reliable data on causes and determinants of mortality are lacking.

Methods and Findings

The vital status of 12,373 people aged 65 y and over was determined 3–5 y after baseline survey in sites in Latin America, India, and China. We report crude and standardised mortality rates, standardized mortality ratios comparing mortality experience with that in the United States, and estimated associations with socioeconomic factors using Cox''s proportional hazards regression. Cause-specific mortality fractions were estimated using the InterVA algorithm. Crude mortality rates varied from 27.3 to 70.0 per 1,000 person-years, a 3-fold variation persisting after standardisation for demographic and economic factors. Compared with the US, mortality was much higher in urban India and rural China, much lower in Peru, Venezuela, and urban Mexico, and similar in other sites. Mortality rates were higher among men, and increased with age. Adjusting for these effects, it was found that education, occupational attainment, assets, and pension receipt were all inversely associated with mortality, and food insecurity positively associated. Mutually adjusted, only education remained protective (pooled hazard ratio 0.93, 95% CI 0.89–0.98). Most deaths occurred at home, but, except in India, most individuals received medical attention during their final illness. Chronic diseases were the main causes of death, together with tuberculosis and liver disease, with stroke the leading cause in nearly all sites.

Conclusions

Education seems to have an important latent effect on mortality into late life. However, compositional differences in socioeconomic position do not explain differences in mortality between sites. Social protection for older people, and the effectiveness of health systems in preventing and treating chronic disease, may be as important as economic and human development. Please see later in the article for the Editors'' Summary     

Factors Influencing Early and Late Mortality in Adults with Invasive Pneumococcal Disease in Calgary,Canada: A Prospective Surveillance Study

Background

Invasive pneumococcal disease continues to be an important cause of mortality. In Calgary, 60% of deaths occur within 5 days of presenting to hospital. This proportion has not changed since before the era of penicillin. The purpose of this study was to investigate what factors may influence death within 5 days of presentation with pneumococcal disease.

Methods and Findings

Demographic and clinical data from the CASPER (Calgary Area Streptococcus pneumoniae Epidemiology Research) study on 1065 episodes of invasive pneumococcal disease in adults (≥18 years) from 2000 to 2010 were analyzed. Adjusted multinomial regression was performed to analyze 3 outcomes: early mortality (<5 days post-presentation), late mortality (5-30 days post-presentation), and survival, generating relative risk ratios (RRR). Patients with severe disease had increased risk of early and late death. In multinomial regression with survivors as baseline, the risk of early death increased in those with a Charlson index ≥2 (RRR: 6.3, 95% CI: 1.8-21.9); the risk of late death increased in those with less severe disease and a Charlson ≥2 (RRR: 6.1, 95% CI: 1.4-27.7). Patients who never received appropriate antibiotics had 5.6X (95% CI: 2.4-13.1) the risk of early death. Risk of both early and late death increased by a RRR of 1.3 (95% CI: 1.2-1.4) per 5-year increase in age. In multinomial regression, there were no significant differences in the effects of the factors tested between early and late mortality.

Conclusions

Presenting with severe invasive pneumococcal disease, multiple comorbidities, and older age increases the risk of both early and late death. Patients who died early often presented too late for effective antibiotic therapy, highlighting the need for an effective vaccine.     

Money,morality and new forms of exchange in postsocialist Ukraine

One of the legacies of Soviet socialism is a moralizing lens through which to evaluate wealth and consumption practices. A contrast between the moral underpinnings of generating and consuming wealth under capitalism and those emerging in postsocialist Ukraine shows that socioeconomic differences are emerging as proxies for moral indictments that strain the social fabric. Soviet-era economic practices and exchange networks of favors are giving way to cash-based forms of exchange that are redefining moral commitments to social obligations. When legal codes are mobilized in diverse ways in response to divergent moralities the forging of moral consensus to shape emerging economic practices is rendered elusive.     

Relationships of Disability with Age Among Adults Aged 50 to 85: Evidence from the United States,England and Continental Europe

Objectives

To extend existing research on the US health disadvantage relative to Europe by studying the relationships of disability with age from midlife to old age in the US and four European regions (England/Northern and Western Europe/Southern Europe/Eastern Europe) including their wealth-related differences, using a flexible statistical approach to model the age-functions.

Methods

We used data from three studies on aging, with nationally representative samples of adults aged 50 to 85 from 15 countries (N = 48225): the US-American Health and Retirement Study (HRS), the English Longitudinal Study of Ageing (ELSA) and the Survey of Health, Ageing and Retirement in Europe (SHARE). Outcomes were mobility limitations and limitations in instrumental activities of daily living. We applied fractional polynomials of age to determine best fitting functional forms for age on disability in each region, while controlling for socio-demographic characteristics and important risk factors (hypertension, diabetes, obesity, smoking, physical inactivity).

Results

Findings showed high levels of disability in the US with small age-related changes between 50 and 85. Levels of disability were generally lower in Eastern Europe, followed by England and Southern Europe and lowest in Northern and Western Europe. In these latter countries age-related increases of disability, though, were steeper than in the US, especially in Eastern and Southern Europe. For all countries and at all ages, disability levels were higher among adults with low wealth compared to those with high wealth, with largest wealth-related differences among those in early old age in the USA.

Conclusions

This paper illustrates considerable variations of disability and its relationship with age. It supports the hypothesis that less developed social policies and more pronounced socioeconomic inequalities are related to higher levels of disability and an earlier onset of disability.