Disruption and selection: the income gradient in mortality among natives and migrants in Sweden.

BACKGROUND: The income gradient in mortality is generated through an interplay between socio-economic processes and health over the life course. International migration entails the displacement of an individual from one context to another and may disrupt these processes. Furthermore, migrants are a selected group that may adopt distinct strategies and face discrimination in the labour market. These factors may have implications for the income gradient in mortality. We investigate whether the income gradient in mortality differs by migrant status and by individual-level factors surrounding the migration event. METHODS: We use administrative register data comprising the total resident population in Sweden aged between 30 and 79 in 2015 (n = 5.7 million) and follow them for mortality during 2015-17. We estimate the income gradient in mortality by migrant status, region of origin, age at migration and country of education using locally estimated scatterplot smoothing and Poisson regression. RESULTS: The income gradient in mortality is less steep among migrants compared with natives. This pattern is driven by lower mortality among migrants at lower levels of income. The gradient is less steep among distant migrants than among close migrants, migrants that arrived as adults compared with children and migrants that received their education in Sweden as opposed to abroad. CONCLUSIONS: Our results are consistent with the notion that income inequalities in mortality are generated through life-course processes that may be disrupted by migration. Data restrictions prevent us from disentangling life-course disruption from selection into migration, discrimination and labour market strategies.

Smoking and inequalities in mortality in 11 European countries: a birth cohort analysis.

PURPOSE: To study the trends of smoking-attributable mortality among the low and high educated in consecutive birth cohorts in 11 European countries. METHODS: Register-based mortality data were collected among adults aged 30 to 79 years in 11 European countries between 1971 and 2012. Smoking-attributable deaths were estimated indirectly from lung cancer mortality rates using the Preston-Glei-Wilmoth method. Rate ratios and rate differences among the low and high-educated were estimated and used to estimate the contribution of inequality in smoking-attributable mortality to inequality in total mortality. RESULTS: In most countries, smoking-attributable mortality decreased in consecutive birth cohorts born between 1906 and 1961 among low- and high-educated men and high-educated women, but not among low-educated women among whom it increased. Relative educational inequalities in smoking-attributable mortality increased among both men and women with no signs of turning points. Absolute inequalities were stable among men but slightly increased among women. The contribution of inequality in smoking-attributable mortality to inequality in total mortality decreased in consecutive generations among men but increased among women. CONCLUSIONS: Smoking might become less important as a driver of inequalities in total mortality among men in the future. However, among women, smoking threatens to further widen inequalities in total mortality.

Next steps in the development of the social determinants of health approach: the need for a new narrative.

During the past 15-20 years the Social Determinants of Health (SDoH) framework has become the main approach to understand health inequalities. With this model a range of factors important for health and inequalities in health over the life-course have been connected into a larger framework. Despite its usefulness and popularity within the field, and wide use in influential reviews, the SDoH framework has not been easy to communicate to stakeholders in other sectors, and we cannot as yet see much of substantial societal change as a result of it. In this Commentary I try to discuss possible reasons behind our difficulties to communicate the SDoH perspective. Some of these reasons relate to how we frame and present the different parts of the framework, others are more linked to common beliefs and practices that I think we should rethink. In both cases, I believe that we would benefit from a more general discussion around these fundamental issues, both in order to communicate our important insights but also to better understand our own key study objective, namely how health inequalities are generated, sustained and potentially reduced.

A gold mine, but still no Klondike: Nordic register data in health inequalities research.

Aims: Future research on health inequality relies on data that cover life-course exposure, different birth cohorts and variation in policy contexts. Nordic register data have long been celebrated as a 'gold mine' for research, and fulfil many of these criteria. However, access to and use of such data are hampered by a number of hurdles and bottlenecks. We present and discuss the experiences of an ongoing Nordic consortium from the process of acquiring register data on socio-economic conditions and health in Denmark, Finland, Norway and Sweden. Methods: We compare experiences of data-acquisition processes from a researcher's perspective in the four countries and discuss the comparability of register data and the modes of collaboration available to researchers, given the prevailing ethical and legal restrictions. Results: The application processes we experienced were time-consuming, and decision structures were often fragmented. We found substantial variation between the countries in terms of processing times, costs and the administrative burden of the researcher. Concerned agencies differed in policy and practice which influenced both how and when data were delivered. These discrepancies present a challenge to comparative research. Conclusions: We conclude that there are few signs of harmonisation, as called for by previous policy documents and research papers. Ethical vetting needs to be centralised both within and between countries in order to improve data access. Institutional factors that seem to facilitate access to register data at the national level include single storage environments for health and social data, simplified ethical vetting and user guidance.

The next step towards more equity in health in Sweden: how can we close the gap in a generation?

In 2015, a national Commission for Equity in Health was appointed by the Swedish Government. In this paper, some key lines of thought from the three reports published by the Commission are summarised. First, the theories and principles for the Commission's work are outlined, in particular regarding the views taken on how health inequalities arise. Second, the importance of process is discussed in relation to cross-sectorial efforts to reduce inequalities in health. More specifically, this brings up some of the proposals made for how to redesign the public health policy framework for cross-sectorial work. Third, the proposed content of cross-sectorial work for more equal health is presented in three steps, namely: (1) overarching recommendations, (2) more equal conditions and opportunities, and (3) general problems of governance. Regarding people's conditions and opportunities, the Commission submitted a number of proposals for the general direction of work that needs to be taken in order to reduce health inequalities, as well as some examples of more specific policy changes or reforms on the basis of each of these general directions, which are summarised here. Finally, some challenges and difficulties that may prevent Sweden from taking the next step towards more equity in health are discussed.

The contribution of national disparities to international differences in mortality between the United States and 7 European countries.

OBJECTIVES: This study examined to what extent the higher mortality in the United States compared to many European countries is explained by larger social disparities within the United States. We estimated the expected US mortality if educational disparities in the United States were similar to those in 7 European countries. METHODS: Poisson models were used to quantify the association between education and mortality for men and women aged 30 to 74 years in the United States, Belgium, Denmark, Finland, France, Norway, Sweden, and Switzerland for the period 1989 to 2003. US data came from the National Health Interview Survey linked to the National Death Index and the European data came from censuses linked to national mortality registries. RESULTS: If people in the United States had the same distribution of education as their European counterparts, the US mortality disadvantage would be larger. However, if educational disparities in mortality within the United States equaled those within Europe, mortality differences between the United States and Europe would be reduced by 20% to 100%. CONCLUSIONS: Larger educational disparities in mortality in the United States than in Europe partly explain why US adults have higher mortality than their European counterparts. Policies to reduce mortality among the lower educated will be necessary to bridge the mortality gap between the United States and European countries.

Income and health in different welfare contexts: a comparison of Sweden, East and West Germany.

BACKGROUND: The aim of the present study is to explore whether the association between income and self-rated health in Sweden is similar to that in Germany. Both countries represent relatively similar economic contexts, but also different welfare traditions and historic experiences. Thus, the study compares Sweden with East Germany and West Germany in order to incorporate the aftereffects of reunification in East Germany. METHODS: The association between adjusted disposable household income and self-rated health is investigated by exploring cross-sectional survey data for the year 2000. In a sequence of logistic regression models, the risk for poor self-rated health across income quintiles is analysed, controlling for educational status and occupational position. Data sources are the Swedish Level-of-Living Survey and the German Socio-Economic Panel. RESULTS: A relationship between income and health was observed for Sweden, East Germany and West Germany, before as well as after controlling for education and occupational position. The associations were somewhat stronger for women than for men. Similar magnitudes of income-related poor health were detected across the investigated subsamples, but patterns were distinct in the three regions. The highest estimates were not always found in groups with the lowest income position. CONCLUSIONS: Given the variation in the results, we found neither advantages nor disadvantages that can be linked to the effectiveness of the welfare contexts under study. We could also not identify an income threshold for poor health across the investigated countries and settings. Nevertheless, the association between income and health persists, although the patterns vary across regional contexts.

Understanding the role of welfare state characteristics for health and inequalities - an analytical review.

BACKGROUND: The past decade has witnessed a growing body of research on welfare state characteristics and health inequalities but the picture is, despite this, inconsistent. We aim to review this research by focusing on theoretical and methodological differences between studies that at least in part may lead to these mixed findings. METHODS: Three reviews and relevant bibliographies were manually explored in order to find studies for the review. Related articles were searched for in PubMed, Web of Science and Google Scholar. Database searches were done in PubMed and Web of Science. The search period was restricted to 2005-01-01 to 2013-02-28. Fifty-four studies met the inclusion criteria. RESULTS: Three main approaches to comparative welfare state research are identified; the Regime approach, the Institutional approach, and the Expenditure approach. The Regime approach is the most common and regardless of the empirical regime theory employed and the amendments made to these, results are diverse and contradictory. When stratifying studies according to other features, not much added clarity is achieved. The Institutional approach shows more consistent results; generous policies and benefits seem to be associated with health in a positive way for all people in a population, not only those who are directly affected or targeted. The Expenditure approach finds that social and health spending is associated with increased levels of health and smaller health inequalities in one way or another but the studies are few in numbers making it somewhat difficult to get coherent results. CONCLUSIONS: Based on earlier reviews and our results we suggest that future research should focus less on welfare regimes and health inequalities and more on a multitude of different types of studies, including larger analyses of social spending and social rights in various policy areas and how these are linked to health in different social strata. But, we also need more detailed evaluation of specific programmes or interventions, as well as more qualitative analyses of the experiences of different types of policies among the people and families that need to draw on the collective resources.

The contribution of educational inequalities to lifespan variation.

BACKGROUND: Studies of socioeconomic inequalities in mortality consistently point to higher death rates in lower socioeconomic groups. Yet how these between-group differences relate to the total variation in mortality risk between individuals is unknown. METHODS: We used data assembled and harmonized as part of the Eurothine project, which includes census-based mortality data from 11 European countries. We matched this to national data from the Human Mortality Database and constructed life tables by gender and educational level. We measured variation in age at death using Theil's entropy index, and decomposed this measure into its between- and within-group components. RESULTS: The least-educated groups lived between three and 15 years fewer than the highest-educated groups, the latter having a more similar age at death in all countries. Differences between educational groups contributed between 0.6% and 2.7% to total variation in age at death between individuals in Western European countries and between 1.2% and 10.9% in Central and Eastern European countries. Variation in age at death is larger and differs more between countries among the least-educated groups. CONCLUSIONS: At the individual level, many known and unknown factors are causing enormous variation in age at death, socioeconomic position being only one of them. Reducing variations in age at death among less-educated people by providing protection to the vulnerable may help to reduce inequalities in mortality between socioeconomic groups.

Socioeconomic inequalities in homicide mortality: a population-based comparative study of 12 European countries.

Recent research has suggested that violent mortality may be socially patterned and a potentially important source of health inequalities within and between countries. Against this background the current study assessed socioeconomic inequalities in homicide mortality across Europe. To do this, longitudinal and cross-sectional data were obtained from mortality registers and population censuses in 12 European countries. Educational level was used to indicate socioeconomic position. Age-standardized mortality rates were calculated for post, upper and lower secondary or less educational groups. The magnitude of inequalities was assessed using the relative and slope index of inequality. The analysis focused on the 35-64 age group. Educational inequalities in homicide mortality were present in all countries. Absolute inequalities in homicide mortality were larger in the eastern part of Europe and in Finland, consistent with their higher overall homicide rates. They contributed 2.5% at most (in Estonia) to the inequalities in total mortality. Relative inequalities were high in the northern and eastern part of Europe, but were low in Belgium, Switzerland and Slovenia. Patterns were less consistent among women. Socioeconomic inequalities in homicide are thus a universal phenomenon in Europe. Wide-ranging social and inter-sectoral health policies are now needed to address the risk of violent victimization that target both potential offenders and victims.

Socioeconomic inequalities in mortality from conditions amenable to medical interventions: do they reflect inequalities in access or quality of health care?

BACKGROUND: Previous studies have reported large socioeconomic inequalities in mortality from conditions amenable to medical intervention, but it is unclear whether these can be attributed to inequalities in access or quality of health care, or to confounding influences such as inequalities in background risk of diseases. We therefore studied whether inequalities in mortality from conditions amenable to medical intervention vary between countries in patterns which differ from those observed for other (non-amenable) causes of death. More specifically, we hypothesized that, as compared to non-amenable causes, inequalities in mortality from amenable causes are more strongly associated with inequalities in health care use and less strongly with inequalities in common risk factors for disease such as smoking. METHODS: Cause-specific mortality data for people aged 30-74 years were obtained for 14 countries, and were analysed by calculating age-standardized mortality rates and relative risks comparing a lower with a higher educational group. Survey data on health care use and behavioural risk factors for people aged 30-74 years were obtained for 12 countries, and were analysed by calculating age-and sex-adjusted odds ratios comparing a low with a higher educational group. Patterns of association were explored by calculating correlation coefficients. RESULTS: In most countries and for most amenable causes of death substantial inequalities in mortality were observed, but inequalities in mortality from amenable causes did not vary between countries in patterns that are different from those seen for inequalities in non-amenable mortality. As compared to non-amenable causes, inequalities in mortality from amenable causes are not more strongly associated with inequalities in health care use. Inequalities in mortality from amenable causes are also not less strongly associated with common risk factors such as smoking. CONCLUSIONS: We did not find evidence that inequalities in mortality from amenable conditions are related to inequalities in access or quality of health care. Further research is needed to find the causes of socio-economic inequalities in mortality from amenable conditions, and caution should be exercised in interpreting these inequalities as indicating health care deficiencies.

Live long and prosper? Childhood living conditions, marital status, social class in adulthood and mortality during mid-life: a cohort study.

AIMS: The aim of the present study was to investigate the impact of childhood living conditions, marital status, and social class in adulthood on the risk of mortality during mid-life. Two questions were addressed: Is there an effect of childhood living conditions on mortality risk during mid-life and if so, is the effect mediated or modified by social class and/or marital status in adulthood? METHODS: A nationally representative, Swedish, level of living survey from 1968 was used as baseline. The study included those aged 25-69 at baseline (n = 4082). Social conditions in childhood and adulthood were assessed using self-reports. These individuals were then followed for 39 years using registry data on mortality. RESULTS: The results showed associations between childhood living conditions, marital status, social class in adulthood and mortality during mid life. Social class and familial conditions during childhood as well as marital status and social class in adulthood all contributed to the risk of mortality during mid-life. Individuals whose father's were manual workers, who grew up in broken homes, who were unmarried, and/or were manual workers in adulthood had an increased risk of mortality during mid life. The effects of childhood conditions were, in part, both mediated and modified by social class in adulthood. CONCLUSIONS: The findings of this study suggest that there are structural, social conditions experienced at different stages of the life course that affect the risk of mortality during mid-life.

Interdependent pathways between socioeconomic position and health: A Swedish longitudinal register-based study.

Health inequalities are generated by the conditions in which people are born, grow, live, work and age. From a life-course perspective, these conditions are formed by complex causal relationships with mutual and intertwined paths between socioeconomic position and health. This study attempts to disentangle some of these processes by examining pathways between socioeconomic position and health across the life-course. We used yearly Swedish national register data with information from over 31 years for two cohorts born 1941-1945 and 1961-1965. We analyzed associations between several indicators of childhood and adult socioeconomic position and health, measured by number of in-patient hospitalizations. We estimated within- and between-person associations using random intercept cross-lagged panel models. The results showed bi-directional associations between socioeconomic position and health that varied in strength across the life-course. Age variations in the associations were primarily observed when individuals aged into or out of age-stratified institutions. In ages where transitions from education to the labor market are common, the associations from health to income and education were strong. Around and after retirement age, the between-person association from health to income was weak, while the association from income to health strengthened. Within-person estimates showed no association between income and subsequent hospitalization among older persons, indicating no direct causal effect of income change on health in this age group. For persons of middle age, the associations were of similar strength in both directions and present at both the between- and within-person level. Our findings highlight the importance of theoretical frameworks and methods that can incorporate the interplay between social, economic, and biological processes over the life-course in order to understand how health inequalities are generated.

Changes in life expectancy and lifespan variability by income quartiles in four Nordic countries: a study based on nationwide register data.

OBJECTIVES: Levels, trends or changes in socioeconomic mortality differentials are typically described in terms of means, for example, life expectancies, but studies have suggested that there also are systematic social disparities in the dispersion around those means, in other words there are inequalities in lifespan variation. This study investigates changes in income inequalities in mean and distributional measures of mortality in Denmark, Finland, Norway, and Sweden over two decades. DESIGN: Nationwide register-based study. SETTING: The Danish, Finnish, Norwegian and Swedish populations aged 30 years or over in 1997 and 2017. MAIN OUTCOME MEASURES: Income-specific changes in life expectancy, lifespan variation and the contribution of 'early' and 'late' deaths to increasing life expectancy. RESULTS: Increases in life expectancy has taken place in all four countries, but there are systematic differences across income groups. In general, the largest gains in life expectancy were observed in Denmark, and the smallest increase among low-income women in Sweden and Norway. Overall, life expectancy increased and lifespan variation decreased with increasing income level. These differences grew larger over time. In all countries, a marked postponement of early deaths led to a compression of mortality in the top three income quartiles for both genders. This did not occur for the lowest income quartile. CONCLUSION: Increasing life expectancy is typically accompanied by postponement of early deaths and reduction of lifespan inequality in the higher-income groups. However, Nordic welfare societies are challenged by the fact that postponing premature deaths among people in the lowest-income groups is not taking place.

The role of welfare state principles and generosity in social policy programmes for public health: an international comparative study.

BACKGROUND: Many important social determinants of health are also the focus for social policies. Welfare states contribute to the resources available for their citizens through cash transfer programmes and subsidised services. Although all rich nations have welfare programmes, there are clear cross-national differences with respect to their design and generosity. These differences are evident in national variations in poverty rates, especially among children and elderly people. We investigated to what extent variations in family and pension policies are linked to infant mortality and old-age excess mortality. METHODS: Infant mortality rates and old-age excess mortality rates were analysed in relation to social policy characteristics and generosity. We did pooled cross-sectional time-series analyses of 18 OECD (Organisation for Economic Co-operation and Development) countries during the period 1970-2000 for family policies and 1950-2000 for pension policies. FINDINGS: Increased generosity in family policies that support dual-earner families is linked with lower infant mortality rates, whereas the generosity in family policies that support more traditional families with gainfully employed men and homemaking women is not. An increase by one percentage point in dual-earner support lowers infant mortality by 0.04 deaths per 1000 births. Generosity in basic security type of pensions is linked to lower old-age excess mortality, whereas the generosity of earnings-related income security pensions is not. An increase by one percentage point in basic security pensions is associated with a decrease in the old age excess mortality by 0.02 for men as well as for women. INTERPRETATION: The ways in which social policies are designed, as well as their generosity, are important for health because of the increase in resources that social policies entail. Hence, social policies are of major importance for how we can tackle the social determinants of health.

Educational inequalities in cancer mortality differ greatly between countries around the Baltic Sea.

OBJECTIVE: To compare educational inequalities in cancer mortality between Poland, Lithuania, Estonia, Finland and Sweden. METHODS: Data are either follow-up or unlinked cross-sectional studies. The relative index of inequality (RII) and the slope index of inequality (SII) are calculated to express the magnitude of mortality differences according to educational level for all cancers and for specific cancers. RESULTS: Large educational inequalities in total cancer mortality were observed, particularly amongst men. Inequalities in upper aero-digestive tract and lung cancer in men and cervix cancer in women were larger in Poland, Lithuania and Estonia, whereas inequalities in lung cancer in women were larger in Finland and Sweden. CONCLUSIONS: Countries of the Baltic Sea region differ strongly with regard to the magnitude and pattern of the educational inequalities in cancer mortality.

The contribution of alcohol consumption and smoking to educational inequalities in life expectancy among Swedish men and women during 1991-2008.

OBJECTIVES: To assess the level and changes in contribution of smoking and alcohol-related mortality to educational differences in life expectancy in Sweden. METHODS: We used register data on the Swedish population at ages 30-74 during 1991-2008. Cause of death was used to identify alcohol-related deaths, while smoking-related mortality was estimated using lung cancer mortality to indirectly assess the impact of smoking on all-cause mortality. RESULTS: Alcohol consumption and smoking contributed to educational differences in life expectancy. Alcohol-related mortality was higher among men and contributed substantially to inequalities among men and made a small (but increasing) contribution to inequalities among women. Smoking-related mortality decreased among men but increased among women, primarily among the low educated. At the end of the follow-up, smoking-related mortality were at similar levels among men and women. The widening gap in life expectancy among women could largely be attributed to smoking. CONCLUSIONS: Smoking and alcohol consumption contribute to educational differences in life expectancy among men and women. The majority of the widening in the educational gap in mortality among women can be attributed to alcohol and smoking-related mortality.

Influence of affordability of alcohol on educational disparities in alcohol-related mortality in Finland and Sweden: a time series analysis.

BACKGROUND: Prices of alcohol and income tend to influence how much people buy and consume alcohol. Price and income may be combined into one measure, affordability of alcohol. Research on the association between affordability of alcohol and alcohol-related harm is scarce. Furthermore, no research exists on how this association varies across different subpopulations. We estimated the effects of affordability of alcohol on alcohol-related mortality according to gender and education in Finland and Sweden. METHODS: Vector-autoregressive time series modelling was applied to the quarter-annual aggregations of alcohol-related deaths and affordability of alcohol in Finland in 1988-2007 and in Sweden in 1991-2008. Alcohol-related mortality was defined using information on both underlying and contributory causes of death. We calculated affordability of alcohol index using information on personal taxable income and prices of various types of alcohol. RESULTS: Among Finnish men with secondary education, an increase of 1% in the affordability of total alcohol was associated with an increase of 0.028% (95% CI 0.004 to 0.053) in alcohol-related mortality. Similar associations were also found for affordability for various types of alcohol and for beer only in the lowest education group. We found few other significant positive associations for other subpopulations in Finland or Sweden. However, reverse associations were found among secondary-educated Swedish women. CONCLUSIONS: Overall, the associations between affordability of alcohol and alcohol-related mortality were relatively weak. Increased affordability of total alcoholic beverages was associated with higher rates of alcohol-related mortality only among Finnish men with secondary education.