Unemployment and mortality in a large Italian cohort.

BACKGROUND: Aim of this study was to examine the association between unemployment and mortality, taking into account potential confounders of this association. A secondary objective was to assess whether the association between unemployment and mortality was modified by lack of household economic resources. METHODS: Prospective cohort composed of a representative sample of Italian subjects 30-55 years who participated in the Italian National Health Survey 1999-2000, followed up for mortality up to 2012 (15 656 men and 11 463 women). Data were analyzed using Cox regression models, stratified by gender and adjusted for health status, behavioral risk factors, socioeconomic position and position in the household. The modifying effect of the lack of economic resources was assessed by testing its interaction with unemployment on mortality. RESULTS: Among women, unemployment was not associated with mortality, whereas among men, higher mortality was found from all causes (HR = 1.82), which was not modified by lack of economic resources, and from neoplasms (HR = 1.59), cardiovascular diseases (HR = 2.58) and suicides (HR = 5.01). CONCLUSIONS: Results for men were robust to the adjustment for main potential confounders, suggesting a causal relationship between unemployment and mortality. The lack of effect modification by economic resources supports the relevance of the loss of non-material benefits of work on mortality.

The contribution of behavioural and metabolic risk factors to socioeconomic inequalities in mortality: the Italian Longitudinal Study.

OBJECTIVES: The aim of this study was to assess social inequalities in overall mortality in a representative sample of the Italian population, and to evaluate the contribution of behavioural and metabolic risk (BMF) factors to these inequalities. METHODS: 85,308 participants aged 25-74 years from the Italian Longitudinal Study were included in the study population and followed up for mortality (1999-2012). Level of education was used as a proxy for socioeconomic status. The contribution of BMF was estimated assessing the attenuation of the risk by education produced by the inclusion of BMF in regression model. RESULTS: Men with the lowest education had 62% and women had 57% greater risk of dying than those with the highest education. Among men, adjustment for BMF produced an attenuation of the mortality risk between extreme classes of education by 22%, while among women the risk attenuation was 7%. CONCLUSIONS: Large educational differences in mortality were observed for both men and women. BMF reduced by approximately 20% differences in mortality relative risk between extreme classes of education in men. In contrast, a very low contribution was observed in women.

The Role of Contextual Socioeconomic Circumstances and Neighborhood Poverty Segregation on Mortality in 4 European Cities.

Several studies have recognized the health disadvantage of residents in socioeconomically deprived neighborhoods, independent of the influence of individual socioeconomic conditions. The effect of neighborhood socioeconomic deprivation on general mortality has appeared heterogeneous among the cities analyzed: the underlying mechanisms have been less empirically explored, and explanations for this heterogeneous health effect remain unclear. The present study aimed to: (1) analyze the distribution of socioeconomically disadvantaged persons in neighborhoods of 4 European cities-Turin, Barcelona, Stockholm and Helsinki-trying to measure segregation of residents according to their socioeconomic conditions. Two measuring approaches were used, respectively, through dissimilarity index and clustering estimated from Bayesian models. (2) Analyze the distribution of mortality in the above mentioned cities, trying to disentangle the independent effects of both neighborhood socioeconomic deprivation and neighborhood segregation of residents according to their socioeconomic conditions, using multilevel models. A significantly higher risk of death was observed among residents in more deprived neighborhoods in all 4 cities considered, slightly heterogeneous across them. Poverty segregation appeared to be slightly associated with increasing mortality in Turin and, among females and only according to dissimilarity, in Barcelona. Few studies have explored the health effects of social clustering, and results could inform urban policy design with regard to social mix.

Decreasing educational differences in mortality over 40 years: evidence from the Turin Longitudinal Study (Italy).

BACKGROUND: Recent studies suggest that inequalities in premature mortality have continued to rise over the last decade in most European countries, but not in southern European countries. METHODS: In this study, we assess long-term trends (1971-2011) in absolute and relative educational inequalities in all-cause and cause-specific mortality in the Turin Longitudinal Study (Turin, Italy), a record-linkage study including all individuals resident in Turin in the 1971, 1981, 1991 and 2001 censuses, and aged 30-99 years (more than 2 million people). We examined mortality for all causes, cardiovascular disease (CVD), all cancers and specific cancers (lung, breast), as well as smoking and alcohol-related mortality. RESULTS: Overall mortality substantially decreased in all educational groups over the study period, although cancer rates only slightly declined. Absolute inequalities decreased for both genders (SII=962/694 in men/women in 1972-1976 and SII=531/259 in 2007-2011, p<0.01). Among men, absolute inequalities for CVD and alcohol-related causes declined (p<0.05), while remaining stable for other causes of death. Among women, declines in absolute inequalities were observed for CVD, smoking and alcohol-related causes and lung cancer (p<0.05). Relative inequalities in all-cause mortality remained stable for men and decreased for women (RII=1.92/2.03 in men/women in 1972-1976 and RII=2.15/1.32 in 2007-2011). Among men, relative inequalities increased for smoking-related causes, while among women they decreased for all cancers, CVD, smoking-related causes and lung cancer (p<0.05). CONCLUSIONS: Absolute inequalities in mortality strongly declined over the study period in both genders. Relative educational inequalities in mortality were generally stable among men; while they tended to narrow among women. In general, this study supports the hypothesis that educational inequalities in mortality have decreased in southern European countries.

Socioeconomic inequalities in cause-specific mortality in 15 European cities.

BACKGROUND: Socioeconomic inequalities are increasingly recognised as an important public health issue, although their role in the leading causes of mortality in urban areas in Europe has not been fully evaluated. In this study, we used data from the INEQ-CITIES study to analyse inequalities in cause-specific mortality in 15 European cities at the beginning of the 21st century. METHODS: A cross-sectional ecological study was carried out to analyse 9 of the leading specific causes of death in small areas from 15 European cities. Using a hierarchical Bayesian spatial model, we estimated smoothed Standardized Mortality Ratios, relative risks and 95% credible intervals for cause-specific mortality in relation to a socioeconomic deprivation index, separately for men and women. RESULTS: We detected spatial socioeconomic inequalities for most causes of mortality studied, although these inequalities differed markedly between cities, being more pronounced in Northern and Central-Eastern Europe. In the majority of cities, most of these causes of death were positively associated with deprivation among men, with the exception of prostatic cancer. Among women, diabetes, ischaemic heart disease, chronic liver diseases and respiratory diseases were also positively associated with deprivation in most cities. Lung cancer mortality was positively associated with deprivation in Northern European cities and in Kosice, but this association was non-existent or even negative in Southern European cities. Finally, breast cancer risk was inversely associated with deprivation in three Southern European cities. CONCLUSIONS: The results confirm the existence of socioeconomic inequalities in many of the main causes of mortality, and reveal variations in their magnitude between different European cities.

Social inequalities in total and cause-specific mortality of a sample of the Italian population, from 1999 to 2007.

BACKGROUND: There is extensive documentation on social inequalities in mortality across Europe, showing heterogeneity among countries. Italy contributed to this comparative research, through longitudinal systems from northern or central cities of the country. This study aims to analyse educational inequalities in general and cause-specific mortality in a sample of the Italian population. METHODS: Study population was selected within a cohort of 123,056 individuals, followed up for mortality through record linkage with national archive of death certificates for the period 1999-2007. People aged between 25 and 74 years were selected (n = 81,763); relative risks of death by education were estimated through Poisson models, stratified according to sex and adjusted for age and geographic area of residence. Heterogeneity of risks by area of residence was evaluated. RESULTS: Men and women with primary education or less show 79% and 63% higher mortality risks, respectively, compared with graduates. Mortality risks seem to frequently increase with decreasing education, with a significant linear trend among men. For men, social inequalities appear related to mortality due to diseases of the circulatory system and to all neoplasms, whereas for women, they are related to inequalities in cancer mortality. CONCLUSIONS: Results from the first follow-up of a national sample highlight that Italy presents significant differences in mortality according to the socio-economic conditions of both men and women. These results not only challenge policies aimed at redistributing resources to individuals and groups, but also those policies that direct programmes and resources for treatment and prevention according to the different health needs.

[Life expectancy, strenuous work and pension system's fairness. First evidence from the Work Histories Italian Panel]. / Aspettative di vita, lavori usuranti ed equità del sistema previdenziale. Prime evidenze dal Work Histories Italian Panel.

OBJECTIVE: the study aims to estimate the differentials in life expectancy by income and work history in Italy during the 2000's, in order to evaluate the level of actuarial equity of the recent Italian retirement reform in computing benefits proportional to the contributions paid. DESIGN: retrospective cohort study. SETTING AND PARTICIPANTS: mortality follow up of a 1% sample of the Italian workforce employed or self employed in the private sector, retired between 1985 and 2003 (about 63,000 people), whose work history and income since 1985 is registered in the National Institute for Social Insurance (INPS) data base. MAIN OUTCOME MEASURE: mortality differentials computed through Cox model. RESULTS: social inequalities in survival in favour of the more advantaged categories of income and occupational classes are observed. CONCLUSION: the principle of actuarial equity assumes that life expectancy varies only according to age and birth cohort; nevertheless inequalities in life expectancy exist also along other dimensions, like income and occupational class: this means that the system is producing an opposite redistribution, from the careers more socially disadvantaged to the less disadvantaged ones.

Educational inequalities in cancer incidence in Turin, Italy.

The objective of this study was to investigate the relationship between cancer incidence and socioeconomic status, and to examine the temporal trends in social inequalities in cancer risk. Educational differentials in the incidence of cancer (25 sites) among adult residents of Turin (Italy) were examined using data from the Turin Longitudinal Study and the Piedmont Cancer Registry. The relationship between cancer incidence and educational level was evaluated over three 5-year periods between 1985 and 1999 using Poisson models. An estimated 17% of malignancies among men in the low-educational group were attributable to education, whereas women with a low educational level were slightly protected. Less-educated men had higher risks of upper aero-digestive tract, stomach, lung, liver, rectal, bladder, central nervous system and ill-defined cancers, and lower risks of melanoma, kidney and prostate cancers. Women with lower educational levels were at higher risk of stomach, liver and cervical cancers, whereas they were less likely to be diagnosed with melanoma, ovarian and breast cancers. For most sites, the educational gradient in risk did not vary substantially over time. The educational inequalities in cancer incidence observed in this cohort appear similar in magnitude and direction to socioeconomic inequalities found in other Western countries; for some cancer sites results partly differ from the results of other studies, and require further investigation. A thorough understanding of the relative burden of well-documented causes of social inequalities in cancer risk is essential to address preventive measures and to direct future research on unexplained social differences.

[Objectives, tools and methods for an epidemiological use of electronic health archives in various areas of Italy]. / Obiettivi, strumenti e metodi per un utilizzo epidemiologico di archivi sanitari elettronici correnti in diverse aree italiane.

The availability of Electronic Health Archives (EHA) has increased remarkably over the last twenty years. As part of a joint project of the Italian Association of Epidemiology (AIE) and the Italian Association of Medical Statistics and Clinical Epidemiology (SISMEC), a workgroup of experts was set up in 2005 with the aim of comparing various experiences and of standardizing the procedures by which electronic sources can be integrated. In particular, the workgroup's aim was to estimate the frequency of certain major diseases using standard algorithms applied to EHA. This volume is published with the purpose of making available in a common publication the methods and the results obtained. The results from a multicentre study using a standard approach to probabilistic record-linkage procedures are also included in a specific chapter. Eleven Italian centres from five Italian regions with an overall population of 11,932,026 collected and treated more than 21,374,426 records (year 2003) from five electronic information sources: death certificates, hospital discharge records (including outpatient discharges), drug prescriptions, tax- exemptions, and pathology records in order to estimate the frequency of the following diseases: diabetes, ischemic heart diseases, acute myocardial infarction, stroke, asthma, chronic obstructive pulmonary disease, obstructive lung diseases. For each pathology a specific algorithm was developed and used by all centres for the identification of the prevalent/incident cases of the selected diseases. Standardized methods were used to estimate the rates. The results confirm the need for a common standard approach to produce estimates based on EHA, considering the variability of the quality and of the completeness of the archives, and the difficulties of standardizing record-linkage operations in the various centres. The main achievement of this work was the elimination of the variability due to the use of different algorithms to identify cases using EHA.

[Diabetes prevalence estimated using a standard algorithm based on electronic health data in various areas of Italy]. / Stima della prevalenza di diabete basata su dati sanitari correnti mediante un algoritmo comune in differenti aree italiane.

AIMS: the goal of this study was to estimate the prevalence of diabetes through record linkage of various data sources in four Italian areas. SETTING: Aulss 12 Veneziana, Aulss 4 Alto vicentino, Torino, ASL10 of Firenze. PARTICIPANTS: all 2002 to 2004 residents in the four areas (n = 2,123,913 on 30th June 2003). MAIN OUTCOME: crude prevalence by age and gender and standardized prevalence by gender. METHODS: we used three different data sources. The first was the set of files of all persons discharged from hospitals with a primary or secondary diagnosis of diabetes (ICD-9-CM code 250*) in the year of interest or in the four previous years. The second data source was the set of files of all prescriptions of antidiabetic drugs (ATC code: A10A* and A10B*) prescribed in the year of interest; we considered as persons with diabetes only those who had at least two prescriptions of antidiabetic drugs at two different times. The third source was the set of files of all subjects who obtained exemption from payment of drugs or laboratory testing due to a diagnosis of diabetes mellitus in the year of interest or in the 3 previous years. All data sources were matched by a deterministic linkage procedure. We defined as "prevalent case" those persons who were present in at least one of the three data sources. We compared the estimated prevalence in the four different areas. RESULTS: in 2003, the prevalence of diabetes in the four areas ranged from 3.93% to 5.55% among men, and from 3.55% to 4.52% among women. After adjustment for age, differences among men were reduced and were no longer present among women. Prevalence is higher among the elderly and among men. CONCLUSIONS: using routinely collected data we were able to identify large cohorts of persons with known diabetes and to estimate the prevalence of the disease, which was shown to be highly homogeneous among participating centres, and similar to that reported in other studies conducted in Italy with more costly and time consuming methods.

Statins prescribing for the secondary prevention of ischaemic heart disease in Torino, Italy. A case of ageism and social inequalities.

BACKGROUND: Socio-demographic and clinical characteristics can influence statins prescribing for the secondary prevention of ischaemic heart disease (IHD). We studied the determinants of the prescription of statins in people with IHD in a population in Italy, the country with the lowest prescribing rate in Europe. METHODS: All 2001/2002 residents in Torino, aged 30-85 years, with a hospital discharge diagnosis of IHD were linked to the regional Database of Drug Prescriptions to identify those persons who, within 3 months after discharge, had been prescribed statins. Log-binomial models were used to test statins prescription associations with clinical and socio-demographic characteristics. RESULTS: Statins were prescribed to 31.0% of 7446 patients. Among persons >74 years of age, the prescription rate was 40% lower than that found for younger persons. A positive association was also found for: female gender, being married, a main discharge diagnosis of acute myocardial infarction, revascularization, diabetes and discharge from a cardiology ward. Age was an important effect modifier of the relationship between the prescribing rate and social, but not clinical, determinants. CONCLUSIONS: The prevention of IHD with statins is influenced by age, clinical and social factors. The prescribing rate is higher among population groups for whom statins are of proven efficacy. Among patients for whom the efficacy is uncertain, the decision to prescribe is influenced by non-clinical factors, suggesting that there exist both age-based and social-based mechanisms of rationing. Age and social determinants act in concert to further reduce the propensity of physicians to prescribe statins.

Factors other than risks in the workplace as determinants of socioeconomic differences in health in Italy.

To evaluate differences in mortality by social class and to determine the impacts of socioeconomic factors on health inequalities in Italy, mortality data from 1981-2001 were analyzed as a function of social class in Turin, controlling for occupational risks, housing conditions, and education. For general and cause-specific mortality, the weight of each socioeconomic indicator was evaluated on population-attributable fraction to social class. Among men, mortality risk was significantly higher in unskilled blue-collar workers (RR = 1.45). Among women, the differences by social class were slighter. Education and economic status mostly explain the mortality differences by social class in men, while economic status showed the highest contribution in women.

[Use of ISTAT mortality records for follow up study and local mortality data base]. / Archivi nominativi di mortalità ISTAT per studi di sopravvivenza e per registri nominativi delle cause di morte: valore d'uso e metodi di linkage.

The aim of the present study is to assess the quality of the variables "name" and "surname" recorded in the mortality records that the Italian Institute of Statistics (ISTAT) releases to its regional offices since 1999. These records could both constitute a regional mortality database in those regions that do not have one, and be a useful tool for ascertainment of vital status in follow-up studies. The study was conducted in Turin, North West Italy, through record linkage between ISTAT database and the local population register that records all deaths occurred among residents. This was considered as the gold standard. Firstly the concordance of name and surname was studied; this was 92% if the full length of name and surname was used raising to 97% using substrings of the two information. Secondly the cohort of 1999-2001 residents in Turin was linked to the ISTAT database using a four step record linkage with four different keys. 94,3% of subjects were correctly found. Within those not linked there was a higher proportion of subjects born abroad, women, young and unmarried. We conclude that the quality of ISTAT database should be further improved before implementing its use for follow-up studies.

Social mobility and health in the Turin longitudinal study.

One of the most controversial explanations of class inequalities in health is the health selection hypothesis or drift hypothesis which suggests there is a casual link between the health status of individuals and their chances of social mobility, both inter- and intra-generational. This study tests this hypothesis, and tries to answer three related questions: (a) to what extent does health status influence the chances of intra-generational mobility of individuals? (b) what is the impact on health inequalities of the various kinds of social mobility (both mobility in the labour market and exit from employment)-do they increase or reduce inequalities? (c) to what extent does health-related intra-generational social mobility contribute to the production of health inequalities? The data analysed in this paper were drawn from the records of the Turin Longitudinal Study, which was set up to monitor health inequality of the Turin population by combining census data, population registry records and medical records. Occupational mobility was observed during the decade 1981-1991. To evaluate the impact of the various processes of social mobility on health inequalities, mortality was observed over the period 1991-1999. The study population consists of men and women aged 25-49 at the beginning of mortality follow-up (1991), and registered as resident in Turin at both the 1981 and the 1991 censuses (N = 127,384). Health status was determined by observing hospital admission. For the purpose of the study healthy individuals were those with no hospital admissions during the period 1984-1986, while those admitted were classed as unhealthy. Social mobility in the labour market was measured via an interval data index of upward and downward movements on a scale of social desirability of occupations, designed for the Italian labour force via an empirical study carried out by de Lillo and Schizzerotto (La valutazione sociale delle occupazioni. Una scala di stratificazione occupazionale per l'Italia contemporanea, Il Mulino, Bologna, 1985). Movement out of the labour market was described by a discrete variable with four conditions: employed, unemployed, early retired and women returning from work to the housewife status. The relationship between health status and occupational mobility was analysed via analysis of variance and multinomial logistic regression. Health inequalities were measured by the ratio of standardised mortality rates in the unskilled working class and the upper middle class. The study found a weak relationship between health status and occupational mobility chances. Decidedly stronger was the impact on occupational mobility of gender, education and "ethnicity" (being born in the South of Italy). The relationship between occupational mobility and health takes two different forms. Occupational mobility in the labour market decreases health inequalities; occupational mobility out of the labour market (early retirement, unemployment, housewife return) widens them. The maximum contribution health-related intra-generational social mobility can make towards health inequalities was estimated at about 13% for men.

Association between social class and food consumption in the Italian EPIC population.

AIMS AND BACKGROUND: The objectives of the present study were to validate the social stratification variables adopted by the European Prospective Investigation into Cancer and Nutrition (EPIC) by comparing them with data from another independent source and to evaluate the geographic and social distribution of eating habits in the Italian EPIC population. METHODS: The validation of the socioeconomic data collected by the EPIC study was performed with the Turin Longitudinal Study as gold standard and using Cohen's kappa statistics to evaluate the concordance between the studies. We then analyzed food groups based on the consumption of meat and fats, carbohydrates, sweets and alcohol, and on an index of the Mediterranean diet. The standardized scores for each food group were subdivided into quartiles, which were used to compare persons in the extreme quartiles. Analysis of the differences in eating habits by center and by educational level was conducted separately for men and women, calculating the prevalence rate ratios and controlling for age, area of birth and body mass index. RESULTS: Concordance between the two data sources was high for educational level and low for the social-class index based on occupation. Most of the eating habits considered to be potentially harmful (high consumption of meat or fats and alcohol and low consumption of olive oil and fish) were more frequent in Northern than in Southern Italy. These habits were inversely correlated with educational level, especially in the South. CONCLUSIONS: A significant improvement in health could be obtained in the Italian population if culturally and socioeconomically disadvantaged individuals were to abandon their diet rich in meat and fats, as done by more advantaged persons. In the absence of preventive interventions specifically addressed to disadvantaged groups, it is likely that social inequalities in mortality and morbidity will increase.