Socioeconomic inequalities in avoidable mortality in Italy: results from a nationwide longitudinal cohort.

BACKGROUND: Disparities in avoidable mortality have never been evaluated in Italy at the national level. The present study aimed to assess the association between socioeconomic status and avoidable mortality. METHODS: The nationwide closed cohort of the 2011 Census of Population and Housing was followed up for 2012-2019 mortality. Outcomes of preventable and of treatable mortality were separately evaluated among people aged 30-74. Education level (elementary school or less, middle school, high school diploma, university degree or more) and residence macro area (North-West, North-East, Center, South-Islands) were the exposures, for which adjusted mortality rate ratios (MRRs) were calculated through multivariate quasi-Poisson regression models, adjusted for age at death. Relative index of inequalities was estimated for preventable, treatable, and non-avoidable mortality and for some specific causes. RESULTS: The cohort consisted of 35,708,459 residents (48.8% men, 17.5% aged 65-74), 34% with a high school diploma, 33.5% living in the South-Islands; 1,127,760 deaths were observed, of which 65.2% for avoidable causes (40.4% preventable and 24.9% treatable). Inverse trends between education level and mortality were observed for all causes; comparing the least with the most educated groups, a strong association was observed for preventable (males MRR = 2.39; females MRR = 1.65) and for treatable causes of death (males MRR = 1.93; females MRR = 1.45). The greatest inequalities were observed for HIV/AIDS and alcohol-related diseases (both sexes), drug-related diseases and tuberculosis (males), and diabetes mellitus, cardiovascular diseases, and renal failure (females). Excess risk of preventable and of treatable mortality were observed for the South-Islands. CONCLUSIONS: Socioeconomic inequalities in mortality persist in Italy, with an extremely varied response to policies at the regional level, representing a possible missed gain in health and suggesting a reassessment of priorities and definition of health targets.

Infant mortality in Italy: large geographic and ethnic inequalities.

BACKGROUND: Neonatal and infant mortality rates are among the most significant indicators for assessing a country's healthcare and social development. This study examined the trends in neonatal, post-neonatal, and infant mortality in Italy from 2016 to 2020 and analysed differences between children of Italian and foreign parents based on areas of residence, as well as the leading causes of death. Special attention was given to the analysis of mortality in 2020, the first year of the Covid-19 pandemic, and its comparison with previous years. METHODS: Data from 2016 to 2020 were collected by the Italian National Institute of Statistics and extracted from two national databases, the Causes of Death register and Live births registered in the population register. Neonatal, post-neonatal, and infant mortality rates were calculated using conventional definitions. The main analyses were conducted by comparing Italian citizens to foreigners and contrasting residents of the North with those of the South. Group comparisons were made using mortality rate ratios. The main causes of death were examined, and Poisson log-linear regression models were employed to investigate the relationships between mortality rate ratios for each cause of death and citizenship, place of residence and calendar year. RESULTS: In Italy, in 2020, the neonatal mortality rate was 1.76 deaths per thousand live births and it was 55% higher in foreign children than in Italian children. Foreign children had a higher mortality rate than Italians for almost all significant causes of death. Children born in the South of Italy, both Italian and foreign, had an infant mortality rate about 70% higher than residents in the North. Regions with higher infant mortality were Calabria, Sicily, Campania, and Apulia. In the South, mortality from neonatal respiratory distress and prematurity was higher. In the first months of 2020, between March and June, the first Covid-19 wave, Italy experienced an increase in neonatal and infant mortality compared to the same period in 2016-2019, not directly related to SARS-CoV-19 infection. The primary cause was neonatal respiratory distress. CONCLUSIONS: The neonatal and infant mortality rates indicate the persistence of profound inequalities in Italy between the North and the South and between Italian and foreign children.

[Effects of the COVID-19 pandemic on the inequalities in total mortality by country of birth]. / Gli effetti della pandemia di COVID-19 sulle disuguaglianze nella mortalità totale per Paese di nascita.

OBJECTIVES: to evaluate the impact on total mortality of the COVID-19 pandemic in Italy, by country of birth. DESIGN: historic cohort study based on administrative databases. SETTING AND PARTICIPANTS: the study is based on subjects included in the Base Register of Individuals of the Italian National Institute of Statistics on 01.01.2019, aged 35-64 years, and followed-up until 31.07.2021. MAIN OUTCOME MEASURES: age-standardized mortality rates were computed to analyse trends in overall mortality by country of birth grouped in three categories: 1. Italy and other high developed countries; 2. European countries with strong migratory pressure (EU-SMP); 3, non-European countries with strong migratory pressure (non-EU-SMP). Variations in mortality rates during the pandemic (March 2020-July 2021) with respect to the pre-pandemic period (January 2019-February 2020) were measured and compared across groups using mortality rate ratios (MRR) estimated by Poisson regression models, separately for men and women. RESULTS: the cohort includes 26,199,241 individuals, of whom 172,847 died during the follow-up. Over the whole period, mortality was consistently lower in individuals born in non-EU-SMP countries as compared to those born in Italy and other high developed countries. During the first pandemic wave (March-April 2020), individuals born in non-EU-SMP countries had higher excesses as compared to those born in Italy or other high developed countries (MRRs: 1.42 vs 1.28 in men and 1.30 vs 1.11 in women). Similar results were observed during the pandemic period October 2020-April 2021, when the MRRs were 1.37 vs 1.20 in men and 1.30 vs 1.11 in women. In the same period, the excess mortality among individuals born in EU-SMP did not significantly differ from that observed among those born in Italy and other high developed countries. CONCLUSIONS: in Italy, excess mortality during the COVID-19 pandemic was higher among immigrants born in non-EU-SMP countries as compared to the native population and immigrants born in high developed countries.

Education inequalities in overall mortality during the first wave of the COVID-19 pandemic in Italy.

BACKGROUND: there is increasing concern that the COVID-19 pandemic has disproportionately affected the most vulnerable individuals. OBJECTIVES: to determine whether education inequalities have widened during the first wave of the COVID-19 pandemic in Italy. DESIGN: historic cohort study based on administrative databases. SETTING AND PARTICIPANTS: the study was based on subjects registered in the Base Register of Individuals on 01.01.2019, aged >=35 years, and followed-up until 30.06.2020. MAIN OUTCOME MEASURES: education inequalities in mortality before, during the first phase (March-April), and during the second phase (May-June) of the first pandemic wave in Italy were measured through the mortality rate ratios (MRRs). MMRs were estimated through negative binomial models. The interaction term between period and education was tested through the likelihood ratio test. RESULTS: the cohort included 37,976,670 individuals, and 719,665 of them died over the follow-up. In high pandemic areas, the MRR among less educated men were: 1.48 (95%CI 1.42-1.55) in the pre-pandemic period, 1.45 (95%CI 1.36-1.55) in the first phase and 1.42 (95%CI 1.30-1.56) in the second phase of the pandemic (p-value: 0.92). Corresponding figures among women were: 1.26 (95%CI 1.21-1.32), 1.39 (95%CI 1.30-1.49), and 1.35 (95%CI 1.23-1.48); p-value: 0.03. The MRRs substantially increased in the first pandemic phase among women aged 35-64 years (from 1.48 to 1.98; p-value; 0.011) and 65-79 years (from 1.22 to 1.51; p-value: 0.017). During the second phase, the MRRs returned to the values observed before the pandemic. CONCLUSIONS: in Italy, education inequality in mortality widened during the COVID-19 pandemic among working-age women and those aged 65-79 years.

Geographic Inequalities in Breast Cancer in Italy: Trend Analysis of Mortality and Risk Factors.

We calculated time trends of standardised mortality rates and risk factors for breast cancer (BC) from 1990 to 2016 for all women resident in Italy. The age-standardised mortality rate in Italy decreased from 4.2 in 1990 to 3.2 (×100,000) in 2016. While participation in organised screening programmes and age-standardised fertility rates decreased in Italy, screening invitation coverage and mammography uptake, the prevalence of women who breastfed and mean age at birth increased. Although southern regions had favourable prevalence of protective risk factors in the 1990s, fertility rates decreased in southern regions and increased in northern regions, which in 2016 had a higher rate (1.28 vs. 1.32 child per woman) and a smaller increase in women who breastfed (+4% vs. +30%). In 2000, mammography screening uptake was lower in southern than in northern and central regions (28% vs. 52%). However, the increase in mammography uptake was higher in southern (203%) than in northern and central Italy (80%), reducing the gap. Participation in mammographic screening programmes decreased in southern Italy (-10%) but increased in the North (6.6%). Geographic differences in mortality and risk factor prevalence is diminishing, with the South losing all of its historical advantage in breast cancer mortality.

Italian Atlas of mortality inequalities by education level. / Atlante italiano delle disuguaglianze di mortalità per livello di istruzione.

OBJECTIVES: To evaluate the geographical and socioeconomic differences in mortality and in life expectancy in Italy; to evaluate the proportion of mortality in the population attributable to a medium-low education level through the use of maps and indicators. DESIGN: Longitudinal design of the population enrolled in the 2011 Italian Census, following the population over time and registering any exit due to death or emigration. SETTING AND PARTICIPANTS: The study used the database of the Italian National Institute of Statistics (Istat) developed by linking the 2011 Census with the Italian National Register of Causes of Death (2012-2014) for 35 groups of causes of death. Age, sex, residence, and education level information were collected from the Census. MAIN OUTCOME MEASURES: Life expectancy at birth was calculated by sex, Italian region, and education level. For the population aged 30-89 years, the following items were developed by sex: 1. provincial maps showing, for each cause of death, the distribution in quintiles of smoothed standardized mortality ratio (SMR), adjusted for age and education level and estimated with Bayesian models for small areas (spatial conditional autoregressive model); 2. regional maps of population attributable fraction (PAF) for low and medium education levels, calculated starting from age-standardized mortality ratios; 3. tables illustrating for each region standardized mortality rates and standardized years of life lost rate by age (standardized YLL rate), and mortality rate ratios standardized by age (MMRs). RESULTS: Males with a lower education level throughout Italy show a life expectancy at birth that is 3 years less than those with higher education; residents in Southern Italy lose an additional year in life expectancy, regardless of education level. Social inequalities in mortality are present in all regions, but are more marked in the poorer regions of Southern Italy. Geographical differences, taking into account the different population distributions in terms of age and education level, produce mortality differences for all causes: from -15% to +30% in women and from -13% to +26% in men, compared to the national average. Among the main groups of causes, the geographical differences are greater for cardiovascular diseases, respiratory diseases, and accidents, and lower for many tumour sites. A clear mortality gradient with an excess in Southern Italy can be seen for cardiovascular diseases: there are some areas where mortality for people with higher education level is higher than that for residents in Northern Italy with low education level. The gradient for "All tumours", instead, is from South to North, as it is for most single tumour sites. Population attributable fraction for low education level in Italy, taking into account the population distribution by age, is 13.4% in women and 18.3% in men. CONCLUSIONS: The study highlighted important geographical differences in mortality, regardless of age and socioeconomic level, with a more significant impact in the poorer Southern regions, revealing a never-before-seen health advantage in the regions along the Adriatic coast. A lower education level explains a considerable proportion of mortality risk, although with differing effects by geographical area and cause of death. There are still mortality inequalities in Italy, therefore, representing a possible missed gain in health in our Country; these inequalities suggest a reassessment of priorities and definition of health targets. Forty years after the Italian National Health Service was instituted, the goal of health equity has not yet been fully achieved.

Inequalities in infant mortality in Italy.

BACKGROUND: All the children of the world should be born equal, but this is not so: even in Italy, there are striking differences already at birth. Neonatal and infant mortality are accurate indexes to assess the demographic wellbeing and quality of life of a population. The aim of the present study is to analyze the infant (IMR) and neonatal (NMR) mortality rates of Italian and foreign children and to evaluate if there is a disparity among geographical macro-areas. METHODS: Data from 2006 to 2015 were collected by the Italian Statistics Bureau (ISTAT) and extracted from two different national databases, which considered i) underlying cause of death and ii) birth registry. Mortality rates were calculated using conventional definitions. The main analyses were made comparing Italian versus foreigners as a single category as well as by country origin and contrasting Northern residents versus Southern ones. Comparisons between groups were done using relative risks. RESULTS: Data show disparity in neonatal and infant mortality among immigrant and Italian residents. In 2015, neonatal (3.0 vs. 1.8/1000) and infant (4.5 vs 2.6/1000) mortality rates were higher among foreign children compared to Italian children. Among babies born to immigrant women, there is a higher infant mortality among children born to women coming from Central and South Africa (8.2 /1000). Inequalities are reported even among Italian regions: in Southern Italy, infant mortality is 1.4 fold higher than in Northern Italy. CONCLUSION: Inequalities in neonatal and infant mortality are evident between Italians and immigrants and among geographical macro-areas There is therefore urgent need for a political and social plan focusing on infancy.

[Differences in mortality by educational level in Italy (2012-2014)]. / Differenze nella mortalità per livello di istruzione in Italia (2012-2014).

OBJECTIVES: to evaluate socioeconomic inequalities in mortality by educational level in Italy. DESIGN: cohort study based on the record linkage between the 2012-2014 archives of mortality and the 2011 Italian population Census. SETTING AND PARTICIPANTS: Italian population registered in the 2011 Census. MAIN OUTCOME MEASURES: life expectancy by educational level, age-standardized mortality rates, mortality rate ratios (MRRs) for overall mortality, and 12 groups of causes of death. RESULTS: life expectancy at birth was 80.3 years among men and 84.9 among women. High-educated men were expected to live 3 years longer than lower educated men, while the gap was narrower in women (1.5 years). Lower educated men had a higher mortality from any cause (MRR: 1.34; 95%CI 1.33-1.35) with larger differentials for lung, upper aerodigestive, and liver cancers, respiratory system diseases, AIDS and accidents. Socioeconomic inequalities were larger in the North-West of the Country for lung and liver cancer. Educational inequalities were smaller among women for all-cause mortality, but remarkably larger for circulatory system diseases (MRR: 1.40; 95%CI 1.38-1.42), particularly in the South (MRR: 1.46; 95%CI 1.42-1.50). CONCLUSIONS: this study documented socioeconomic inequalities in mortality in Italy for many causes of death; some of them resulted heterogeneous by area of residence. Most of the inequalities can be counteracted with specific measures aimed to improve behavioural risk factors among less educated people.

Mortality by occupation-based social class in Italy from 2012 to 2014.

OBJECTIVES: Evaluating socio-economic inequality in cause-specific mortality among the working population requires large cohort studies. Through this census-based study, we aimed to quantify disparities in mortality across occupation-based social classes in Italy. METHODS: We conducted a historical cohort study on a sample of more than 16 million workers. We estimated the mortality rate ratios for each social class, considering upper non-manual workers as reference. RESULTS: Non-skilled manual workers showed an increased mortality from upper aero-digestive tract, stomach and liver cancers, and from diseases of the circulatory system, transport accidents and suicides in both sexes, and from infectious diseases, diabetes, lung and bladder cancers only in men. Among women, an excess mortality emerged for cervical cancer, whereas mortality from breast and ovarian cancers was lower. When education was taken into account, the excess mortality decreased in men while was no longer significant in women. CONCLUSIONS: There are remarkable disparities across occupation-based social classes in the Italian working population that favour the upper non-manual workers. Our data could be useful in planning policies for a more effective health and social security system.

Differences in education and premature mortality: a record linkage study of over 35 million Italians.

Background: Large, representative studies are needed to evaluate cause-specific aspects of socio-economic inequalities in mortality. Methods: We conducted a census-based retrospective cohort study to quantify differences in cause-specific premature mortality by educational level in Italy. We linked the 2011 Italian census with 2012 and 2013 death registries. We used the mortality rate ratio (MRR) as a measure of relative inequality. Results: Overall, 305 043 deaths (190 061 men-114 982 women) were registered from a population of 35 708 445 subjects aged 30-74. The age-standardized mortality rate for all educational levels was 57.68 deaths per 10 000 person-years among men and 31.41 among women. MRR from all causes was 0.51 (95% CI: 0.49; 0.52) in men and 0.63 (95% CI: 0.61; 0.65) in women for the highest (university) compared to the lowest level of education (none or primary school). The association was stronger in single than in married individuals: MRRs were 0.36 (95% CI: 0.34; 0.39) in single men, 0.57 (95% CI: 0.55; 0.59) in married men, 0.44 (95% CI: 0.40; 0.47) in single women and 0.69 (95% CI: 0.66; 0.72) in married women. High education was associated with lower mortality from liver, circulatory, chronic respiratory and genitourinary diseases in both sexes. Highly educated men had a lower mortality from lung cancer than less educated men, whereas highly educated women did not have a reduced mortality from lung and breast cancers. Conclusion: Level of education is a strong indicator of premature mortality. The magnitude of the association between educational level and mortality differs across sexes, marital status and causes of death.

Educational inequality in cancer mortality: a record linkage study of over 35 million Italians.

PURPOSE: Large studies are needed to evaluate socioeconomic inequality for site-specific cancer mortality. We conducted a longitudinal census-based national study to quantify the relative inequality in cancer mortality among educational levels in Italy. METHODS: We linked the 2011 Italian census with the 2012 and 2013 death registries. Educational inequality in overall cancer and site-specific cancer mortality were evaluated by computing the mortality rate ratio (MRR). RESULTS: A total of 35,708,445 subjects aged 30-74 years and 147,981 cancer deaths were registered. Compared to the lowest level of education (none or primary school), the MRR for all cancers in the highest level (university) was 0.57 (95% CI 0.55; 0.58) in men and 0.84 (95% CI 0.81; 0.87) in women. Higher education was associated with reduced risk of mortality from lip, oral cavity, pharynx, oesophagus, stomach, colon and liver in both sexes. Higher education (university) was associated with decreased risk of lung cancer in men (MRR: 0.43, 95% CI 0.41; 0.46), but not in women (MRR: 1.00, 95% CI 0.92; 1.10). Highly educated women had a reduced risk of mortality from cervical cancer than lower educated women (MRR: 0.39, 95% CI 0.27; 0.56), but they had a similar risk for breast cancer (MRR: 1.01, 95% CI 0.94; 1.09). CONCLUSIONS: Education is inversely associated with total cancer mortality, and the association was stronger in men. Different patterns and trends in tobacco smoking in men and women account for at least most of the gender differences.

Estimating the need for palliative care at the population level: A cross-national study in 12 countries.

BACKGROUND: To implement the appropriate services and develop adequate interventions, detailed estimates of the needs for palliative care in the population are needed. AIM: To estimate the proportion of decedents potentially in need of palliative care across 12 European and non-European countries. DESIGN: This is a cross-sectional study using death certificate data. SETTING/PARTICIPANTS: All adults (⩾18 years) who died in 2008 in Belgium, Czech Republic, France, Hungary, Italy, Spain (Andalusia, 2010), Sweden, Canada, the United States (2007), Korea, Mexico, and New Zealand ( N = 4,908,114). Underlying causes of death were used to apply three estimation methods developed by Rosenwax et al., the French National Observatory on End-of-Life Care, and Murtagh et al., respectively. RESULTS: The proportion of individuals who died from diseases that indicate palliative care needs at the end of life ranged from 38% to 74%. We found important cross-country variation: the population potentially in need of palliative care was lower in Mexico (24%-58%) than in the United States (41%-76%) and varied from 31%-83% in Hungary to 42%-79% in Spain. Irrespective of the estimation methods, female sex and higher age were independently associated with the likelihood of being in need of palliative care near the end of life. Home and nursing home were the two places of deaths with the highest prevalence of palliative care needs. CONCLUSION: These estimations of the size of the population potentially in need of palliative care provide robust indications of the challenge countries are facing if they want to seriously address palliative care needs at the population level.

[Healthy Life Years: a very promising indicator to be handled with caution]. / La speranza di vita per condizioni di salute (Healthy Life Years): un indice di grande interesse, ma da utilizzare con prudenza.

In several public debates, scientific conferences and, recently, also in the scientific literature, some figures from EUROSTAT have been presented; they show a relevant decrease in the healthy life expectancy in Italy. This idea is based on the analysis of the trend of Healthy Life Years (HLY), an indicator synthesizing the grade of functional limitation of individuals based on the answers to a self-completed questionnaire. In particular, the dramatic decrease of HLY in Italy from 2005 to 2007 raised concerns. This paper analyses the reasons suggesting caution in interpreting these data considering first and foremost the changes across years in the formulation of questions and answers. Even though HLY and the other indicators selected by the European Union have a great potential in terms of communication and synthetic view, caution is needed in using these data and in drawing conclusions from figures and instruments of recent application that are still evolving.