Parents survive longer after stroke than childless individuals: a prospective cohort study of Swedes over the age of 65.

BACKGROUND: Parents have lower mortality than childless individuals, and one possible explanation is support provided by adult children. Since stroke often results in functional limitations, support from children may be of particular importance. Here, we examine whether the presence of children matters for survival after stroke among older Swedish men and women. METHODS: This prospective cohort study linked data from several Swedish population registers. Individuals aged 65 years and older hospitalized for their first ischemic stroke between 1998 and 2002 (33 960 men and 36 189 women) were followed 12 years for survival. Hazard ratios for all-cause mortality were calculated by number of children using Cox proportional hazard regression stratified by sex and marital status and adjusted for education, income and comorbidities. RESULTS: Childlessness and having only one child was associated with higher mortality after stroke compared with having two children among men and women. The relative survival disadvantage of childless individuals was largest among married women [HR 1.28 (1.18-1.39)] and smallest among married men [1.09 (1.03-1.15)]. The differences in predicted median survival between childless individuals and those with two children were 4 and 7 months among married and unmarried men, and 15 and 9 months among married and unmarried women, respectively. CONCLUSIONS: Having children is associated with a longer survival after stroke among men and women regardless of marital status. Our findings further suggest that the presence of children is especially connected to married women's survival. These results may have implications for the improvement of informal care for childless older individuals.

The Spillover Influence of Partner's Education on Myocardial Infarction Incidence and Survival.

BACKGROUND: Education is believed to have positive spillover effects across network connections. Partner's education may be an important resource preventing the incidence of disease and helping patients cope with illness. We examined how partner's education predicted myocardial infarction (MI) incidence and survival net of own education and other socioeconomic resources in Finland. METHODS: A sample of adults aged 40-69 years at baseline in Finland in 1990 was followed up for MI incidence and mortality during the period 1991-2007 (n = 354,100). RESULTS: Lower own and spousal education both contributed independently to a higher risk of MI incidence and fatality when mutually adjusted. Having a partner with basic education was particularly strongly associated with long-term fatality in women with a hazard ratio of 1.53 (95% confidence interval, 1.22-1.92) compared with women with tertiary level educated partners. There was some evidence that the incidence risk associated with basic spousal education was weaker in those with own basic education. The highest risks of MI incidence and fatality were consistently found in those without a partner, whereas the most favorable outcomes were in households where both partners had a tertiary level of education. CONCLUSIONS: Accounting for spousal education demonstrates how health-enhancing resources accumulate to some households. Marriage between people of similar educational levels may therefore contribute to the widening of educational differences in MI incidence and survival.

Causal effect of education on mortality in a quasi-experiment on 1.2 million Swedes.

In 1949-1962, Sweden implemented a 1-y increase in compulsory schooling as a quasi-experiment. Each year, children in a number of municipalities were exposed to the reform and others were kept as controls, allowing us to test the hypothesis that education is causally related to mortality. We studied all children born between 1943 and 1955, in 900 Swedish municipalities, with control for birth-cohort and area differences. Primary outcome measures are all-cause and cause-specific mortality until the end of 2007. The analyses include 1,247,867 individuals, of whom 92,351 died. We found lower all-cause mortality risk in the experimental group after age 40 [hazard ratio (HR) = 0.96, 95% confidence interval (CI) 0.93-0.99] but not before (HR = 1.03, 95% CI 0.98-1.07) or during the whole follow-up (HR = 0.98, 95% CI 0.95-1.01). After age 40, the experimental group had lower mortality from overall cancer, lung cancer, and accidents. In addition, exposed women had lower mortality from ischemic heart disease, and exposed men lower mortality from overall external causes. In analyses stratified for final educational level, we found lower mortality in the experimental group within the strata that settled for compulsory schooling only (HR = 0.94, 95% CI 0.89-0.99) and compulsory schooling plus vocational training (HR = 0.92, 95% CI 0.88-0.97). Thus, the experimental group had lower mortality from causes known to be related to education. Lower mortality in the experimental group was also found among the least educated, a group that clearly benefited from the reform in terms of educational length. However, all estimates are small and there was no evident impact of the reform on all-cause mortality in all ages.

Social class and cause of death.

BACKGROUND: Previous studies have shown that causes of death differ in their relationship to social class, but we lack a more comprehensive description of this variation. The present study provides a detailed and extensive list of social class differences for a large number of specific causes of death. METHODS: All deaths between 1991 and 2003 in Sweden were linked with information on household social class from 1990. Relative death risks and excess mortality in groups of causes according to the European shortlist were estimated separately for men and women in eight classes using Cox Regression. RESULTS: A clear mortality gradient among employees was found for the majority of causes, from low-relative death risks among higher managerial and professional occupations to relatively high risks for the unskilled working class. There is considerable variation in the strength of the association, from causes such as malignant melanoma, breast cancer and transport accidents among women, where no clear class differences were found. At the other extreme, mental and behavioural disorders, endocrine, nutritional and metabolic diseases and diseases of the respiratory system all show steep slopes for both men and women. Circulatory diseases and cancer together account for 15-20% of excess mortality. CONCLUSIONS: Exceptions to the general pattern--causes of death in which higher social classes are exposed to greater death risks or in which there is no mortality gradient--are practically non-existent. There is nevertheless significant variation in the strength of the class differences in specific causes.

Partner resources and incidence and survival in two major causes of death.

Because people tend to marry social equals - and possibly also because partners affect each other's health - the social position of one partner is associated with the other partner's health and mortality. Although this link is fairly well established, the underlying mechanisms are not fully identified. Analyzing disease incidence and survival separately may help us to assess when in the course of the disease a partner's resources are of most significance. This article addresses the importance of partner's education, income, employment status, and health for incidence and survival in two major causes of death: cancer and cardiovascular diseases (CVD). Based on a sample of Finnish middle-aged and older couples (around 200,000 individuals) we show that a partner's education is more often connected to incidence than to survival, in particular for CVD. Once ill, any direct effect of partner's education seems to decline: The survival chances after being hospitalized for cancer or CVD are rather associated with partner's employment status and/or income level when other individual and partner factors are adjusted for. In addition, a partner's history of poor health predicted higher CVD incidence and, for women, lower cancer survival. The findings suggest that various partner's characteristics may have different implications for disease and survival, respectively. A wider focus on social determinants of health at the household level, including partner's social resources, is needed.

Family of origin and educational inequalities in mortality: Results from 1.7 million Swedish siblings.

Circumstances in the family of origin have short- and long-term consequences for people's health. Family background also influences educational achievements - achievements that are clearly linked to various health outcomes. Utilizing population register data, we compared Swedish siblings with different levels of education (1,732,119 individuals within 662,095 sibships) born between 1934 and 1959 and followed their death records until the end of 2012 (167,932 deaths). The educational gradient in all-cause mortality was lower within sibships than in the population as a whole, an attenuation that was strongest at younger ages (< 50 years of age) and for those with a working class or farmer background. There was substantial variation across different causes of death with clear reductions in educational inequalities in, e.g., lung cancer and diabetes, when introducing shared family factors, which may indicate that part of the association can be ascribed to circumstances that siblings have in common. In contrast, educational inequalities in suicide and, for women, other mental disorders increased when adjusting for factors shared by siblings. The vast variation in the role of childhood conditions for the education-mortality association may help us to further understand the interplay between family background, education, and mortality. The increase in the education gradient in suicide when siblings are compared may point towards individually oriented explanations ('non-shared environment'), perhaps particularly in mental disorders, while shared family factors primarily seem to play a more important role in diseases in which health behaviors are most significant.

Four Decades of Educational Inequalities in Hospitalization and Mortality among Older Swedes.

BACKGROUND: The inverse association between education and mortality has grown stronger the last decades in many countries. During the same period, gains in life expectancy have been concentrated to older ages; still, old-age mortality is seldom the focus of attention when analyzing trends in the education-mortality gradient. It is further unknown if increased educational inequalities in mortality are preceded by increased inequalities in morbidity of which hospitalization may be a proxy. METHODS: Using administrative population registers from 1971 and onwards, education-specific annual changes in the risk of death and hospital admission were estimated with complimentary log-log models. These risk changes were supplemented by estimations of the ages at which 25, 50, and 75% of the population had been hospitalized or died (after age 60). RESULTS: The mortality decline among older people increasingly benefitted the well-educated over the less well-educated. This inequality increase was larger for the younger old, and among men. Educational inequalities in the age of a first hospital admission generally followed the development of growing gaps, but at a slower pace than mortality and inequalities did not increase among the oldest individuals. CONCLUSIONS: Education continues to be a significant predictor of health and longevity into old age. That the increase in educational inequalities is greater for mortality than for hospital admissions (our proxy of overall morbidity) may reflect that well-educated individuals gradually have obtained more possibilities or resources to survive a disease than less well-educated individuals have the last four decades.

Adult children's socioeconomic positions and their parents' mortality: a comparison of education, occupational class, and income.

Recent research has shown that the parents of well-educated children live longer than do other parents and that this association is only partly confounded by the parent's own socioeconomic position. However, the relationships between other aspects of children's socioeconomic position (e.g., occupational class and economic resources) and parental mortality have not been examined. Using the Swedish Multi-generation Register that connects parents to their children, this paper studies the associations of children's various socioeconomic resources (education, occupation, and income) and parents' mortality. The models are adjusted for a range of parental socioeconomic resources and include the resources of the parents' partners. In addition to all-cause mortality, five causes of death are analyzed separately (circulatory disease mortality, overall cancer, lung cancer, breast cancer, and prostate cancer). The results show net associations between all included indicators of children's socioeconomic position and parents' mortality risk, with the clearest association for education. Children's education is significantly associated with all of the examined causes of death except prostate cancer. Breast cancer mortality is negatively related to offspring's education but not the mothers' own education. To conclude, children's education seems to be a key factor compared with other dimensions of socioeconomic position in the offspring generation. This finding suggests that explanations linked to behavioral norms or knowledge are more plausible than those linked to access to material resources. However, it is possible that children's education - to a greater degree than class and income - captures unmeasured parental characteristics. The cause-specific analyses imply that future research should investigate whether offspring's socioeconomic position is linked to the likelihood of developing diseases and/or the chances of treating them. A broader family perspective in the description and explanations of social inequalities in health that includes the younger generation may increase our understanding of why these inequalities persist across the life course.

From child to parent? The significance of children's education for their parents' longevity.

In addition to own education and other socioeconomic resources, the education of one's children may be important for individual health and longevity. Mothers and fathers born between 1932 and 1941 were analyzed by linking them to their children in the Swedish Multi-generation Register, which covers the total population. Controlling for parents' education, social class, and income attenuates but does not remove the association between children's education and parents' mortality risk. Shared but unmeasured familial background characteristics were addressed by comparing siblings in the parental generation. In these fixed-effects analyses, comparing parents whose children had tertiary education with parents whose children completed only compulsory schooling (the reference group) yields a hazard ratio of 0.79 (95 % CI: 0.70-0.89) when the socioeconomic position of both parents is controlled for. The relationship is certainly not purely causal, but part of it could be if, for example, well-educated adult children use their resources to find the best available health care for their aging parents. I therefore introduce the concept of "social foreground" and suggest that children's socioeconomic resources may be an important factor in trying to further understand social inequalities in health.

Clerics die, doctors survive: a note on death risks among highly educated professionals.

AIMS: Mortality is strongly associated with education. We present relative death risks of men and women in 12 educational/ occupational groups in Sweden today, with a focus on individuals with higher education. METHODS: Results from Cox regressions are reported for 12 educational groups with special emphasis on those with professional education, e.g. clerics, physicians, people with medical PhDs, and university teachers. The study is based on register data of the total Swedish population in the age group of 30-64 (n = 3,734,660). RESULTS: There is a considerable variation in mortality between educational groups. Men with compulsory education run a risk that is more than three times higher than that of professors outside medicine, and other educational groups fall in between. Medical doctors and physicians have relatively low death risks compared to those with compulsory education - less than 50% among men and less than 60% among women - although professors in medicine deviate by having higher risks than their colleagues in other subjects. Those with a theological exam show higher risks of dying during the follow-up period compared to others of a similar educational level. Professors outside medicine experience the lowest death risks of all identified groups. CONCLUSIONS: Men and women with a professional education have comparatively low death risks, particularly low among medical doctors and university employees, while the clergy seems to experience relatively higher death risks than others with a similar level of education. These patterns may reflect the effects of education as well as the selection of men and women to higher education.