The effects of family type on child mortality.

BACKGROUND: A growing number of children live in single-parent families, which seems to be associated with negative effects on a child's health. Little is known about the health of children in cohabiting two-parent families that are also increasingly common, and more susceptible to family break-up than married two-parent families. This study seeks to determine if family type is associated with child mortality and whether any association remains after controlling for socio-economic factors. METHODS: We used longitudinal nationally representative register data from Statistics Finland to study deaths between ages 1-14 years (1780 deaths, N = 201,211) during 1990-2004. The relative effects of family characteristics on mortality were estimated using Cox regression models. RESULTS: Compared with children of married parents, children of single parents carried an excess risk in mortality in ages 1-4 years [Hazard Ratio (HR) 2.02, 95% CI 1.63-2.51] and in ages 5-9 years (HR 1.44, 95% CI 1.15-1.80). The relationship between single parenthood and mortality was largely, but not entirely, explained by associated low parental education and lower household income. Mortality among children in cohabiting-parent families showed no difference from children of married parents. CONCLUSION: Mainly due to accidental and violent causes of death, the largest excess mortality risks concentrated among children of single, less-educated and less-earning parents. The most vulnerable age period in this respect was early childhood (ages 1-4 years), whereas no association between mortality and family type was found among children aged 10-14 years.

The effects of individual taxable income, household taxable income, and household disposable income on mortality in Finland, 1998-2004.

To improve our understanding of the association between income and mortality, we analysed prospective record linkage data on Finns aged 30 and over in 1997. The results show a weaker association of mortality with household disposable income-the measure that best captures consumption potential-than with individual income, particularly above age 65 when the ability to work does not bias the associations. The association between income and mortality is greatly weakened by adjustment for socio-economic status and economic activity, and there is also weak evidence of curvature in the relationship with household disposable income. Among younger participants, social characteristics of the family of origin and early career incomes have a very limited effect on the association between adult income and mortality. The causal effects of income on mortality remain difficult to establish with certainty, and may easily be overestimated. Causal explanations based solely on material factors should be treated with scepticism.

The reversed social gradient: higher breast cancer mortality in the higher educated compared to lower educated. A comparison of 11 European populations during the 1990s.

Higher socioeconomic position has been reported to be associated with increased risk of breast cancer mortality. Our aim was to see if this is consistently observed within 11 European populations in the 1990s. Longitudinal data on breast cancer mortality by educational level and marital status were obtained for Finland, Norway, Denmark, England and Wales, Belgium, France, Switzerland, Austria, Turin, Barcelona and Madrid. The relationship between breast cancer mortality and education was summarised by means of the relative index of inequality. A positive association was found in all populations, except for Finland, France and Barcelona. Overall, women with a higher educational level had approximately 15% greater risk of dying from breast cancer than those with lower education. This was observed both among never- and ever-married women. The greater risk of breast cancer mortality among women with a higher level of education was a persistent and generalised phenomenon in Europe in the 1990s.

Change in the total and independent effects of education and occupational social class on mortality: analyses of all Finnish men and women in the period 1971-2000.

OBJECTIVES: To estimate changes in the total and independent effects of education and occupational social class on mortality over 30 years, and to assess the causes of changes in the independent effects. METHODS: Census records linked with death records for 1971-2000 for all Finns aged 30-59 years were studied. The total and independent effects of education and social class on mortality were calculated from relative risks in nested Poisson regression models. RESULTS: Among men and women, the model shows that the total effects of education, and particularly occupational social class on mortality, have increased over time. Among 40-59-year-old people, the effects of education are currently less independent of social class than in the 1970s, but among younger Finns the independent effects have remained stable. The effects of social class on mortality that are independent of education have grown among people of older ages, particularly among men. CONCLUSIONS: Changes in the independent effects of socioeconomic measures on mortality are determined by changes in their associations with mortality, and distributional changes that affect the strength of the associations between these measures. Distributional changes are driven by changes in educational systems and labour markets, and are of major importance for the understanding of socioeconomic inequalities in mortality.

Educational inequalities in cause-specific mortality in middle-aged and older men and women in eight western European populations.

BACKGROUND: Studies of socioeconomic disparities in patterns of cause of death have been limited to single countries, middle-aged people, men, or broad cause of death groups. We assessed contribution of specific causes of death to disparities in mortality between groups with different levels of education, in men and women, middle-aged and old, in eight western European populations. METHODS: We analysed data from longitudinal mortality studies by cause of death, between Jan 1, 1990, and Dec 31, 1997. Data were included for more than 1 million deaths in 51 million person years of observation. FINDINGS: Absolute educational inequalities in total mortality peaked at 2127 deaths per 100000 person years in men, and at 1588 deaths per 100000 person years in women aged 75 years and older. In this age-group, rate ratios were greater than 1.00 for total mortality and all specific causes of death, apart form prostate cancer in men and lung cancer in women, showing increased mortality in low versus high educational groups. In men, cardiovascular diseases accounted for 39% of the difference between low and high educational groups in total mortality, cancer for 24%, other diseases for 32%, and external causes for 5%. Among women, contributions were 60%, 11%, 30%, and 0%, respectively. The contributions of cerebrovascular disease, other cardiovascular diseases, pneumonia, and COPD strongly increased by age, whereas those of cancer and external causes declined. Although relative inequalities in total mortality were closely similar in all populations, we noted striking differences in the contribution of specific causes to these inequalities. INTERPRETATION: Research needs to be broadened to include older populations, other diseases, and populations from different parts of Europe. Effective interventions should be developed and implemented to reduce exposure to cardiovascular risk factors in low-educational groups.

Mortality trends and setbacks: global convergence or divergence?

Health trends over much of the past century have been generally, and notably, positive throughout the world. In several regions, however, life expectancy has declined over the past 1-2 decades. This trend suggests that the expectation that emerged in the 1960s and 1970s of worldwide gains and convergence in population health status is not guaranteed by a general deterministic process. National populations can now be clearly grouped into those that have achieved rapid gains in life expectancy; those whose gains are slower or are perhaps plateauing; and those in which the trends have reversed. Over the past two centuries, outside times of war and famine, such reversals have been rare. Exploration of these varied population health trends elucidates better the close relation between population health and the processes of economic, social, and technological change. Such analysis has shown that the health status of human populations should be a guiding criterion in the debate on sustainable development.

Educational level and stroke mortality: a comparison of 10 European populations during the 1990s.

BACKGROUND AND PURPOSE: Variations between countries in occupational differences in stroke mortality were observed among men during the 1980s. This study estimates the magnitude of differences in stroke mortality by educational level among men and women aged >or=30 years in 10 European populations during the 1990s. METHODS: Longitudinal data from mortality registries were obtained for 10 European populations, namely Finland, Norway, Denmark, England/Wales, Belgium, Switzerland, Austria, Turin (Italy), Barcelona (Spain), and Madrid (Spain). Rate ratios (RRs) were calculated to assess the association between educational level and stroke mortality. The life table method was used to estimate the impact of stroke mortality on educational differences in life expectancy. RESULTS: Differences in stroke mortality according to educational level were of a similar magnitude in most populations. However, larger educational differences were observed in Austria. Overall, educational differences in stroke mortality were of similar size among men (RR, 1.27; 95% CI, 1.24 to 1.30) and women (RR, 1.29; 95% CI, 1.27 to 1.32). Educational differences in stroke mortality persisted at all ages in all populations, although they generally decreased with age. Eliminating these differences would on average reduce educational differences in life expectancy by 7% among men and 14% among women. CONCLUSIONS: Educational differences in stroke mortality were observed across Europe during the 1990s. Risk factors such as hypertension and smoking may explain part of these differences in several countries. Other factors, such as socioeconomic differences in healthcare utilization and childhood socioeconomic conditions, may have contributed to educational differences in stroke mortality across Europe.

Inequalities in lung cancer mortality by the educational level in 10 European populations.

Previous studies have shown that due to differences in the progression of the smoking epidemic European countries differ in the direction and size of socioeconomic variations in smoking prevalence. We studied differences in the direction and size of inequalities in lung cancer mortality by the educational level of subjects in 10 European populations during the 1990's. We obtained longitudinal mortality data by cause of death, age, sex and educational level for 4 Northern European populations (England/Wales, Norway, Denmark, Finland), 3 continental European populations (Belgium, Switzerland, Austria), and 3 Southern European populations (Barcelona, Madrid, Turin). Age- and sex-specific mortality rates by educational level were calculated, as well as the age- and sex-specific mortality rate ratios. Patterns of educational inequalities in lung cancer mortality suggest that England/Wales, Norway, Denmark, Finland and Belgium are the farthest advanced in terms of the progression of the smoking epidemic: these populations have consistently higher lung cancer mortality rates among the less educated in all age-groups in men, including the oldest men, and in all age-groups in women up to those aged 60-69 years. Madrid appears to be less advanced, with less educated men in the oldest age-group and less educated women in all age-groups still benefiting from lower lung cancer mortality rates. Switzerland, Austria, Turin and Barcelona occupy intermediate positions. The lung cancer mortality data suggest that inequalities in smoking contribute substantially to the educational differences in total mortality among men in all populations, except Madrid. Among women, these contributions are probably substantial in the Northern European countries and in Belgium, but only small in Switzerland, Austria, Turin and Barcelona, and negative in Madrid. In many European countries, policies and interventions that reduce smoking in less educated groups should be one of the main priorities to tackle socioeconomic inequalities in mortality. In some countries, particularly in Southern Europe, it may not be too late to prevent women in less educated groups from taking up the smoking habit, thereby avoiding large inequalities in mortality in the future in these countries.

Widening socioeconomic inequalities in mortality in six Western European countries.

OBJECTIVES: During the past decades a widening of the relative gap in death rates between upper and lower socioeconomic groups has been reported for several European countries. Although differential mortality decline for cardiovascular diseases has been suggested as an important contributory factor, it is not known what its quantitative contribution was, and to what extent other causes of death have contributed to the widening gap in total mortality. METHODS: We collected data on mortality by educational level and occupational class among men and women from national longitudinal studies in Finland, Sweden, Norway, Denmark, England/Wales, and Italy (Turin), and analysed age-standardized death rates in two recent time periods (1981-1985 and 1991-1995), both total mortality and by cause of death. For simplicity, we report on inequalities in mortality between two broad socioeconomic groups (high and low educational level, non-manual and manual occupations). RESULTS: Relative inequalities in total mortality have increased in all six countries, but absolute differences in total mortality were fairly stable, with the exception of Finland where an increase occurred. In most countries, mortality from cardiovascular diseases declined proportionally faster in the upper socioeconomic groups. The exception is Italy (Turin) where the reverse occurred. In all countries with the exception of Italy (Turin), changes in cardiovascular disease mortality contributed about half of the widening relative gap for total mortality. Other causes also made important contributions to the widening gap in total mortality. For these causes, widening inequalities were sometimes due to increasing mortality rates in the lower socioeconomic groups. We found rising rates of mortality from lung cancer, breast cancer, respiratory disease, gastrointestinal disease, and injuries among men and/or women in lower socioeconomic groups in several countries. CONCLUSIONS: Reducing socioeconomic inequalities in mortality in Western Europe critically depends upon speeding up mortality declines from cardiovascular diseases in lower socioeconomic groups, and countering mortality increases from several other causes of death in lower socioeconomic groups.

The effects of regional characteristics on alcohol-related mortality-a register-based multilevel analysis of 1.1 million men.

The aim of this study is to assess to what extent selected characteristics of functional regions affect alcohol-related mortality among men in Finland after adjusting for individual-level characteristics. The study was conducted as a multilevel Poisson regression analysis, with individuals (n = 1.1 million) as the first level and functional regions of Finland (n = 84) as the second level. The analysis covered men aged 25-64. The data are based on the 1990 census records, which were linked to death records in 1991-1996. The outcome measure was alcohol-related mortality, which was defined using information on the underlying and contributory causes of death. The individual-level covariates included age, education, socioeconomic status, marital status and mother tongue. The area-level variables considered were the proportion of manual workers, unemployment level, median household income, Gini coefficient of income, family cohesion, voting turnout, level of urbanisation and proportion of Swedish-speaking inhabitants. A high proportion of manual workers and of unemployed and low social cohesion (family cohesion and voting turnout) were found to produce adverse effects on alcohol-related mortality, and the independent effects of these variables remained after adjustment for all individual-level and area-level characteristics. The protective effect of high level of urbanisation was revealed after adjustment for other individual- and area-level characteristics. Neither mean income nor income inequality were related to alcohol-related mortality. Adjusting for individual-level variables diminished the average relative deviation of alcohol-related mortality among the functional regions by 41%. The inclusion of area-level characteristics in the model resulted in a total diminution of variation of 79%. The area characteristics considered in this study had a notable effect on alcohol-related mortality, although these effects were smaller than those of the individual-level characteristics. Fuller understanding of the mechanisms underlying the effects of area measures of social structure and cohesion on risky alcohol consumption and alcohol-related mortality is needed.

Trends in life expectancy by income from 1988 to 2007: decomposition by age and cause of death.

BACKGROUND: Less attention has been paid to mortality trends across income groups than those measured by other socioeconomic indicators. This study assessed the change in life expectancy by income over 20 years in the Finnish general population. METHODS: Life expectancy among 35-year-olds by household income quintiles was studied. Change in life expectancy from 1988-92 to 2003-7 was decomposed by age and cause of death. The dataset contained 754,087 deaths by oversample of 80% of all deaths during the period. RESULTS: The gap in life expectancy between the highest and the lowest income quintiles widened during the study period by 5.1 years among men and 2.9 years among women, and in 2007 it stood at 12.5 years and 6.8 years, respectively. Stagnation in the lowest income group was the main reason for the increased disparity for both sexes. Increasing mortality attributable to alcohol-related diseases and increasing or stagnating mortality for many cancers, as well as a slower decline in mortality due to ischaemic heart disease among men in the lowest income quintile, were the most significant factors increasing the gap. CONCLUSIONS: The increasing gap in life expectancy was mostly due to the stagnation of mortality in the lowest income quintile and especially because of the increasing mortality in alcohol-related diseases. The increase in disparity may be more extreme when using income instead of occupational class or education, possibly because income identifies a lower and economically more deprived segment on a social hierarchy more clearly. The results identify a clear need to tackle the specific health problems of the poorest.

Increasing absolute mortality disparities by education in Finland, Norway and Sweden, 1971-2000.

BACKGROUND AND OBJECTIVES: Studies on socioeconomic health disparities often suffer from a lack of uniform data and methodology. Using high quality, census-linked data and sensible inequality measures, this study documents the changes in absolute and relative mortality differences by education in Finland, Norway and Sweden over the period 1971 to 2000. METHODS: The age-standardised mortality rates and the population exposures for three educational categories were computed from detailed data provided by the national statistical offices. Mortality disparities by education were assessed using two range measures (rate differences and rate ratios), and two Gini-like measures (the average inter-group difference (AID) and the Gini coefficient (G)). The formulae for the decomposition of the change in the AID into (1) the contribution of change in population composition by education, and (2) the contribution of mortality change were introduced. RESULTS: Mortality decreases were often greater for high than for medium and low education. Both relative and absolute mortality disparities tend to increase over time. The magnitude and timing of the increases in absolute disparities vary by country. Both the rate differences and the AIDs have increased since the 1970s in Norway and Sweden, and since the 1980s in Finland. The contributions of the changes in population composition to the total AID increase were substantial in all countries, and for both sexes. The mortality contributions were substantial for males in Norway and Sweden. CONCLUSIONS: The study reports increases in absolute mortality disparity, and its components. This trend needs to be further studied and addressed by policies.

Mortality inequalities by parental education among children and young adults in Finland 1990-2004.

BACKGROUND: Knowledge on health inequalities in early life is less complete and less consistent than with the well-documented differentials in the adult population. This study examines the presence and strength of the association between parental education and mortality during different periods of childhood and young adulthood, and changes in the association over time. METHODS: Longitudinal individual level data were used in a register follow-up of 15 years. The data include an 11% sample of the Finnish population with an oversample of 80% of all deaths between the ages of 1 and 24. Mortalities and relative indices of inequality (RII) were calculated by parental education, sex, age group and cause of death. RESULTS: Lower parental education was associated with a higher risk of mortality during the whole period of 1990-2004. The differentials were largest among 1-4-year-old children (RII=2.4, 95% CI 1.57 to 3.56 for males and RII=4.5, 2.71 to 7.32 for females) and among young men aged 15-19 (RII=2.4, 2.00 to 2.98). The educational gradient was sharper in accidental and violent causes of death, but deaths from diseases contributed to differentials for both sexes among the youngest and the oldest. CONCLUSION: The association between parental education and mortality in young age was consistent, although distinctively patterned by sex, age and cause of death. The results provide some support for the idea of equalisation of health inequalities during the child-youth transition. The convergence of differences in late childhood, and re-emergence in early adulthood, particularly among men, was, however, related to changes in the cause composition of deaths.

Effect of parental social class, own education and social class on mortality among young men.

BACKGROUND: The aim of the study is to examine the effects of parental class, own education and social class on mortality by cause of death among young men. METHODS: The study is based on 1990 census records for 186,408 Finnish men, aged 30-34 in 1990, linked with death records for 1991-95 (1530 deaths). RESULTS: Parental class was associated with all-cause (Index of Relative Dissimilarity (IRD) = 12%) and cause-specific mortality before adjustment for one's own social class and education. Adjustment reduced the IRD by 18-58%, depending on the cause of death, and caused mortality differences to disappear for causes other than cardiovascular diseases and those related to alcohol. The unadjusted variation in all-cause mortality by educational attainment (IRD = 33%) and by own class (IRD = 38%) was greater than by parental class. Adjustment for parental class had only a minor effect on the variation by education and own class. Adjustment for own class reduced the IRD for education in all-cause mortality by 31%, in mortality from disease by 17%, and in mortality from external causes by 33%. For own class the reductions in the IRD obtained by adjustment for education were 36%, 46%, and 33%, respectively. CONCLUSIONS: The effect of parental class on the mortality of young men is indirect and mainly mediated through its influence on education and social class. The effect of education on mortality is as strong as that of occupation-based social class. These variables are not interchangeable measures of socioeconomic status; they both should be taken into account in studies on inequalities in mortality.

Contribution of deaths related to alcohol or smoking to the gender difference in life expectancy: Finland in the early 1990s.

BACKGROUND: In comparison to most other countries in Western Europe, Finland ranks high with regard to male excess mortality. This study examined the contribution of smoking and alcohol to the gender difference in mortality in Finland during 1991-93 among the population aged 15 or over. METHODS: The study is based on data from linked registers. The number of alcohol-related deaths was assessed on the basis of information included in the death certificate, while the conventional method of population attributable fraction was applied to estimate the aggregated contribution of smoking. In combining the effects of alcohol and smoking, three alternative assumptions of their overlap were used. RESULTS: Approximately 51-56% of the gender difference of 7.6 years in the life expectancy at age 15 was estimated to be attributable to alcohol or smoking, depending on the assumption about the overlap of the contribution of alcohol and smoking. CONCLUSIONS: The study confirms the important role of alcohol and smoking as a mechanism contributing to the difference in mortality between men and women in Finland.