Education as a social pathway from parental socioeconomic position to depression in late adolescence and early adulthood: a Finnish population-based register study

PURPOSE

There is inconsistent evidence for social differentials in the risk of depression in youth, and little is known about how education at this age influences the risk. We assess how parental socioeconomic position (SEP) and education predict depression from late adolescence to early adulthood, a time of major educational transitions.

METHODS

We followed a nationally representative 20 % sample of Finnish adolescents born in 1986-1990 (n = 60,829) over two educational transitory stages at the age of 17-19 and 20-23 covering the years 2003-2011. We identified incident depression using health care register data. We estimated the risk of depression by parental SEP and personal education using Cox regression, adjusting for family structure, parental depression and the individual's own psychiatric history.

RESULTS

Lower parental income was associated with up to a twofold risk of depression. This effect was almost fully attributable to other parental characteristics or mediated by the individual's own education. Educational differences in risk were attenuated following adjustment for prior psychiatric history. Adjusted for all covariates, not being in education increased the risk up to 2.5-fold compared to being enrolled in general upper secondary school at the age of 17-19 and in tertiary education at the age of 20-23. Vocationally oriented women experienced a 20 % higher risk than their academically oriented counterparts in both age groups.

CONCLUSIONS

Education constitutes a social pathway from parental SEP to the risk of depression in youth, whereby educational differences previously shown in adults are observed already before the establishment of adulthood SEP.

Contribution of smoking-attributable mortality to life expectancy differences by marital status among Finnish men and women, 1971-2010

BACKGROUND

Smoking is known to vary by marital status, but little is known about its contribution to marital status differences in longevity. We examined the changing contribution of smoking to mortality differences between married and never married, divorced or widowed Finnish men and women aged 50 years and above in 1971-2010.

DATA AND METHODS

The data sets cover all persons permanently living in Finland in the census years 1970, 1975 through 2000 and 2005 with a five-year mortality follow-up. Smoking-attributable mortality was estimated using an indirect method that uses lung cancer mortality as an indicator for the impact of smoking on mortality from all other causes.

RESULTS

Life expectancy differences between the married and the other marital status groups increased rapidly over the 40-year study period because of the particularly rapid decline in mortality among married individuals. In 1971-1975 37-48% of life expectancy differences between married and divorced or widowed men were attributable to smoking, and this contribution declined to 11-18% by 2006-2010. Among women, in 1971-1975 up to 16% of life expectancy differences by marital status were due to smoking, and the contribution of smoking increased over time to 10-29% in 2006-2010.

CONCLUSIONS

In recent decades smoking has left large but decreasing imprints on marital status differences in longevity between married and previously married men, and small but increasing imprints on these differences among women. Over time the contribution of other factors, such as increasing material disadvantage or alcohol use, may have increased.

Shape of the association between income and mortality: a cohort study of Denmark, Finland, Norway and Sweden in 1995 and 2003

OBJECTIVES

Prior work has examined the shape of the income-mortality association, but work has not compared gradients between countries. In this study, we focus on changes over time in the shape of income-mortality gradients for 4 Nordic countries during a period of rising income inequality. Context and time differentials in shape imply that the relationship between income and mortality is not fixed.

SETTING

Population-based cohort study of Denmark, Finland, Norway and Sweden.

PARTICIPANTS

We collected data on individuals aged 25 or more in 1995 (n=12.98 million individuals, 0.84 million deaths) and 2003 (n=13.08 million individuals, 0.90 million deaths). We then examined the household size equivalised disposable income at the baseline year in relation to the rate of mortality in the following 5 years.

RESULTS

A steep income gradient in mortality in men and women across all age groups except the oldest old in Denmark, Finland, Norway and Sweden. From the 1990s to 2000s mortality dropped, but generally more so in the upper part of the income distribution than in the lower part. As a consequence, the shape of the income gradient in mortality changed. The shift in the shape of the association was similar in all 4 countries.

CONCLUSIONS

A non-linear gradient exists between income and mortality in most cases and because of a more rapid mortality decline among those with high income the income gradient has become steeper over time.

How voter turnout varies between different chronic conditions? A population-based register study

BACKGROUND

While poor self-rated health is known to decrease an individual's propensity to vote, disaggregation of the components of health on turnout has thus far received only little attention. This study deepens on the understanding of such relationships by examining the association between chronic diseases and voting.

METHODS

The study uses an individual-level register-based data set that contains an 11% random sample of the entire electorate in the 1999 Finnish parliamentary elections. With information on hospital discharge diagnoses and reimbursements for drugs prescribed, we identify persons with chronic hospital-treated diseases (coronary heart disease, chronic obstructive pulmonary disease (COPD) and asthma, depression, cancer, psychotic mental disease, diabetes, cerebrovascular disease, rheumatic disease, epilepsy, arthrosis, alcoholism, dementia, atherosclerosis, Parkinson's disease, other degenerative brain diseases, multiple sclerosis and kidney disease).

RESULTS

After adjusting for gender, age, education, occupational class, income, partnership status, cohabitation with underaged children and hospitalisation during Election Day, neurodegenerative brain diseases had the strongest negative relationship with voting (dementia OR=0.20, 95% CI 0.18 to 0.22; others up to OR=0.70). Alcoholism (OR=0.66) and mental disorders also had a negative association (depression OR=0.91; psychotic mental disease OR=0.79), whereas cancer and COPD/asthma had a positive association (both OR=1.05). Having more than one condition at a time further decreased voting probability.

CONCLUSIONS

By showing how different health conditions are related to voter turnout, this study provides essential information for identifying gaps in the potential for political participation and for further inquiries aiming to develop models that explain the link between health and voting probability.

Long-term trends of inequalities in mortality in 6 European countries

Objectives

We aimed to assess whether trends in inequalities in mortality during the period 1970–2010 differed between Finland, Norway, England and Wales, France, Italy (Turin) and Hungary.

Methods

Total and cause-specific mortality data by educational level and, if available, occupational class were collected and harmonized. Both relative and absolute measures of inequality in mortality were calculated.

Results

In all countries except Hungary, all-cause mortality declined strongly over time in all socioeconomic groups. Relative inequalities in all-cause mortality generally increased, but more so in Hungary and Norway than elsewhere. Absolute inequalities often narrowed, but went up in Hungary and Norway. As a result of these trends, Hungary (where inequalities in mortality where almost absent in the 1970s) and Norway (where inequalities in the 1970s were among the smallest of the six countries in this study) now have larger inequalities in mortality than the other four countries.

Conclusions

While some countries have experienced dramatic setbacks, others have made substantial progress in reducing inequalities in mortality.

Electronic supplementary material

The online version of this article (doi:10.1007/s00038-016-0922-9) contains supplementary material, which is available to authorized users.

Intergenerational transmission of depressive symptoms - The role of gender, socioeconomic circumstances, and the accumulation of parental symptoms

BACKGROUND

The relationship between parental and offspring depression is well established. Evidence regarding the significance of gender, socioeconomic circumstances, and the accumulation of parental symptoms in intergenerational transmission is, however, mixed and scarce.

METHODS

Using a 20% random sample of Finns born between 1986 and 1996 (n=138,559), we performed a Cox proportional hazards regression to analyze the incidence of depressive symptoms between ages 15-20 by exposure to maternal and paternal depressive symptoms earlier in life. Depressive symptoms were inferred from antidepressant purchases and/or a diagnosis of depression at outpatient or inpatient health services.

RESULTS

Exposure to maternal depressive symptoms posed an equal risk for girls and boys (hazard ratio, HR, 2.09 vs. 2.28 respectively, p=0.077), whereas the effect of paternal depressive symptoms was weaker for girls (HR 1.77 vs. 2.22, p<0.001). Parental socioeconomic status neither confounded nor moderated these effects. Dual exposure to both maternal and paternal depressive symptoms posed a larger risk than single exposure, and children exposed recurrently at ages 0-5 and 9-14 faced an elevated risk compared with those exposed at only one period.

LIMITATIONS

Since depressive symptoms were inferred from prescription purchases and treatment records, we were unable to observe untreated depression or to determine the underlying condition the antidepressants were prescribed for.

CONCLUSIONS

Our results support the idea that maternal depression affects both genders equally, whereas paternal depression affects girls less than boys. We show that parental depression and low socioeconomic status are mainly independent risk factors of adolescent depressive symptoms and do not cause an interactive effect.

Are some populations resilient to recessions? Economic fluctuations and mortality during a period of economic decline and recovery in Finland

This paper uses individual-level longitudinal data on working-age Finns to examine the health effects of economic fluctuations during a period of economic decline (1989–1996) and recovery (1997–2007) in Finland. We used a nationally representative, longitudinal sample formed by linking population, employment and mortality registers (n = 698,484; 7,719,870 person-years). We implemented a region fixed-effect model that exploits within-regional variations over time in the unemployment rate to identify the effect of economic fluctuations on mortality, controlling for individual employment transitions. Unemployment rates increased from 5.2 % in 1989 to 19.8 % in 1996, declining gradually thereafter and reaching 9.7 % in 2007. Results indicate that these large fluctuations in the economy had no impact on the overall mortality of most working age Finns. The exception was highly educated men, who experienced an increase of 7 % (Rate ratio = 1.07, 95 % confidence interval 1.04, 1.10) for every one-point increase in the regional unemployment rate during the period 1989–1996 due to increased mortality from cardiovascular disease and suicide. This increase, however, was not robust in models that used the employment to population ratio as measure of the economy. Unemployment rates were unrelated to mortality among females, lower educated men, and among any group during economic recovery (1997–2007). For most Finns, we found no consistent evidence of changes in mortality in response to contractions or expansions in the economy. Possible explanations include the weak impact of the recession on wages, as well as the generous unemployment insurance and social benefit system in Finland.

Does survey non-response bias the association between occupational social class and health?

Aims: A non-response rate of 20—40%is typical in questionnaire studies. The authors evaluate non-response bias and its impact on analyses of social class inequalities in health. Methods: Set in the context of a health survey carried out among the employees of the City of Helsinki (non-response 33%) in 2000—02. Survey response and non-response records were linked with a personnel register to provide information on occupational social class and long sickness absence spells as an indicator of health status. Results: Women and employees in higher occupational social classes were more likely to respond. Non-respondents had about 20—30% higher sickness absence rates. Relative social class differences in sickness absence in the total population were similar to those among either respondents or non-respondents. Conclusions: In working populations survey non-response does not seriously bias analyses of social class inequalities in sickness absence and possibly health inequalities more generally.

Effect of living conditions in the parental home and youth paths on the social class differences in mortality among women

Aims: A longitudinal study was undertaken to assess the effects of parental home and youth paths on the adult social class differences in mortality among women. Methods: The study used population registration data on all Finnish women aged 30 - 34 in 1990 for whom information on their childhood characteristics and youth paths were available from the 1970, 1975, 1980, 1985, and 1990 censuses. Cause of death follow-up was for the period 1991-98 (1,185 deaths). Results: Adjusting for parental social class, family type, and number of siblings attenuated the effects of adult social class on cardiovascular disease mortality by 27%; for all external causes this attenuation was negligible. Educational, marital, and employment paths accounted for a substantial part (30 - 85%) of the social class differences in mortality for all specific causes of death. Conclusions: Although living conditions in the parental home were associated with mediating life trajectories in youth their effect on adult social class differences in mortality was moderate. Youth paths have a pervasive influence on mortality risks and social class differences in mortality in middle adulthood.

Mental health functioning (SF-36) and intentions to retire early among ageing municipal employees: The Helsinki Health Study

Aims: To examine the associations of mental health functioning with intentions to retire early among ageing municipal employees. Methods: Cross-sectional survey data (n=7,765) from the Helsinki Health Study in 2000, 2001, and 2002 were used. Intentions to retire early were sought with a question: ``Have you considered retiring before normal retirement age?'' The dependent variable was divided into three categories: 1=no intentions to retire early; 2=weak intentions; 3=strong intentions. Mental health functioning was measured by the Short Form 36 (SF-36) mental component summary (MCS). Other variables included age, sex, physical health functioning (SF-36), limiting longstanding illness, socioeconomic status, and spouse's employment status. Multinomial regression analysis was used to examine the association of mental health functioning with intentions to retire early. Results: Employees with the poorest mental health functioning were much more likely to report strong intentions to retire early (OR 6.09, 95% CI 4.97—7.47) than those with the best mental health functioning. Adjustments for physical health, socioeconomic status, and spouse's employment status did not substantially affect this association. Conclusions: The findings highlight the importance of mental health for intentions to retire early. Strategies aimed at keeping people at work for longer should emphasize the importance of mental well-being and the prevention of poor mental health. More evidence is needed on why mental problems among ageing baby-boomer employees are giving rise to increasing social consequences, although the overall prevalence of mental problems has not increased.

Trends in socioeconomic differences in sickness absence among Finnish municipal employees 1990—99

Aims: This study examined the associations of key dimensions of socioeconomic status and long sickness absence spells as well as their changes over time from 1990 to 1999. Methods: Municipal employees of the City of Helsinki, Finland, aged 25— 59 were studied. The number of participants varied yearly from 24,029 women and 6,523 men to 27,861 women and 7,521 men. Socioeconomic status was assessed by education, occupational class, and individual income. The outcome was the number of over three days' sickness absence spells/100 person years, for which the employer requires medical certification.

Results: Low education, occupational class, and individual income were consistently associated with a 2—3 times higher sickness absence rates among both men and women. The age-adjusted sickness absence rates were relatively stable from 1990 to 1994 but increased from 1994 to 1999 among men and women. Socioeconomic differences in sickness absence rates tended to increase. Conclusions: The increase in the level of socioeconomic differences in sickness absence took place during a period of declining unemployment and staff increases at the City of Helsinki, which indicates that labour market conditions play a role in sickness absence.

Association of socioeconomic status and cognitive functioning change among elderly Chinese people

BACKGROUND AND OBJECTIVE

the inverse association between high socioeconomic status and impaired cognitive functioning in old age has been widely studied. However, it is still inconclusive whether higher socioeconomic status slows the rate of cognitive decline over ageing, especially in non-Western populations. We examined this association using a large population-based longitudinal survey of older Chinese persons.

METHODS

the sample came from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) (from the years 2002 to 2011, N = 15,798 at baseline, aged 65-105). The Mini-Mental State Examination (MMSE) based on face-to-face interviews was used to assess cognitive functioning. Socioeconomic status was assessed using educational attainment and household income per capita. Latent growth curve and selection model considering the attrition during the follow-up were utilised to assess the effect of socioeconomic status on the rate of change in cognitive functioning.

RESULTS

at baseline, younger elderly people, urban residents and elderly people living alone had better cognitive performance in both genders. Educational attainment was positively associated with cognitive functioning at baseline but did not have a significant effect on the rate of change in cognitive functioning. Higher incomes were associated with better cognitive functioning at baseline, but this difference diminished during the follow-up.

CONCLUSION

higher socioeconomic status was associated with better cognitive performance at baseline but could not protect against the rate of decline in cognitive functioning measured by MMSE in this longitudinal study for elderly Chinese people.

Hospital Admissions Before an Alcohol-Related Death Among Middle-Aged Employed Men and Women: A Cohort Study Using Routine Data

BACKGROUND

Due to lack of appropriate longitudinal data, relatively little is known about how and when persons who ultimately die due to alcohol-related causes interact with hospitals during the years before death. Using routinely collected nationwide data, we aimed to establish the timing and causes of all hospitalizations during a 10-year period before an alcohol-related death.

METHODS

We traced back the timing and causes of all hospitalizations occurring during a 10-year period before death among men and women (n = 2,981) who were aged 35 and in employment at study entry, and who died from alcohol-related causes at ages 45 to 54 in 1997 to 2007. The study data consisted of 80% of all persons living in Finland who died during the study period. Those who died at ages 45 to 54 without alcohol involvement were used as a reference group.

RESULTS

Persons who ultimately died from alcohol-related causes had on average 7 (mean 7.4, SD 9.9) hospital admissions, and they spent on average 56 days (mean 56.2, SD 105.1) in hospital during the study period. By the fifth year before death (from the year -10 to year -5), about three-fifths of these persons had been hospitalized due to any cause at least once, but less than one-third had a hospital admission with an alcohol-related diagnosis. Those who died without alcohol involvement had an average 9 hospital admissions (mean 9.3, SD 11.2), and they spent on average 81 days (mean 81.2, SD 163.9) in hospital during the study period.

CONCLUSIONS

The majority of employed middle-aged persons who ultimately died due to alcohol-related causes interacted with hospitals frequently and already several years before death. Additional research is warranted to evaluate whether enhanced patient management at hospitals targeted to this population could potentially reduce alcohol-related harms.

Childhood Family Income and Violent Victimization During Youth and Young Adulthood: Trends in Hospital Care During 1988-2007 in Finland

The purpose of the current study was to examine whether the relationship between childhood family income and risk of violent victimization has changed between 1988 and 2007 in Finland, as prior studies have suggested that socioeconomic differences in exposure to violence have increased during the recent decades. Existing studies have mostly relied on survey data, while such trends in hospital discharge data-a data source that covers the total population well and is not compromised by attrition or self-report bias-have not been thoroughly investigated before. The current study used register-based individual-level data from 1988-2007 (n = 283,505) to study changes in the relationship between childhood family income and victimization risk among 15- to 30-year-old Finnish men and women. We found a persisting difference in violent victimization between the top and bottom income quintiles for both men and women. While the estimates suggest that this difference has increased rather than decreased during the observation period particularly among women, this change was not statistically significant. These conclusions remain after controlling for the composition of income quintiles. Research could benefit from more extensive use of administrative hospital records in analyzing of the trends and causes of serious violence.

Number of children and later-life mortality among Finns born 1938-50

We investigated the association between number of offspring and later-life mortality of Finnish men and women born 1938-50, and whether the association was explained by living conditions in own childhood and adulthood, chronic conditions, fertility timing, and unobserved characteristics common to siblings. We used a longitudinal 1950 census sample to estimate mortality at ages 50-72. Relative to parents of two children, all-cause mortality is highest among childless men and women, and elevated among those with one child, independently of observed confounders. Fixed-effect models, which control for unobserved characteristics shared by siblings, clearly support these findings among men. Cardiovascular mortality is higher among men with no, one, or at least four children than among those with two. Living conditions in adulthood contribute to the association between the number of children and mortality to a greater extent than childhood background, and chronic conditions contribute to the excess mortality of the childless.

A longitudinal study of educational differences in antidepressant use before and after hospital care for depression

BACKGROUND

Despite social inequalities in depression various studies report small or even reversed social gradients for antidepressant treatment, suggesting unmet need for treatment among those with low social position. However, few studies assess need for treatment or compare longitudinal antidepressant use patterns between socioeconomic groups.

METHODS

We used a nationally representative register cohort of Finnish adults with hospital care for depression in 1998-2007 (n = 7249). We compared the prevalence of any use and daily use of antidepressants across educational groups in consecutive 3-month periods up to 5 years before admission and 5 years after discharge, adjusting for important confounders.

RESULTS

We found no educational differences in any antidepressant use in the 5 years leading to hospital care for depression but a 3-4 percentage-point higher prevalence among those with high education in the 3-month periods immediately preceding and following hospital care for depression. Furthermore, decline in the prevalence of antidepressant use after discharge was more rapid in low education resulting in a significant 4-6 percentage-point higher prevalence among the highly educated lasting until 2.5 years after discharge. Daily use was significantly more common among the highly educated for a year before admission, immediately after discharge and for 2.5 years thereafter, the excess being 3-8 percentage-points.

CONCLUSION

Our results suggest rather equitable access to antidepressant treatment at the time of evident need, i.e. immediately after discharge from hospital care for depression. However, early discontinuation of treatment as well as below guideline use of antidepressants were more common among the low educated.

Effects of Individual, Spousal, and Offspring Socioeconomic Status on Mortality Among Elderly People in China

BACKGROUND

The relationship between socio-economic status and health among elderly people has been well studied, but less is known about how spousal or offspring's education affects mortality, especially in non-Western countries. We investigated these associations using a large sample of Chinese elderly.

METHODS

The data came from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) from the years 2005 to 2011 (n = 15 355, aged 65-105 years at baseline; 5046 died in 2008, and 2224 died in 2011). Educational attainment, occupational status, and household income per capita were used as indicators of socio-economic status. Spousal and offspring's education were added into the final models. The Cox proportional hazards model was used to study mortality risk by gender.

RESULTS

Adjusted for age, highly educated males and females had, on average, 29% and 37% lower mortality risk, respectively, than those with a lower education. Particularly among men, this effect was observed among those whose children had intermediate education only. A higher household income was also associated with lower mortality risk among the elderly. Male elderly living with a well-educated spouse (HR 0.79; 95% CI, 0.64-0.99) had a lower mortality risk than those living with a low-educated spouse.

CONCLUSIONS

Both the socio-economic status of the individual and the educational level of a co-resident spouse or child are associated with mortality risk in elderly people. The socio-economic position of family members plays an important role in producing health inequality among elderly people.

Contribution of smoking to socioeconomic inequalities in mortality: a study of 14 European countries, 1990-2004

BACKGROUND

Smoking contributes to socioeconomic inequalities in mortality, but the extent to which this contribution has changed over time and driven widening or narrowing inequalities in total mortality remains unknown. We studied socioeconomic inequalities in smoking-attributable mortality and their contribution to inequalities in total mortality in 1990-1994 and 2000-2004 in 14 European countries.

METHODS

We collected, harmonised and standardised population-wide data on all-cause and lung-cancer mortality by age, gender, educational and occupational level in 14 European populations in 1990-1994 and 2000-2004. Smoking-attributable mortality was indirectly estimated using the Preston-Glei-Wilmoth method.

RESULTS

In 2000-2004, smoking-attributable mortality was higher in lower socioeconomic groups in all countries among men, and in all countries except Spain, Italy and Slovenia, among women, and the contribution of smoking to socioeconomic inequalities in mortality varied between 19% and 55% among men, and between -1% and 56% among women. Since 1990-1994, absolute inequalities in smoking-attributable mortality and the contribution of smoking to inequalities in total mortality have decreased in most countries among men, but increased among women.

CONCLUSIONS

In many European countries, smoking has become less important as a determinant of socioeconomic inequalities in mortality among men, but not among women. Inequalities in smoking remain one of the most important entry points for reducing inequalities in mortality.

Health as a predictor of early retirement before and after introduction of a flexible statutory pension age in Finland

BACKGROUND

Little is known of how pension reforms affect the retirement decisions of people with different health statuses, although this is crucial for the understanding of the broader societal impact of pension policies and for future policy development. We assessed how the Finnish statutory pension age reform introduced in 2005 influenced the role of health as a predictor of retirement.

METHODS

We used register-based data and cox regression analysis to examine the association of health (measured by purchases of psychotropic medication, hospitalizations due to circulatory and musculoskeletal diseases, and the number of any prescription medications) with the risk of retirement at age 63-64 among those subject to the old pension system with fixed age limit at 65 (pre-reform group born in 1937-1941) and the new flexible system with 63 as the lower age limit (post-reform group born in 1941-1945) while controlling for socio-demographic factors.

RESULTS

Retirement at age 63-64 was more likely among the post- than the pre-reform group (HR = 1.50; 95% CI 1.43-1.57). This reform-related increase in retirement was more pronounced among those without a history of psychotropic medication or hospitalizations due to circulatory and musculoskeletal diseases, as well as among those with below median level medication use. As a result, poor health became a weaker predictor of retirement after the reform.

CONCLUSION

Contrary to the expectations of the Finnish pension reform aimed at extending working lives, offering choice with respect to the timing of retirement may actually encourage healthy workers to choose earlier retirement regardless of the provided economic incentives for continuing in work.

Changes in mortality inequalities over two decades: register based study of European countries

OBJECTIVE

To determine whether government efforts in reducing inequalities in health in European countries have actually made a difference to mortality inequalities by socioeconomic group.

DESIGN

Register based study.

DATA SOURCE

Mortality data by level of education and occupational class in the period 1990-2010, usually collected in a census linked longitudinal study design. We compared changes in mortality between the lowest and highest socioeconomic groups, and calculated their effect on absolute and relative inequalities in mortality (measured as rate differences and rate ratios, respectively).

SETTING

All European countries for which data on socioeconomic inequalities in mortality were available for the approximate period between years 1990 and 2010. These included Finland, Norway, Sweden, Scotland, England and Wales (data applied to both together), France, Switzerland, Spain (Barcelona), Italy (Turin), Slovenia, and Lithuania.

RESULTS

Substantial mortality declines occurred in lower socioeconomic groups in most European countries covered by this study. Relative inequalities in mortality widened almost universally, because percentage declines were usually smaller in lower socioeconomic groups. However, as absolute declines were often smaller in higher socioeconomic groups, absolute inequalities narrowed by up to 35%, particularly among men. Narrowing was partly driven by ischaemic heart disease, smoking related causes, and causes amenable to medical intervention. Progress in reducing absolute inequalities was greatest in Spain (Barcelona), Scotland, England and Wales, and Italy (Turin), and absent in Finland and Norway. More detailed studies preferably using individual level data are necessary to identify the causes of these variations.

CONCLUSIONS

Over the past two decades, trends in inequalities in mortality have been more favourable in most European countries than is commonly assumed. Absolute inequalities have decreased in several countries, probably more as a side effect of population wide behavioural changes and improvements in prevention and treatment, than as an effect of policies explicitly aimed at reducing health inequalities.

The contribution of education, social class and economic activity to the income-mortality association in alcohol-related and other mortality in Finland in 1988-2012

AIMS

First, to quantify trends in the contribution of alcohol-related mortality to mortality disparity in Finland by income quintiles. Secondly, to estimate the degree to which education, social class and economic activity explain the income-mortality association in alcohol-related and other mortality in four periods within 1988-2012.

DESIGN

Register-based longitudinal study using an 11% random sample of Finnish residents linked to socio-economic and mortality data in 1988-2012 augmented with an 80% sample of all deaths during 1988-2007. Mortality rates and discrete time survival regression models were used to assess the income-mortality association following adjustment for covariates in 6-year periods after baseline years of 1988, 1994, 2001, and 2007.

SETTING

Finland.

PARTICIPANTS

Individuals aged 35-64 years at baselines. For the four study periods for men/women, the final data set comprised, respectively, 26,360/12,825, 22,561/11,423, 20,342/11,319 and 2651/1514 deaths attributable to other causes and 7517/1217, 8199/1450, 9807/2116, 1431/318 deaths attributable to alcohol-related causes.

MEASUREMENTS

Alcohol-related deaths were analysed with household income, education, social class and economic activity as covariates.

FINDINGS

The income disparity in mortality originated increasingly from alcohol-related causes of death, in the lowest quintile the contribution increasing from 28 to 49% among men and from 11 to 28% among women between periods 1988-93 and 2007-12. Among men, socio-economic characteristics attenuated the excess mortality during each study period in the lowest income quintile by 51-62% in alcohol-related and other causes. Among women, in the lowest quintile the attenuation was 47-76% in other causes, but there was a decreasing tendency in the proportion explained by the covariates in alcohol-related mortality.

CONCLUSIONS

The income disparity in mortality among working-age Finns originates increasingly from alcohol-related causes of death. Roughly half the excess mortality in the lowest income quintile during 2007-12 is explained by the covariates of household income, education, social class and economic activity.