Socioeconomic differentials in mortality in Finland and the United States: the role of education and income

The impact of the COVID-19 pandemic on inequalities in preventive health screenings: Trends and implications for U.S. population health

The COVID-19 pandemic has profoundly impacted population well-being in the United States, exacerbating existing racial and socioeconomic inequalities in health and mortality. Importantly, as the pandemic disrupted the provision of vital preventive health screenings for cardiometabolic diseases and cancers, more research is needed to understand whether this disruption had an unequal impact across racialized and socioeconomic lines. We draw on the 2019 and 2021 National Health Interview Survey to explore whether the COVID-19 pandemic contributed to racialized and schooling inequalities in the reception of preventive screenings for cardiometabolic diseases and cancers. We find striking evidence that Asian Americans, and to a lesser extent Hispanic and Black Americans, reported decreased reception of many types of cardiometabolic and cancer screenings in 2021 relative to 2019. Moreover, we find that across schooling groups, those with a bachelor's degree or higher experienced the greatest decline in screening reception for most cardiometabolic diseases and cancers, and those with less than a high school degree experienced the greatest decline in screening reception for diabetes. Findings have important implications for health inequalities and U.S. population health in the coming decades. Research and health policy attention should be directed toward ensuring that preventive health care is a key priority for public health, particularly among socially marginalized groups who may be at increased risk of delayed diagnosis for screenable diseases.

A distributional approach to measuring lifespan stratification

The study of the mortality differences between groups has traditionally focused on metrics that describe average levels of mortality, for example life expectancy and standardized mortality rates. Additional insights can be gained by using statistical distance metrics to examine differences in lifespan distributions between groups. Here, we use a distance metric, the non-overlap index, to capture the sociological concept of stratification, which emphasizes the emergence of unique, hierarchically layered social strata. We show an application using Finnish registration data that cover the entire population over the period from 1996 to 2017. The results indicate that lifespan stratification and life-expectancy differences between income groups both increased substantially from 1996 to 2008; subsequently, life-expectancy differences declined, whereas stratification stagnated for men and increased for women. We conclude that the non-overlap index uncovers a unique domain of inequalities in mortality and helps to capture important between-group differences that conventional approaches miss.

Suicide and other causes of death among Chernobyl cleanup workers from Estonia, 1986 - 2020: an update

Mortality was studied in a cohort of 4831 men from Estonia who participated in the environmental cleanup of the radioactively contaminated areas around Chernobyl in 1986-1991. Their mortality in 1986-2020 was compared with the mortality in the Estonian male population. A total of 1503 deaths were registered among the 4812 traced men. The all-cause standardized mortality ratio (SMR) was 1.04 (95% CI 0.99-1.09). All-cancer mortality was elevated (SMR 1.16, 95% CI 1.03-1.28). Radiation-related cancers were in excess (SMR 1.20, 95% CI 1.03-1.36); however, the excesses could be attributed to tobacco and alcohol consumption. For smoking-related cancers, the SMR was 1.20 (95% CI 1.06-1.35) and for alcohol-related cancers the SMR was 1.56 (95% CI 1.26-1.86). Adjusted relative risks (ARR) of all-cause mortality were increased among workers who stayed in the Chernobyl area ≥ 92 days (ARR 1.20, 95% CI 1.08-1.34), were of non-Estonian ethnicity (ARR 1.33, 95% CI 1.19-1.47) or had lower (basic or less) education (ARR 1.63, 95% CI 1.45-1.83). Suicide mortality was increased (SMR 1.31, 95% CI 1.05-1.56), most notably among men with lower education (ARR 2.24, 95% CI 1.42-3.53). Our findings provide additional evidence that unhealthy behaviors such as alcohol and smoking play an important role in shaping cancer mortality patterns among Estonian Chernobyl cleanup workers. The excess number of suicides suggests long-term psychiatric and substance use problems tied to Chernobyl-related stressors, i.e., the psychosocial impact was greater than any direct carcinogenic effect of low-dose radiation.

Differences in all-cause and cause-specific mortality due to external causes and suicide between young adult refugees, non-refugee immigrants and Swedish-born young adults: The role of education and migration-related factors

BACKGROUND

International migration has increased during the past years and little is known about the mortality of young adult immigrants and refugees that came to Sweden as children. This study aimed to investigate 1) the risk of all-cause and cause-specific mortality in young accompanied and unaccompanied refugees and non-refugee immigrants compared to Swedish born individuals; and 2) to determine the role of educational level and migrations-related factors in these associations.

METHODS

This register linkage study is based on 682,358 individuals (633,167 Swedish-born, 2,163 unaccompanied and 25,658 accompanied refugees and 21,370 non-refugee immigrants) 19-25 years old, who resided in Sweden 31.12.2004. Outcomes were all-cause mortality and mortality due to suicide and external causes. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated using Cox regression models with a maximum follow-up to 2016.

RESULTS

After adjusting for covariates, all-cause mortality was significantly lower in non-refugee immigrants (aHR 0.70, 95% CI 0.59-0.84) and refugees (aHR 0.76, 95% CI 0.65-0.88) compared to Swedish-born individuals. The same direction of association was observed for mortality due to suicide and external causes. No differences between accompanied and unaccompanied refugees were found. Risk estimates for all migrant groups varied with educational level, duration of residency, age at arrival and country of birth. Further, the mortality risk of migrants arriving in Sweden before the age of 6 years did not significantly differ from the risk of their Swedish-born peers. Low education was a considerable risk factor.

CONCLUSION

In general, young adult refugees and non-refugee immigrants have a lower risk of all-cause and cause-specific mortality than Swedish-born individuals. The identified migrant groups with higher mortality risk need specific attention.

Inequality in the Face of Death: The Income Gradient in Mortality of the Spanish Pre-Recession Working-Age Population

The purpose of this paper is to evaluate the association between socioeconomic status (SES) and mortality over a three-year period for working-age Spaniards (2007-2009), paying particular attention to the effect of income level. The analysis is relatively new in Spain, and the studies are limited. Neither income nor wealth are included in existing Spanish mortality studies. The main reason for this limitation is the nature of the data sets used, mainly Census Records. We overcome this problem by using data on 693,994 individuals taken from a Social Security sampling and used to estimate the probabilities of death for each income decile and the mortality rate ratios in three different models: (1) using only income, controlled by age and sex, (2) adding socio-economic and geographical variables, and (3) adding level of education. However, the data used here also have some limitations. They do not include government employees, the military or the Department of Justice personnel, whose exclusion we believe causes an under-representation of highly educated people in our sample. The results confirm that there is a non-linear relationship between mortality and income. This non-linear relationship implies that income redistribution resulting from progressive taxation systems could lead to higher reductions in mortality for low-income groups than the reductions induced in the mortality of the high-income population, thus reducing overall mortality.

The impact of income definitions on mortality inequalities

Income is a strong predictor of adult mortality. Measuring income is not as simple as it may sound. It can be conceptualized at the individual or the household level, with the former better reflecting an individual's earning ability, and the latter better capturing living standards. Furthermore, respondents are often grouped into income categories based on their positions in the income distribution, and this operationalization can be done on the basis of age-specific or total population income distributions. In this study, we look at how four combinations of different conceptualizations (individual vs. household) and operationalizations (age-specific vs. total population) of income can affect mortality inequality estimates. Using Finnish registry data, we constructed period life tables for ages 25+ from 1996 to 2017 by gender and for four income definitions. The results indicated that the slope index of inequality for life expectancy varied by 1.1-5.7 years between income definitions, with larger differences observed for women than for men. The overall age patterns of relative index of inequality for mortality rates yielded by the four definitions were similar, but the levels differed. The period trends across income definitions were consistent for men, but not for women. We conclude that researchers should pay particular attention to the choice of the income definitions when analyzing the association between income and mortality, and when comparing the magnitude of inequality across studies and over time.

The implications of changing education distributions for life expectancy gradients

Recent research has proposed that shifting education distributions across cohorts are influencing estimates of educational gradients in mortality. We use data from the United States and Finland covering four decades to explore this assertion. We base our analysis around our new finding: a negative logarithmic relationship between relative education and relative mortality. This relationship holds across multiple age groups, both sexes, two very different countries, and time periods spanning four decades. The inequality parameters from this model indicate increasing relative mortality differentials over time. We use these findings to develop a method that allows us to compute life expectancy for any given segment of the education distribution (e.g., education quintiles). We apply this method to Finnish and American data to compute life expectancy gradients that are adjusted for changes in the education distribution. In Finland, these distribution-adjusted education differentials in life expectancy between the top and bottom education quintiles have increased by two years for men, and remained stable for women between 1971 and 2010. Similar distribution-adjusted estimates for the U.S. suggest that educational disparities in life expectancy increased by 3.3 years for non-Hispanic white men and 3.0 years for non-Hispanic white women between the 1980s and 2000s. For men and women, respectively, these differentials between the top and bottom education quintiles are smaller than the differentials between the top and bottom education categories by 18% and 39% in the U.S. and by 39% and 100% in Finland. Had the relative inequality parameters of mortality governing the Finnish and U.S. populations remained constant at their earliest period values, the difference in life expectancy between the top and bottom education quintiles would - because of overall mortality reductions - have declined moderately. The findings suggest that educational expansion may bias estimates of trends in educational differences in life expectancy upwards.

A Systematic Review of the Association between Poverty and Biomarkers of Toxic Stress

Purpose: Toxic stress has been identified as a key mechanism by which poverty impacts health and empirical evidence on the relationship between poverty and biological markers of toxic stress is accumulating. This study synthesizes the empirical evidence of the relationship between poverty and biomarkers of toxic stress. Method: We conduct a systematic literature review using PRISMA guidelines to assess the relationship between poverty and toxic stress. A total of 56 articles are included in the review assessing 63 poverty and toxic stress relationships. Results: Seventeen of 30 reviewed relationships showed a statistically significant relationship between our measures of poverty and biomarker outcomes. Additionally, 12 of the remaining 13 studies demonstrated partially statistically significant relationship between our poverty measures and biomarker outcomes. Conclusion: Findings demonstrate evidence of the relationship between poverty and toxic stress. Consistently, poverty was related to biological stress and neighborhood poverty was related to physical stress outcomes.

Changing educational gradient in long-term care-free life expectancy among German men, 1997-2012

BACKGROUND

The inverse association between mortality and individual socioeconomic status is well-documented. Due to the lack of appropriate data, little is known about the nature of this association among individuals with long-term care (LTC) needs.

OBJECTIVES

We aim to fill in this knowledge gap by estimating life expectancy (LE), life expectancy without (CFLE) and with (CLE) long-term care by education for older German men; and by assessing the trends in the education-LE/CFLE/CLE gradient over time.

DATA AND METHODS

We apply survival analysis and Gompertz regression to German Socioeconomic Panel data (1997-2012) to estimate the mortality levels and to construct the life tables for three educational categories. Using the administrative data from the health insurance, we adjust mortality rates upward to account for the institutionalized population. We estimate age-specific LTC prevalence from the German Microcensus data (2004, 2012) and compute life expectancy with and without LTC by employing Sullivan's method. Slope and Relative Indices of Inequality are computed to evaluate the magnitude of educational inequalities in CFLE.

RESULTS

There is a clear and growing educational gradient in LE and CFLE among older men in Germany. In 2004, LE at age 65 among men with low education was 14.2 years, or 3.3 years lower than among highly educated individuals. The CFLE of these two educational categories ranged from 13.6 to almost 17 years. The gradient increased over time and in 2012 the difference constituted 4.6 years. The gaps between educational groups were not pronounced for CLE. The declining health ratio of years without LTC to remaining LE suggests the expansion of LTC needs, irrespective of the educational level.

CONCLUSIONS

Growing inequalities by educational status among older German men with care needs demand the attention of policy-makers. Prompt actions are needed to increase the survival chances of the most vulnerable groups.

Social group dynamics predict stress variability among children in a New Zealand classroom

Previous research proposes stress as a mechanism for linking social environments and biological bodies. In particular, non-human primate studies investigate relationships between cortisol as a measure of stress response and social hierarchies. Because human social structures often include hierarchies of dominance and social status, humans may exhibit similar patterns. Studies of non-human primates, however, have not reached consistent conclusions with respect to relationships between social position and levels of cortisol. While human studies report associations between cortisol and various aspects of social environments, studies that consider social status as a predictor of stress response also report mixed results. Others have argued that perceptions of social status may have different implications for stress response depending upon social context. We propose here that characteristics of children's social networks may be a better predictor of central tendencies and variability of stress response than their perceptions of social status. This is evaluated among 24 children from 9.4 to 11.3 years of age in one upper middle-class New Zealand primary school classroom, assessed through observation within the classroom, self-reports during semi-structured interviews and 221 serial saliva samples provided daily over 10 consecutive school days. A synthetic assessment of the children's networks and peer-relationships was developed prior to saliva-cortisol analysis. We found that greater stability of peer-relationships within groups significantly predicts lower within-group variation in mid-morning cortisol over the two-week period, but not overall within-group differences in mean cortisol.

Children's educational attainment, occupation, and income and their parents' mortality

Using data from Finland, this paper contributes to a small but growing body of research regarding adult children's education, occupation, and income and their parents' mortality at ages 50+ in 1970-2007. Higher levels of children's education are associated with 30-36 per cent lower parental mortality at ages 50-75, controlling for parents' education, occupation, and income. This association is fully mediated by children's occupation and income, except for cancer mortality. Having at least one child educated in healthcare is associated with 11-16 per cent lower all-cause mortality at ages 50-75, an association that is largely driven by mortality from cardiovascular diseases. Children's higher white-collar occupation and higher income is associated with 39-46 per cent lower mortality in the fully adjusted models. At ages 75+, these associations are much smaller overall and children's schooling remains more strongly associated with mortality than children's occupation or income.

International Differences in the Risk of Death from Smoking and Obesity: The Case of the United States and Finland

Despite much interest in the health risks associated with behavioral factors, little is known about whether individuals residing in different countries experience a different set of risks. International comparisons of the death risks from major behavioral factors can shed light on whether features of health systems and epidemiological histories modify the health effects of risky behaviors. We used nationally representative samples and mortality linkages spanning the 1971-2014 period from the United States and Finland to examine cross-national differences in the risks of death from cigarette smoking and obesity. We evaluated both current and former smoking and current and prior obesity. In 1990, the approximate midpoint of our study, the death risks from current smoking were about 55% higher in U.S. women compared to Finnish women, but similar for men in the two countries. Death risks from smoking significantly increased over the period for women in both countries and there was no parallel increase in risks among men. Death risks from obesity did not significantly differ in the two countries and no significant trend in the risks were detected in either country. Reasons for the relatively high and increasing risks from smoking among American women warrant further evaluation.

Cash Transfers and Child Nutrition: Pathways and Impacts

Childhood malnutrition remains a significant global problem, with an estimated 162 million children under the age of five suffering from stunted growth. This article examines the extent to which cash transfer programmes can improve child nutrition. It adopts a framework that captures and explains the pathways and determinants of child nutrition. The framework is then used to organize and discuss relevant evidence from the impact evaluation literature, focusing on impact pathways and new and emerging findings from sub-Saharan Africa to identify critical elements that determine child nutrition outcomes as well as knowledge gaps requiring further research, such as children's dietary diversity, caregiver behaviours and stress.

Educational Attainment and Mortality in the United States: Effects of Degrees, Years of Schooling, and Certification

Researchers have extensively documented a strong and consistent education gradient for mortality, with more highly educated individuals living longer than those with less education. This study contributes to our understanding of the education-mortality relationship by determining the effects of years of education and degree attainment on mortality, and by including nondegree certification, an important but understudied dimension of educational attainment. We use data from the mortality-linked restricted-use files of the Panel Study of Income Dynamics (PSID) sample (N=9,821) and Cox proportional hazards models to estimate mortality risk among U.S. adults. Results indicate that more advanced degrees and additional years of education are associated with reduced mortality risk in separate models, but when included simultaneously, only degrees remain influential. Among individuals who have earned a high school diploma only, additional years of schooling (beyond 12) and vocational school certification (or similar accreditation) are both independently associated with reduced risks of death. Degrees appear to be most important for increasing longevity; the findings also suggest that any educational experience can be beneficial. Future research in health and mortality should consider including educational measures beyond a single variable for educational attainment.

Association of Lower Socioeconomic Position in Pregnancy with Lower Diurnal Cortisol Production and Lower Birthweight in Male Infants

PURPOSE

Low maternal socioeconomic position (SEP) has been associated with adverse neonatal outcomes, including preterm birth, low birthweight, intrauterine growth restriction, and infant mortality. A key biological mechanism that has been proposed to explain this association is hypothalamic-pituitary-adrenal (HPA) activity, yet the association between SEP and HPA activity in pregnancy has received little attention. In this study we aimed to examine the associations between SEP and 2 forms of maternal cortisol regulation-diurnal slope and wakening response-across pregnancy. Furthermore, we aimed to assess whether these associations differed by the sex of the fetus.

METHODS

A total of 217 pregnant women aged 18 to 40 years with singleton pregnancies participated. Women were excluded from participating if they were aged <18 or >40 years and if they were at risk for maternal or obstetric complications. Women provided information on socioeconomic characteristics of adults contributing to the participants' household to compute a Hollingshead Four Factor Index of Social Status score of SEP. Women provided salivary cortisol samples on awakening, 30 minutes after wakeup, and at bedtime, at 3 times over pregnancy and once 30 days postpartum to calculate the diurnal slope and cortisol awakening response (CAR). Using linear regression analyses, we examined the relationships between maternal SEP and maternal diurnal slope and CAR. We explored the relationships between maternal SEP and cortisol by fetal sex using linear regression analyses. We also explored links between maternal SEP, maternal cortisol, and infant birth outcomes.

FINDINGS

Women of lower SEP displayed smaller awakening responses and less change over the day compared with women of higher SEP. SEP was significantly associated with attenuated diurnal slope only among women carrying female fetuses, whereas for CAR, the association between SEP and attenuated CAR was significant only for women carrying male fetuses. Lower SEP was associated with decreased birthweight, and this association was partially explained by maternal HPA activity in pregnancy.

IMPLICATIONS

Women of low SEP displayed attenuated HPA activity across the perinatal period, and patterns varied by fetal sex and cortisol metric. Findings are in need of replication. More research is needed to understand the links between SEP, HPA activity, and neonatal health.

Unobserved Heterogeneity of Frailty in the Analysis of Socioeconomic Differences in Health and Mortality

The concepts of unobserved frailty and selection have been extensively analyzed with respect to phenomena like mortality deceleration at old ages and mortality convergence or cross overs between populations (for example American black and white populations, men and women). Despite the long-time observation of converging mortality risks in differential socioeconomic mortality research, the interest in the connection between frailty, selection, and health and mortality inequalities over a life course approach has increased only recently. This overview of the literature summarizes the main concepts of unobserved frailty and socioeconomic differences in mortality and how frailty and selection relate to these differences at old ages. It then reviews the evidence coming from the existing studies. Although the number of studies is still limited, the body of research on unobserved frailty and socioeconomic inequalities in health and mortality in a life course approach is growing. The results, however, are contradictory, and whether selection plays a major role in shaping the observed socioeconomic mortality patterns at old ages is still controversial.

Longevity and Education: A Demographic Perspective

In the second half of the 20th century, the advances in human longevity observed have been accompanied by an increase in the disparities between countries and regions. Education is one of the strongest predictors of life expectancy. Studies have shown that both relative and absolute mortality differences by education within countries have been increasing, even in the most developed and egalitarian countries. It is possible to assume that groups of highly educated people who systematically display life expectancy levels which are higher than the observed best practice (record) life expectancy at the national level are vanguards who are leading the way toward a lengthening of life for the remaining population groups. This evidence based on population-level statistics and exploring an important single factor could inspire further discussion about the possibilities for extending human length of life at the national level. However, more comprehensive and reliable data covering a larger number of countries and more covariates are needed for understanding health effects of education and prospects of human longevity.

Work-Family Context and the Longevity Disadvantage of US Women

Female life expectancy is currently shorter in the United States than in most high-income countries. This study examines work-family context as a potential explanation. While work-family context changed similarly across high-income countries during the past half century, the United States has not implemented institutional supports, such as universally available childcare and family leave, to help Americans contend with these changes. We compare the United States to Finland-a country with similar trends in work-family life but generous institutional supports-and test two hypotheses to explain US women's longevity disadvantage: (1) US women may be less likely than Finnish women to combine employment with childrearing; and (2) US women's longevity may benefit less than Finnish women's longevity from combining employment with childrearing. We used data from women aged 30-60 years during 1988-2006 in the US National Health Interview Survey Linked Mortality File and harmonized it with data from Finnish national registers. We found stronger support for hypothesis 1, especially among low-educated women. Contrary to hypothesis 2, combining employment and childrearing was not less beneficial for US women's longevity. In a simulation exercise, more than 75 percent of US women's longevity disadvantage was eliminated by raising their employment levels to Finnish levels and reducing mortality rates of non-married/non-employed US women to Finnish rates.

Childhood family background and mortality differences by income in adulthood: fixed-effects analysis of Finnish siblings

BACKGROUND

Events and conditions during childhood have been found to affect health and mortality at later stages in life. We studied whether childhood conditions explain the observed all-cause and cause-specific mortality disparity between income groups in adulthood.

METHODS

We used a 10% register linked sample of Finnish households in the 1950 census identifying 51 647 children aged 0-14 with at least one sibling of the same sex and followed them for mortality from the age 35 until ages 57-72. Using Cox regression with sibling design, we estimated hazard ratios (HRs) for quintiles of personal income at the age 35. We controlled for observed childhood family sociodemographic characteristics and allowed different baseline hazard functions for each group of siblings in order to control for all shared unobserved characteristics within families.

RESULTS

Accounting for the observed childhood characteristics did not attenuate the income disparity in mortality, whereas adjusting for the sociodemographic characteristics in adulthood reduced the difference of the lowest quintiles by ∼70% among men and 30-40% among women. Controlling for the unobserved childhood characteristics in the sibling design did not provide any further explanation to the income differentials in mortality. This applied also for cause-specific mortality among men. HR to the cardiovascular diseases was 38% higher and 73% higher in alcohol, accidental and violent causes in the lowest quintile even after adjusting for all observed and unobserved characteristics.

CONCLUSIONS

The excess mortality in the lowest income quintiles persists even after shared childhood family conditions among siblings are accounted for.

Lifespan variation by occupational class: compression or stagnation over time?

Cross-sectional analyses of adult lifespan variation have found an inverse association between socioeconomic position and lifespan variation, but the trends by social class are unknown. We investigated trends in lifespan variation over four decades (1971-2010) by occupational social class (manual, lower nonmanual, upper nonmanual, other) using Finnish register data. We performed age and cause-of-death decompositions of lifespan variation for each sex (a) by occupational class over time and (b) between occupational classes at a shared level of life expectancy. Although life expectancy increased in all classes, lifespan variation was stable among manual workers and decreased only among nonmanual classes. These differences were caused by early-adult mortality: older-age lifespan variation declined for all the classes, but variation in early-adult mortality increased for all classes except the highest. The manual class's high and stagnant lifespan variation was driven by declines in circulatory diseases that were equally spread over early mortality-compressing and older mortality-expanding ages, as well as by high early-adult mortality from external causes. Results were similar for men and women. The results of this study, which is the first to document trends in lifespan variation by social class, suggest that mortality compression is compatible with increasing life expectancy but currently achieved only by higher occupational classes.

THE NONEQUIVALENT HEALTH OF HIGH SCHOOL EQUIVALENTS

OBJECTIVES

Millions of U.S. adults are recipients of the high school equivalency (GED) diploma. Virtually nothing is known about the health of this large group, although literature suggests GED recipients are considerably worse off than high school graduates in numerous economic and social outcomes. We analyze general health among working-age adults with a high school diploma, GED recipients, and high school dropouts.

METHODS

Ordered and binary logistic models of self-rated health and activity limitations were estimated using data from the 1997-2009 National Health Interview Surveys (N=76,703).

RESULTS

GED recipients have significantly and substantially worse health than high school graduates, among both sexes. In fact, the GED recipients' health is generally comparable to that of high school dropouts. Health behaviors and economic factors explain a large proportion of the difference but the gap remains significant.

CONCLUSIONS

In terms of health, adults with a terminal GED are not equivalent to high school graduates. GED recipients report considerably worse general health and activity limitations. The disadvantage is only partly due to the worse economic outcomes and health behaviors; a significant difference remains unexplained and may be due to other, unobserved pathways, or to selection mechanisms.

Patterns of widowhood mortality

OBJECTIVES

Becoming widowed is a known risk factor for mortality. This article examines the magnitude of, explanations for, and variation in the association between widowhood and mortality. Previous research on widowhood mortality has revealed variation by socioeconomic status (SES), in that SES is not protective in widowhood, and by gender, such that men's mortality increases more than women's mortality after the death of spouse.

METHOD

Using data from the Health and Retirement Study, we estimated Cox proportional hazard models to estimate the association between widowhood and mortality.

RESULTS

Becoming widowed is associated with a 48% increase in risk of mortality. Approximately one third of the increase can be attributed to selection, in that those who become widows are socioeconomically disadvantaged. In contrast to previous studies, SES is protective for widows. Widowhood mortality risk increases for men if their wives' deaths were unexpected rather than expected; for women, the extent to which their husbands' death was expected matters less.

DISCUSSION

Widowhood's harmful association with mortality show how strongly social support and individual's health and mortality are related. These findings support the larger literature on the importance of social support for health and longevity.

The Nonlinear Relationship between Education and Mortality: An Examination of Cohort, Race/Ethnic, and Gender Differences

Researchers investigating the relationship between education and mortality in industrialized countries have consistently shown that higher levels of education are associated with decreased mortality risk. The shape of the education-mortality relationship and how it varies by demographic group have been examined less frequently. Using the U.S. National Health Interview Survey-Linked Mortality Files, which link the 1986 through 2004 NHIS to the National Death Index through 2006, we examine the shape of the education-mortality curve by cohort, race/ethnicity, and gender. Whereas traditional regression models assume a constrained functional form for the dependence of education and mortality, in most cases semiparametric models allow us to more accurately describe how the association varies by cohort, both between and within race/ethnic and gender subpopulations. Notably, we find significant changes over time in both the shape and the magnitude of the education-mortality gradient across cohorts of women and white men, but little change among younger cohorts of black men. Such insights into demographic patterns in education and mortality can ultimately help increase life expectancies.

HEALTHIER, WEALTHIER, AND WISER: A DEMONSTRATION OF COMPOSITIONAL CHANGES IN AGING COHORTS DUE TO SELECTIVE MORTALITY

The gradual changes in cohort composition that occur as a result of selective mortality processes are of interest to all aging research. We present the first illustration of changes in the distribution of specific cohort characteristics that arise purely as a result of selective mortality. We use data on health, wealth, education, and other covariates from two cohorts (the AHEAD cohort, born 1900-23 and the HRS cohort, born 1931-41) included in the Health and Retirement Survey, a nationally representative panel study of older Americans spanning nearly two decades (N=14,466). We calculate sample statistics for the surviving cohort at each wave. Repeatedly using only baseline information for these calculations so that there are no changes at the individual level (what changes is the set of surviving respondents at each specific wave), we obtain a demonstration of the impact of mortality selection on the cohort characteristics. We find substantial changes in the distribution of all examined characteristics across the nine survey waves. For instance, the median wealth increases from about $90,000 to $130,000 and the number of chronic conditions declines from 1.5 to 1 in the AHEAD cohort. We discuss factors that influence the rate of change in various characteristics. The mortality selection process changes the composition of older cohorts considerably, such that researchers focusing on the oldest old need to be aware of the highly select groups they are observing, and interpret their conclusions accordingly.

More variation in lifespan in lower educated groups: evidence from 10 European countries

BACKGROUND

Whereas it is well established that people with a lower socio-economic position have a shorter average lifespan, it is less clear what the variability surrounding these averages is. We set out to examine whether lower educated groups face greater variation in lifespans in addition to having a shorter life expectancy, in order to identify entry points for policies to reduce the impact of socio-economic position on mortality.

METHODS

We used harmonized, census-based mortality data from 10 European countries to construct life tables by sex and educational level (low, medium, high). Variation in lifespan was measured by the standard deviation conditional upon survival to age 35 years. We also decomposed differences between educational groups in lifespan variation by age and cause of death.

RESULTS

Lifespan variation was higher among the lower educated in every country, but more so among men and in Eastern Europe. Although there was an inverse relationship between average life expectancy and its standard deviation, the first did not completely predict the latter. Greater lifespan variation in lower educated groups was largely driven by conditions causing death at younger ages, such as injuries and neoplasms.

CONCLUSIONS

Lower educated individuals not only have shorter life expectancies, but also face greater uncertainty about the age at which they will die. More priority should be given to efforts to reduce the risk of an early death among the lower educated, e.g. by strengthening protective policies within and outside the health-care system.

Are there education differentials in disability and mortality transitions and active life expectancy among Japanese older adults? Findings from a 10-year prospective cohort study

OBJECTIVES

To investigate the robust education-health association found in Western developed nations in the Japanese context. We examined disability and mortality transitions and computed active life expectancy (ALE) by educational attainment for a cohort of Japanese adults aged 65+ years.

METHOD

Nationally representative data from the Nihon University Japanese Longitudinal Study of Aging over a 10-year period in Japan (1999, 2001, 2003, 2006, and 2009) were used (N = 4,968). Disability was measured by difficulties in performing daily activities. A multistate life table method was employed using an interpolated Markov chain approach.

RESULTS

There is little effect of education on disability and mortality transitions. Except for transiting from an active to inactive state (disability incidence), the other health transitions, including to mortality, are not statistically significant. ALE computations show that Japanese men and women with more education can expect more years of remaining life and active life.

DISCUSSION

The robust education-health relationship found in Western societies does not seem applicable in Japan. We discuss the casual mechanisms addressed in the literature in relation to Japan's relatively egalitarian society and specific characteristics.

Educational attainment and adult mortality in the United States: a systematic analysis of functional form

A vast literature has documented the inverse association between educational attainment and U.S. adult mortality risk but given little attention to identifying the optimal functional form of the association. A theoretical explanation of the association hinges on our ability to describe it empirically. Using the 1979-1998 National Longitudinal Mortality Study for non-Hispanic white and black adults aged 25-100 years during the mortality follow-up period (N = 1,008,215), we evaluated 13 functional forms across race-gender-age subgroups to determine which form(s) best captured the association. Results revealed that the preferred functional form includes a linear decline in mortality risk from 0 to 11 years of education, followed by a step-change reduction in mortality risk upon attainment of a high school diploma, at which point mortality risk resumes a linear decline but with a steeper slope than that prior to a high school diploma. The findings provide important clues for theoretical development of explanatory mechanisms: an explanation for the selected functional form may require integrating a credentialist perspective to explain the step-change reduction in mortality risk upon attainment of a high school diploma, with a human capital perspective to explain the linear declines before and after a high school diploma.

Education and health among U.S. working-age adults: a detailed portrait across the full educational attainment spectrum

This article presents detailed estimates of relative and absolute health inequalities among U.S. working-age adults by educational attainment, including six postsecondary schooling levels. We also estimate the impact of several sets of mediating variables on the education-health gradient. Data from the 1997-2009 National Health Interview Survey (N = 178,103) show remarkable health differentials. For example, high school graduates have 3.5 times the odds of reporting "worse" health than do adults with professional or doctoral degrees. The probability of fair or poor health in mid-adulthood is less than 5 percent for adults with the highest levels of education but over 20 percent for adults without a high school diploma. The probability of reporting excellent health in the mid-forties is below 25 percent among high school graduates but over 50 percent for those adults who have professional degrees. These health differences characterize all the demographic subgroups examined in this study. Our results show that economic indicators and health behaviors explain about 40 percent of the education-health relationship. In the United States, adults with the highest educational degrees enjoy a wide array of benefits, including much more favorable self-rated health, compared to their less-educated counterparts.

The contribution of psychological distress to socio-economic differences in cause-specific mortality: a population-based follow-up of 28 years

BACKGROUND

Psychological factors associated with low social status have been proposed as one possible explanation for the socio-economic gradient in health. The aim of this study is to explore whether different indicators of psychological distress contribute to socio-economic differences in cause-specific mortality.

METHODS

The data source is a nationally representative, repeated cross-sectional survey, "Health Behaviour and Health among the Finnish Adult Population" (AVTK). The survey results were linked with socio-economic register data from Statistics Finland (from the years 1979-2002) and mortality follow-up data up to 2006 from the Finnish National Cause of Death Register. The data included 32,451 men and 35,420 women (response rate 73.5%). Self-reported measures of depression, insomnia and stress were used as indicators of psychological distress. Socio-economic factors included education, employment status and household income. Mortality data consisted of unnatural causes of death (suicide, accidents and violence, and alcohol-related mortality) and coronary heart disease (CHD) mortality. Adjusted hazard ratios were calculated using the Cox regression model.

RESULTS

In unnatural mortality, psychological distress accounted for some of the employment status (11-31%) and income level (4-16%) differences among both men and women, and for the differences related to the educational level (5-12%) among men; the educational level was associated statistically significantly with unnatural mortality only among men. Psychological distress had minor or no contribution to socio-economic differences in CHD mortality.

CONCLUSIONS

Psychological distress partly accounted for socio-economic disparities in unnatural mortality. Further studies are needed to explore the role and mechanisms of psychological distress associated with socio-economic differences in cause-specific mortality.

Deeper and wider: income and mortality in the USA over three decades

BACKGROUND

Literature on the socio-economic 'gradient' in health often asserts that income is associated with better health not only for the very poor, but also across the entire income distribution. In addition, changes in the shape of the association between incomes during a period of increasing economic inequality have not been previously studied. The goal of the current study was to estimate and compare the shape of the relationship between income and mortality in the USA for the 1970s, the 1980s and the 1990s.

METHODS

Using income and mortality data from the Panel Study of Income Dynamics for respondents aged 35-64 years, we used a Bayesian Cox Model with regression splines to model the risk of mortality over three 10-year follow-up periods. To identify whether income was more strongly associated with mortality at different parts of the income distribution, we treated income as a linear spline with an unknown knot location.

RESULTS

The shape of the association between income and mortality was quite non-linear, with a much stronger association at lower levels of income. The relationship between income and mortality in the USA was also not invariant across time, with the increased risk of death associated with lower income applying to an increasing proportion of the US population over time (9th percentile of income in 1970-79, 20th percentile in 1980-89 and 32nd percentile in 1990-99).

CONCLUSIONS

Our analyses do not support the claim that income is associated with mortality throughout the income distribution, nor is the association between income and mortality the same across periods. Based on our analyses, a focus on the bottom 30% of the income distribution would seem to return the greatest benefits in reducing socio-economic inequalities in health.

Increased educational attainment and its effect on child mortality in 175 countries between 1970 and 2009: a systematic analysis

BACKGROUND

In addition to the inherent importance of education and its essential role in economic growth, education and health are strongly related. We updated previous systematic assessments of educational attainment, and estimated the contribution of improvements in women's education to reductions in child mortality in the past 40 years.

METHODS

We compiled 915 censuses and nationally representative surveys, and estimated mean number of years of education by age and sex. By use of a first-differences model, we investigated the association between child mortality and women's educational attainment, controlling for income per person and HIV seroprevalence. We then computed counterfactual estimates of child mortality for every country year between 1970 and 2009.

FINDINGS

The global mean number of years of education increased from 4·7 years (95% uncertainty interval 4·4-5·1) to 8·3 years (8·0-8·6) for men (aged ≥25 years) and from 3·5 years (3·2-3·9) to 7·1 years (6·7 -7·5) for women (aged ≥25 years). For women of reproductive age (15-44 years) in developing countries, the years of schooling increased from 2·2 years (2·0-2·4) to 7·2 years (6·8-7·6). By 2009, in 87 countries, women (aged 25-34 years) had higher educational attainment than had men (aged 25-34 years). Of 8·2 million fewer deaths in children younger than 5 years between 1970 and 2009, we estimated that 4·2 million (51·2%) could be attributed to increased educational attainment in women of reproductive age.

INTERPRETATION

The substantial increase in education, especially of women, and the reversal of the gender gap have important implications not only for health but also for the status and roles of women in society. The continued increase in educational attainment even in some of the poorest countries suggests that rapid progress in terms of Millennium Development Goal 4 might be possible.

FUNDING

Bill & Melinda Gates Foundation.

A case-control analysis of socio-economic and marital status differentials in alcohol- and non-alcohol-related mortality among working-age Russian males

BACKGROUND

We examined the role of socio-economic status (SES) and marital status in premature mortality among working-age Russian males. Life expectancy among this group dropped sharply following the collapse of the Soviet Union and has yet to recover despite the relative economic and political stability of the last decade.

METHODS

We employed individual-level data from a large-scale, population-based, case-control study (n = 3500). Adjusting for age group, hazardous drinking and smoking status, we estimated mortality odds ratios to determine the impact of SES and marital status on premature mortality due to all, alcohol- and non-alcohol-related causes of death.

RESULTS

Results revealed clear protective effects of SES and marital status against premature mortality. Although the effects for marital status were significant across alcohol- and non-alcohol-related causes of death, the effects of SES were largely limited to non-alcohol-related causes of death. When heavy drinkers were excluded from the analysis, however, SES was found to protect against premature mortality for alcohol-related causes.

CONCLUSION

While hazardous drinking is known to be a leading cause of premature mortality among working-age Russian males, it is unwise to ignore other factors. Given the substantial social and economic impacts in Russia of the dissolution of the Soviet Union, it is important to examine the health effects of SES and marital status and other social forces in the nation. Our results reveal that while Russia has a very different past in terms of medicine, public health and economic institutions, it currently faces public health threats that follow similar patterns to those found in Western nations.

Educational degrees and adult mortality risk in the United States

We present the first published estimates of U.S. adult mortality risk by detailed educational degree, including advanced postsecondary degrees. We use the 1997-2002 National Health Interview Survey (NHIS) Linked Mortality Files and Cox proportional hazards models to reveal wide graded differences in mortality by educational degree. Compared to adults who have a professional degree, those with an MA are 5 percent, those with a BA are 26 percent, those with an AA are 44 percent, those with some college are 65 percent, high school graduates are 80 percent, and those with a GED or 12 or fewer years of schooling are at least 95 percent more likely to die during the followup period, net of sociodemographic controls. These differentials vary by gender and cohort. Advanced educational degrees are associated not only with increased workforce skill level but with a reduced risk of death.

Socio-economic status, cortisol and allostatic load: a review of the literature

BACKGROUND

The notion that chronic stress contributes to health inequalities by socio-economic status (SES) through physiological wear and tear has received widespread attention. This article reviews the literature testing associations between SES and cortisol, an important biomarker of stress, as well as the summary index of allostatic load (AL).

METHODS

A search of all published literature on the PubMed and ISI Web of Knowledge literature search engines was conducted using broad search terms. The authors reviewed abstracts and selected articles that met the inclusion criteria. A total of 26 published studies were included in the review.

RESULTS

Overall, SES was not consistently related to cortisol. Although several studies found an association between lower SES and higher levels of cortisol, many found no association, with some finding the opposite relationship. Lower SES was more consistently related to a blunted pattern of diurnal cortisol secretion, but whether this corresponded to higher or lower overall cortisol exposure varied by study. Approaches to collecting and analysing cortisol varied widely, likely contributing to inconsistent results. Lower SES was more consistently related to higher levels of AL, but primarily via the cardiovascular and metabolic components of AL rather than the neuroendocrine markers.

CONCLUSIONS

Current empirical evidence linking SES to cortisol and AL is weak. Future work should standardize approaches to measuring SES, chronic stress and cortisol to better understand these relationships.

Gender differences in education effects on all-cause mortality for white and black adults in the United States

The existence of education differentials in adult mortality has been well established. The issue of gender differences in the education-mortality association, however, remains an open question, despite its importance for understanding of causal pathways through which education affects health outcomes. The goal of this paper is to analyze gender differences in education gradients in mortality among non-Hispanic white and black U.S. adults born between 1906 and 1965. The analysis is based on data from the 1986-2000 National Health Interview Surveys linked to the National Death Index through 2002 (NHIS-LMF) with over 700,000 respondents. Full-sample and cohort-stratified Cox proportional hazard models of all-cause mortality were estimated. Results indicate a great deal of similarity between men and women in the education-mortality association, with some exceptions. The most notable difference is the steeper educational gradient at high schooling levels for white men compared to white women. This difference was fully explained by marital status. No systematic gender differences in the relationship between education and adult mortality were observed among black adults in any birth cohorts. The findings suggest that men do not benefit from educational attainment uniformly more than women.

Socioeconomic and race/ethnic patterns in persistent infection burden among U.S. adults

BACKGROUND

The pathophysiological mechanisms that underlie health disparities by socioeconomic status and race/ethnicity are poorly understood. Promising new research suggests that the burden of persistent infection may influence adult disease risk and mortality. This article examines how multiple persistent infections cluster within individuals and how this clustering varies by socioeconomic position and race/ethnicity in U.S. adults.

METHODS

We analyze data from the National Health and Nutrition Examination Survey III (N = 19,275) for adults aged 17-90 years. The clustering of infections within individuals is studied using tetrachoric correlations. Multiple indicator multiple cause models are used to analyze the infection burden construct as measured by seropositivity to Helicobacter pylori, cytomegalovirus, herpes simplex virus-1, and hepatitis B, focusing on the burden's distribution by socioeconomic position and race/ethnicity. The results are corroborated using ordered logistic regression for a commonly used count index of individual infections.

RESULTS

Seroprevalence of individual persistent infections is positively correlated, suggesting common factors related to exposure or susceptibility. Education, income, and race/ethnicity are strong and significant independent predictors of infection burden in U.S. adults in all models.

CONCLUSION

The disproportionate burden of persistent infections among disadvantaged groups across all ages may be one biologic pathway by which low socioeconomic position is related to increased rates of morbidity and mortality in the United States.

The non-linear risk of mortality by income level in a healthy population: US National Health and Nutrition Examination Survey mortality follow-up cohort, 1988-2001

BACKGROUND

An examination of where in the income distribution income is most strongly associated with risk of mortality will provide guidance for identifying the most critical pathways underlying the connections between income and mortality, and may help to inform public health interventions to reduce socioeconomic disparities. Prior studies have suggested stronger associations at the lower end of the income distribution, but these studies did not have detailed categories of income, were unable to exclude individuals whose declining health may affect their income and did not use methods to determine exact threshold points of non-linearity. The purpose of this study is to describe the non-linear risks of all-cause and cause-specific mortality across the income distribution.

METHODS

We examined potential non-linear risk of mortality by family income level in a population that had not retired early, changed jobs, or changed to part-time work due to health reasons, in order to minimize the effects of illness on income. We used data from the US National Health and Nutrition Examination Survey (1988-1994), among individuals age 18-64 at baseline, with mortality follow-up to the year 2001 (ages 25-77 at the end of follow-up, 106 037 person-years of time at risk). Differential risk of mortality was examined using proportional hazard models with penalized regression splines in order to allow for non-linear associations between mortality risk and income, controlling for age, race/ethnicity, marital status, level of educational attainment and occupational category.

RESULTS

We observed significant non-linear risks of all-cause mortality, as well as for certain specific causes of death at different levels of income. Typically, risk of mortality decreased with increasing income levels only among persons whose family income was below the median; above this level, there was little decreasing risk of mortality with higher levels of income. There was also some variation in mortality risk at different levels of income by cause and gender.

CONCLUSION

The majority of the income associated mortality risk in individuals between the ages of 18-77 in the United States is among the population whose family income is below the median (equal to $20,190 in 1991, 3.2 times the poverty level). Efforts to decrease socioeconomic disparities may have the greatest impact if focused on this population.

Cause-of-Death Contributions to Educational Inequalities in Mortality in Austria between 1981/1982 and 1991/1992: Les contributions des causes de décès aux inégalités de mortalité par niveau d'éducation en Autriche entre 1981/1982 et 1991/1992

This article uses census records and deaths records to analyze trends in educational inequalities in mortality for Austrian women and men aged 35-64 years between 1981/1982 and 1991/1992. We find an increasing gradient in mortality by education for circulatory diseases and especially ischaemic heart disease. Respiratory diseases and, in addition for women, cancers showed the opposite trend. Using decomposition analysis, we give evidence that in many cases changes in the age-structure within the 10-year interval had a bigger effect than direct improvements in mortality on the analyzed subpopulations.