Changes in inequalities of mortality by education level in Lithuania between 2001 and 2014

Relationship between educational level and survival of patients with cancer: A multicentre cohort study

BACKGROUND

Although socioeconomic factors are important determinants of population mortality, the effect of educational level on the survival of patients with cancer in China is unclear. This study aimed to assess whether educational level is associated with the prognosis of patients with cancer and to explore the mediators of this association.

METHODS

This multicentre cohort study included 18,251 patients diagnosed with cancer between May 2013 and December 2018. The main parameters measured were overall survival (OS) and all-cause mortality. The relationship between educational level and all-cause mortality was assessed using multifactor-corrected Cox survival analysis. Logistic regression was used to analyze the association between educational level and patient-generated subjective global assessment (PG-SGA).

RESULTS

The mean age of the 18,251 participants (men, 9939 [54.4%]) was 57.37 ± 11.66 years. Multifactorial survival analysis showed that patients survived longer with increasing education (university and above vs. elementary school and below; p = p = <0.001, HR = 0.84, 95% CI: 0.77-0.92), and the differences were statistically significant in different subgroups. The potential impact factors included sex, age, TNM stage, and PG-SGA score. Logistic regression showed a significant negative association between educational level and the modifiable factor PG-SGA (secondary vs. primary and below; p = 0.004, HR = 0.90, 95% CI: 0.83-0.97; university and above vs. primary and below; p < 0.001, HR = 0.79, 95% CI: 0.71-0.88).

CONCLUSIONS

Educational level was a significant prognostic factor for patients with cancer, independent of other known prognostic factors. This association was further improved by modifying the nutritional status.

Assessment of risk factors associated with long-term mortality in nursing homes: result from the SENIOR cohort

BACKGROUND

Previous studies on risk factors for death in nursing homes have focused on short-term observation and limited number risk factors.

AIMS

This study aims to identify factors predictive of 8-year survival in nursing homes.

METHODS

The study used the baseline measurements from the SENIOR cohort collected in 2013-2014. Data included clinical assessments (i.e., body composition, nutritional status, physical performance, level of dependence and cognition, frailty phenotype) as well as demographic information, number of medications and medical history. Mortality data were collected annually for 8 years. Univariate analyses were initially performed to assess potential predictive factors, followed by a Cox regression model using stepwise selection.

RESULTS

Of the 662 participants enrolled in the cohort, 58 (8.8%) were not further assessed due to the withdrawal of 2 nursing homes and 71 (10.7%) had no mortality data available (i.e., relocation, refusal to continue the study). Among the 533 patients included, 111 (20.8%) were still alive in 2022. Median survival time was 4 years (1.93-6.94). Multivariate regression showed that younger age (HR = 1.04 (1.03-1.06)), higher body mass index (HR = 0.96 (0.94-0.98)), higher score on the Mini-Mental State-Examination (HR = 0.97 (0.94-0.99)) and higher score on the Short Physical Performance Battery (HR = 0.93 (0.90-0.97)) were protective factors against mortality.

CONCLUSIONS

This study highlights that certain modifiable factors related to physical or mental health contribute to increased survival in nursing homes. Because of its ability to improve physical performance and partly cognitive function, promoting physical activity in nursing homes appears to be a public health priority.

Educational inequalities in mortality and their mediators among generations across four decades: nationwide, population based, prospective cohort study based on the ChinaHEART project

OBJECTIVES

To assess the different educational inequalities in mortality among generations born between 1940 and 1979 in China, and to investigate the role of socioeconomic, behavioural, and metabolic factors as potential contributors to the reduction of educational inequalities.

DESIGN

Nationwide, population based, prospective cohort study.

SETTING

The ChinaHEART (China Health Evaluation And risk Reduction through nationwide Teamwork) project in all 31 provinces in the mainland of China.

PARTICIPANTS

1 283 774 residents aged 35-75 years, divided into four separate cohorts born in 1940s, 1950s, 1960s, and 1970s.

MAIN OUTCOME MEASURES

Relative index of inequality and all cause mortality.

RESULTS

During a median follow-up of 3.5 years (interquartile range 2.1-4.7), 22 552 deaths were recorded. Among the four generations, lower education levels were found to be associated with a higher risk of all cause death: Compared with participants with college level education or above, the hazard ratio for people with primary school education and below was 1.4 (95% confidence interval 1.2 to 1.7) in the 1940s cohort, 1.8 (1.5 to 2.1) in the 1950s cohort, 2.0 (1.7 to 2.4) in the 1960s cohort, and 1.8 (1.4 to 2.4) in the 1970s cohort. Educational relative index of inequality in mortality increased from 2.1 (95% confidence interval 1.9 to 2.3) in the 1940s cohort to 2.6 (2.1 to 3.3) in the 1970s cohort. Overall, the mediation proportions were 37.5% (95% confidence interval 32.6% to 42.8%) for socioeconomic factors, 13.9% (12.0% to 16.0%) for behavioural factors, and 4.7% (3.7% to 5.8%) for metabolic factors. Except for socioeconomic measurements, the mediating effects by behavioural and metabolic factors decreased in younger generations.

CONCLUSION

Educational inequalities in mortality increased over generations in China. Improving healthy lifestyles and metabolic risk control for less educated people, especially for younger generations, is essential to reduce health inequalities.

Low educational status correlates with a high incidence of mortality among hypertensive subjects from Northeast Rural China

Objective

Cumulative evidence indicates that education plays a major role in predicting cardiovascular risk factors. In this study, we intend to examine the possible relationship between education status and mortality in a large general subject from rural China.

Methods

Adult hypertensive subjects (n = 5,227, age = 57.22 ± 10.18 years; 49.1% men) were recruited from general population surveys (Northeast China Rural Cardiovascular Health Study). Their educational status was categorized into two groups as follows: (1) Low education (illiterate or lower than primary school) and (2) medium-high education (higher than primary school). Cardiometabolic comorbidities, related cardiovascular risk factors, and echocardiographic measurements were analyzed in both groups.

Results

Less educated hypertensive subjects had significantly higher prevalence of obesity, diabetes, dyslipidemia, and left ventricular hypertrophy than medium-high educated hypertensive subjects. In the medium-high educated subjects, a significant increase in left ventricular ejection fraction and lower rate of antihypertensive medication was found. Cox proportional hazards analysis indicated that medium-high education was independently associated with all-cause mortality (hazard ratio = 0.76; 95% confidence interval, 0.58, 0.99; P = 0.043) and cardiovascular mortality (hazard ratio = 0.65; 95% confidence interval, 0.44, 0.96; P = 0.028).

Conclusion

Education may act as the best predictor of all-cause and cardiovascular mortality in rural hypertensive subjects. This finding suggests that in rural areas, education is likely to represent a cardiovascular specific risk factor and should be evaluated in the strategies of hypertension.

Interrupted time series analyses to assess the impact of alcohol control policy on socioeconomic inequalities in mortality in Lithuania: a study protocol

INTRODUCTION

Alcohol use is a major risk factor for mortality. Previous studies suggest that the alcohol-attributable mortality burden is higher in lower socioeconomic strata. This project will test the hypothesis that the 2017 increase of alcohol excise taxes linked to lower all-cause mortality rates in previous analyses will reduce socioeconomic mortality inequalities.

METHODS AND ANALYSIS

Data on all causes of deaths will be obtained from Statistics Lithuania. Record linkage will be implemented using personal identifiers combining data from (1) the 2011 whole-population census, (2) death records between 1 March 2011 (census date) and 31 December 2019, and (3) emigration records, for individuals aged 40-70 years. The analyses will be performed separately for all-cause and for alcohol-attributable deaths. Monthly age-standardised mortality rates will be calculated by sex, education and three measures of socioeconomic status (SES). Inequalities in mortality will be assessed using absolute and relative indicators between low and high SES groups. We will perform interrupted time series analyses, and test the impact of the 2017 rise in alcohol excise taxation using generalised additive mixed models. In these models, we will control for secular trends for economic development.

ETHICS AND DISSEMINATION

This work is part of project grant 1R01AA028224-01 by the National Institute on Alcohol Abuse and Alcoholism. It has been granted research ethics approval 050/2020 by Centre for Addiction and Mental Health Research Ethics Board on 17 April 2020, renewed on 30 March 2021. The time series of mortality inequalities as well as the statistical code will be made publicly available, allowing other researchers to adapt the proposed method to other jurisdictions.

Amenable mortality inequalities and their changes by place of residence during 1990-2019: the case of Lithuania

OBJECTIVE

The aim of this study was to analyze inequalities of amenable mortality by place of residence and its changes in Lithuania during 1990-2019.

STUDY DESIGN

A record-linked cohort study.

METHODS

Information on deaths was obtained from Statistics Lithuania and the Institute of Hygiene. Mortality rates from amenable causes of death by urban and rural among men and women were calculated per 100,000 population and were standardized by age. Inequalities in mortality were assessed using rate differences. For the assessment of the trends of mortality and its inequalities during 1990-2019, joinpoint regression analysis was applied.

RESULTS

During 1990-2019, amenable mortality of men and women in rural areas was higher compared to urban areas (P < 0.05). Changes in men's and women's mortality and its inequalities between rural and urban areas were characterized by three cut-off points (P < 0.05). However, not all the periods between the cut-off points were characterized by statistically significant changes in mortality. A reduction in amenable mortality was more evident in women, especially those living in rural areas. During 1990-2004 and in 2006, the differences in amenable mortality were greater among rural and urban women than among men. However, during 2013-2019, the differences were smaller (P < 0.05). Inequalities of men's mortality decreased during 1990-2001 and 2005-2012, and inequalities of women's mortality decreased during 1993-2006, 2006-2017, and 2017-2019 (P < 0.05). Inequalities of men's mortality decreased most rapidly during 2005-2012 (on average, by 10.24% per year), while inequalities of women's mortality decreased most rapidly during 2017-2019 (on average by 18.32% per year) (P < 0.05).

CONCLUSION

During 1990-2019, inequalities and a decline of inequalities in amenable mortality among rural and urban men and women were identified in Lithuania. The amenable mortality of the residents of Lithuania remained high, changed unevenly, and no significant sharp decrease was observed. Further reduction of inequalities in amenable mortality between rural and urban inhabitants with a special focus on men remain the health policy challenges in Lithuania.

Changes in Mortality Inequalities in Urban and Rural Populations during 1990-2018: Lithuanian Experience

Background and Objectives: Reduction in health inequalities is a highly important task in public health policies worldwide. In Lithuania, inequalities in mortality by place of residence are among the greatest, compared to other European Union (EU) countries. However, studies on inequalities in mortality by place of residence over a long-term period have not been investigated in Lithuania. The aim of this study was to present changes in mortality inequalities in urban and rural populations during 1990-2018. Materials and Methods: Mortality rates from all causes, cardiovascular diseases, cancer, external causes, and gastrointestinal diseases in urban and rural population by sex were calculated per 100,000 populations and were standardized by age. Inequalities in mortality were assessed using rate differences and rate ratio. For the assessment of inequality trends during 1990-2018, the joinpoint regression analysis was applied. Results: Mortality between urban and rural populations varied. In rural areas, mortality lower than that in urban areas was observed only in 1990 among women, in case of mortality from cancer and gastrointestinal diseases (compared with in 2018) (p < 0.05). In 2018, mortality from all causes, cardiovascular diseases, and external causes in urban and rural areas was lower than in 1990 in both sexes. However, mortality from gastrointestinal diseases was higher (p < 0.05). In 2018, mortality from cancer among both sexes was lower only in urban areas (p < 0.05). Mortality inequalities between rural and urban areas decreased statistically significantly only among men from external causes and from all causes (respectively, on average, by 0.52% per year and, on average, by 0.21% per year). Meanwhile, mortality from cardiovascular and gastrointestinal diseases increased in both sexes, and mortality from cancer and all causes of death increased among women. The increase in the inequalities of mortality from gastrointestinal diseases was the most rapid: among men-on average, by 0.69% per year, and among women-on average, by 1.43% per year, p < 0.0001. Conclusions: During 1990-2018, the inequalities in mortality by place of residence in Lithuania statistically significantly decreased only among men, in terms of mortality from external causes and from all causes. Therefore, reduction in inequalities in mortality must be the main the health policy challenge in Lithuania.

Inequalities in Life Expectancy by Education and Its Changes in Lithuania during 2001-2014

Background and Objectives: Reduction of health inequalities is a highly important task in public health policies worldwide. In Lithuania, inequalities in life expectancy (LE) by education level are among the greatest, compared to other European countries. However, studies on inequalities in LE by level of education over a long-term period are quite scarce in Lithuania. The aim of the study was to analyze inequalities in life expectancy by education and its changes in Lithuania during 2001–2014. Materials and Methods: Information on deaths (in population aged ≥30 years) was obtained from Statistics Lithuania. Life expectancy at age 30 (LE30) and 95% confidence intervals (CIs) were calculated using life tables. Inequalities in LE30 were assessed using rate differences. Joinpoint regression analysis was used to assess the trends and inequalities of LE30 during 2001–2014. Results: During 2001–2014, LE30 in males and females with post-secondary education was higher than in those with up-to-secondary education (p < 0.05). Among males and females, LE30 increased in both education groups, except for males with up-to-secondary education. Among individuals with post-secondary education, LE30 started increasing earlier and more quickly than in those with up-to-secondary education. Over the analyzed period, greater differences in LE30 between post-secondary and up-to-secondary education groups were found among males. Differences in LE30 due to different educational background were statistically significantly, increasing across the sexes with a more rapid increase for females than for males. During 2001 and 2014, the highest number of years of LE30 lost in both education groups was due to cardiovascular diseases. Conclusions: Throughout the period of 2001–2014, life expectancy in Lithuania in the post-secondary education group was statistically significantly longer and was increasing more rapidly compared to the up-to secondary education group. Inequalities in life expectancy by level of education significantly increased among both males and females.

Socioeconomic Inequalities in Mortality among Foreign-Born and Spanish-Born in Small Areas in Cities of the Mediterranean Coast in Spain, 2009-2015

Many studies have analysed socioeconomic inequalities and its association with mortality in urban areas. However, few of them have differentiated between native and immigrant populations. This study is an ecological study of mortality by overall mortality and analyses the inequalities in mortality in these populations according to the level of deprivation in small areas of large cities in the Valencian Community, from 2009 to 2015. The census tract was classified into five deprivation levels using an index based on socioeconomic indicators from the 2011 census. Rates and relative risks of death were calculated by sex, age, level of deprivation and country of birth. Poisson regression models have been used. In general, there was a higher risk of death in natives at the levels of greatest deprivation, which did not happen in immigrants. During the 2009-2015 period, there were socioeconomic inequalities in mortality, particularly in natives, who presented a higher risk of death than immigrants. Future interventions and social policies should be implemented in order to reduce inequalities in mortality amongst socioeconomic levels and to maintain the advantage that the immigrant population enjoys.