Trends in educational inequalities in smoking-attributable mortality and their impact on changes in general mortality inequalities: evidence from England and Wales, Finland, and Italy (Turin)

BACKGROUND

Socioeconomic mortality inequalities are persistent in Europe but have been changing over time. Smoking is a known contributor to inequality levels, but knowledge about its impact on time trends in inequalities is sparse.

METHODS

We studied trends in educational inequalities in smoking-attributable mortality (SAM) and assessed their impact on general mortality inequality trends in England and Wales (E&W), Finland, and Italy (Turin) from 1972 to 2017. We used yearly individually linked all-cause and lung cancer mortality data by educational level and sex for individuals aged 30 and older. SAM was indirectly estimated using the Preston-Glei-Wilmoth method. We calculated the slope index of inequality (SII) and performed segmented regression on SIIs for all-cause, smoking and non-SAM to identify phases in inequality trends. The impact of SAM on all-cause mortality inequality trends was estimated by comparing changes in SII for all-cause with non-SAM.

RESULTS

Inequalities in SAM generally declined among males and increased among females, except in Italy. Among males in E&W and Finland, SAM contributed 93% and 76% to declining absolute all-cause mortality inequalities, but this contribution varied over time. Among males in Italy, SAM drove the 1976-1992 increase in all-cause mortality inequalities. Among females in Finland, increasing inequalities in SAM hampered larger declines in mortality inequalities.

CONCLUSION

Our findings demonstrate that differing education-specific SAM trends by country and sex result in different inequality trends, and consequent contributions of SAM on educational mortality inequalities. The following decades of the smoking epidemic could increase educational mortality inequalities among Finnish and Italian women.

Does the time spent in retirement improve health? An IV-Poisson assessment on the incidence of cardiovascular diseases

In recent decades, pension reforms have been implemented to address the financial sustainability of social security systems, resulting in an increase in the retirement age. This adjustment has led to ongoing debates about the relationship between retirement and health. This study investigates the impact of time spent in retirement on the risk of cardiovascular disease (CVD) in Italy. It uses a comprehensive dataset that includes socioeconomic, health, and behavioural risk factors, which is linked to administrative hospitalisation and mortality registers. To address the potential endogeneity of retirement, we employ an instrumental variables approach embedded in a Poisson rate model. The results show that, on average, years spent in retirement have a beneficial effect on the risk of CVD for both men and women. Each additional year spent in retirement reduces the incidence of such diseases by about 17% for men and 29% for women. Stratified analyses and robustness tests show that the benefits of retirement appear to be more robust and pronounced in men and in certain groups, particularly men in manual occupations or with poor ergonomic conditions at work. These results highlight that delaying access to retirement may lead to an increased burden of CVD in the older population. In addition, the protective effect of retirement on the development of CVD among workers with poorer ergonomic conditions underlines the different impact of increasing the retirement age on different categories of workers and the need for targeted and differentiated policies to avoid hitting the more vulnerable.

The impact of estimation methods for alcohol-attributable mortality on long-term trends for the general population and by educational level in Finland and Italy (Turin)

BACKGROUND AND AIMS

This paper assesses the impact of estimation methods for general and education-specific trends in alcohol-attributable mortality (AAM), and develops an alternative method that can be used when the data available for study is limited.

METHODS

We calculated yearly adult (30+) age-standardised and age-specific AAM rates by sex for the general population and by educational level (low, middle, high) in Finland and Turin (Italy) from 1972 to 2017. Furthermore the slope index of inequality and relative inequality index were computed by country and sex. We compared trends, levels, age distributions, and educational inequalities in AAM according to three existing estimation methods: (1) Underlying COD (UCOD), (2) Multiple COD (MCOD) method, and (3) the population attributable fractions (PAF)-method. An alternative method is developed based on the pros and cons of these methods and the outcomes of the comparison.

RESULTS

The UCOD and MCOD approaches revealed mainly increasing trends in AAM compared to the declining trends according to the PAF approach. These differences are more pronounced when examining AAM trends by educational groups, particularly for Finnish men. Until age 65, age patterns are similar for all methods, and levels nearly identical for MCOD and PAF in Finland. Our novel method assumes a similar trend and age pattern as observed in UCOD, but adjusts its level upwards so that it matches the level of the PAF approach for ages 30-64. Our new method yields levels in-between UCOD and PAF for Turin (Italy), and resembles the MCOD rates in Finland for females. Relative inequalities deviate for the PAF-method (lower levels) compared to other methods, whereas absolute inequalities are generally lower for UCOD than all three methods that combine wholly and partly AAM.

CONCLUSIONS

The choice of method to estimate AAM affects not only levels, but also general and education-specific trends and inequalities. Our newly developed method constitutes a better alternative for multiple-country studies by educational level than the currently used UCOD-method when the data available for study is limited to underlying causes of death.

Reversals in past long-term trends in educational inequalities in life expectancy for selected European countries

BACKGROUND

Across Europe, socioeconomic inequalities in mortality are large and persistent. To better understand the drivers of past trends in socioeconomic mortality inequalities, we identified phases and potential reversals in long-term trends in educational inequalities in remaining life expectancy at age 30 (e30), and assessed the contributions of mortality changes among the low-educated and the high-educated at different ages.

METHODS

We used individually linked annual mortality data by educational level (low, middle and high), sex and single age (30+) from 1971/1972 onwards for England and Wales, Finland and Italy (Turin). We applied segmented regression to trends in educational inequalities in e30 (e30 high-educated minus e30 low-educated) and employed a novel demographic decomposition technique.

RESULTS

We identified several phases and breakpoints in the trends in educational inequalities in e30. The long-term increases (Finnish men, 1982-2008; Finnish women, 1985-2017; and Italian men, 1976-1999) were driven by faster mortality declines among the high-educated aged 65-84, and by mortality increases among the low-educated aged 30-59. The long-term decreases (British men, 1976-2008, and Italian women, 1972-2003) were driven by faster mortality improvements among the low-educated than among the high-educated at age 65+. The recent stagnation of increasing inequality (Italian men, 1999) and reversals from increasing to decreasing inequality (Finnish men, 2008) and from decreasing to increasing inequality (British men, 2008) were driven by mortality trend changes among the low-educated aged 30-54.

CONCLUSION

Educational inequalities are plastic. Mortality improvements among the low-educated at young ages are imperative for achieving long-term decreases in educational inequalities in e30.

A spatial indicator of environmental and climatic vulnerability in Rome

BACKGROUND

Urban areas are disproportionately affected by multiple pressures from overbuilding, traffic, air pollution, and heat waves that often interact and are interconnected in producing health effects. A new synthetic tool to summarize environmental and climatic vulnerability has been introduced for the city of Rome, Italy, to provide the basis for environmental and health policies.

METHODS

From a literature overview and based on the availability of data, several macro-dimensions were identified on 1,461 grid cells with a width of 1 km² in Rome: land use, roads and traffic-related exposure, green space data, soil sealing, air pollution (PM_2.5, PM₁₀, NO₂, C₆H₆, SO₂), urban heat island intensity. The Geographically Weighted Principal Component Analysis (GWPCA) method was performed to produce a composite spatial indicator to describe and interpret each spatial feature by integrating all environmental dimensions. The method of natural breaks was used to define the risk classes. A bivariate map of environmental and social vulnerability was described.

RESULTS

The first three components explained most of the variation in the data structure with an average of 78.2% of the total percentage of variance (PTV) explained by the GWPCA, with air pollution and soil sealing contributing most in the first component; green space in the second component; road and traffic density and SO₂ in the third component. 56% of the population lives in areas with high or very high levels of environmental and climatic vulnerability, showing a periphery-centre trend, inverse to the deprivation index.

CONCLUSIONS

A new environmental and climatic vulnerability indicator for the city of Rome was able to identify the areas and population at risk in the city, and can be integrated with other vulnerability dimensions, such as social deprivation, providing the basis for risk stratification of the population and for the design of policies to address environmental, climatic and social injustice.

Differences in Cancer Death Risk Long After ACS Among Selected Urban and Rural Areas in North Italy: The ABC-7a Study on Heart Disease

Background

An increased risk of cancer death has been demonstrated for patients diagnosed with acute coronary syndrome (ACS). We are investigating possible geographic risk disparities.

Methods

This prospective study included 541 ACS patients who were admitted to hospitals and discharged alive in three provinces of Italy’s Veneto region. The patients were classified as residing in urban or rural areas in each province.

Results

With 3 exceptions, all patients completed the 22-year follow-up or were followed until death. Urban (46%) and rural (54%) residents shared most of their baseline demographic and clinical characteristics. Pre-existing malignancy was noted in 15 patients, whereas 106 patients developed cancer during the follow-up period, which represented 6232 person-years. No difference in the cancer death risk was found between the urban and rural areas or between southern and northern provinces (hazard ratio [HR] 1.1; 95% confidence interval [CI] 0.7–1.7; p = 0.59 and HR 1.1; 95% CI 0.9–1.4; p = 0.29, respectively) according to the unadjusted Cox regression analysis. Geographic areas, however, showed a strong positive interaction, with risk increasing from the urban to rural areas from southern to northern provinces (HR 1.9; 95% CI 1.1–3.0; p = 0.01). The fully adjusted Cox regression and Fine-Gray competing risk regression models provided similar results. Interestingly, these results persisted, and even strengthened, after exclusion of the 22 patients who developed malignancy and survived to the end of follow-up. We did not observe an urban/rural difference in non-neoplastic death risk or a significant interaction between the geographic areas.

Conclusion

Our analysis reveals that the cancer death risk among unselected ACS patients in Italy’s Veneto region significantly differs by geography. The northern rural area has the highest risk. These results highlight the importance of implementing a preventive policy based on area-specific knowledge.

Occupational physical activity, mortality and CHD events in the Italian Longitudinal Study

Purpose

Several recent studies have suggested a ‘physical activity paradox’ whereby leisure-time physical activity benefits health, but occupational physical activity is harmful. However, other studies imply that occupational physical activity is beneficial. Using data from a nationally representative Italian sample, we investigate if the context, or domain, of physical activity matters for mortality and coronary heart disease (CHD) events.

Methods

Among 40,220 men and women aged 40–55 at baseline, we used Cox models to compare associations of occupational, domestic and leisure-time physical activity with risk of mortality and CHD events over a follow-up period of up to 14 years. We accounted for sociodemographic factors, smoking, body mass index (BMI), physical and mental health, and educational qualifications.

Results

Occupational physical activity was not significantly associated with risk of mortality or CHD events for women, or with CHD events for men. In crude models, risk of mortality was higher for men in the highest occupational activity group, compared to the lowest (HR 1.26, 95% CI 1.01, 1.57). This attenuated with adjustment for health-related behaviours, health, and education (HR 1.03, 95% CI 0.77, 1.38). In crude models, leisure-time physical activity was significantly associated with decreased mortality and CHD risk only for men. Domestic physical activity was not associated with either outcome for either gender.

Conclusion

In a large sample of middle-aged Italian workers, we found limited evidence of harmful or beneficial effects of occupational physical activity on mortality or CHD events. However, confidence intervals were wide, and results consistent with a range of effects in both directions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00420-021-01765-0.

Unemployment and mortality in a large Italian cohort

BACKGROUND

Aim of this study was to examine the association between unemployment and mortality, taking into account potential confounders of this association. A secondary objective was to assess whether the association between unemployment and mortality was modified by lack of household economic resources.

METHODS

Prospective cohort composed of a representative sample of Italian subjects 30-55 years who participated in the Italian National Health Survey 1999-2000, followed up for mortality up to 2012 (15 656 men and 11 463 women). Data were analyzed using Cox regression models, stratified by gender and adjusted for health status, behavioral risk factors, socioeconomic position and position in the household. The modifying effect of the lack of economic resources was assessed by testing its interaction with unemployment on mortality.

RESULTS

Among women, unemployment was not associated with mortality, whereas among men, higher mortality was found from all causes (HR = 1.82), which was not modified by lack of economic resources, and from neoplasms (HR = 1.59), cardiovascular diseases (HR = 2.58) and suicides (HR = 5.01).

CONCLUSIONS

Results for men were robust to the adjustment for main potential confounders, suggesting a causal relationship between unemployment and mortality. The lack of effect modification by economic resources supports the relevance of the loss of non-material benefits of work on mortality.

Disaggregation of official demographic projections in sub-groups by education level: the neglected “composition effect” in the future path of life expectancy

We developed an innovative method to break down official population forecasts by educational level. The mortality rates of the high education group and low education group were projected using an iterative procedure, whose starting point was the life tables by education level for Italy, based on the year 2012. We provide a set of different scenarios on the convergence/divergence of the mortality differential between the high and low education groups. In each scenario, the demographic size and the life expectancy of the two sub-groups were projected annually over the period 2018–2065. We compared the life expectancy paths in the whole population and in the sub-groups. We found that in all of our projections, population life expectancy converges to the life expectancy of the high education group. We call this feature of our outcomes the “composition effect”, and we show how highly persistent it is, even in scenarios where the mortality differential between social groups is assumed to decrease over time. In a midway scenario, where the mortality differential is assumed to follow an intermediate path between complete disappearance in year 2065 and stability at the 2012 level, and in all the scenarios with a milder convergence hypothesis, our “composition effect” prevails over the effect of convergence for men and women. For instance, assuming stability in the mortality differential, we estimated a life expectancy increase at age 65 of 2.9 and 2.6 years for men, and 3.2 and 3.1 for women, in the low and high education groups, respectively, over the whole projection period. Over the same period, Italian official projections estimate an increase of 3.7 years in life expectancy at age 65 for the whole population. Our results have relevant implications for retirement and ageing policies, in particular for those European countries that have linked statutory retirement age to variations in population life expectancies. In all the scenarios where the composition effect is not offset by a strong convergence of mortality differentials, we show that the statutory retirement age increases faster than the group-specific life expectancies, and this finding implies that the expected time spent in retirement will shrink for the whole population. This potential future outcome seems to be an unintended consequence of the indexation rule.

Smoking and inequalities in mortality in 11 European countries: a birth cohort analysis

Purpose

To study the trends of smoking-attributable mortality among the low and high educated in consecutive birth cohorts in 11 European countries.

Methods

Register-based mortality data were collected among adults aged 30 to 79 years in 11 European countries between 1971 and 2012. Smoking-attributable deaths were estimated indirectly from lung cancer mortality rates using the Preston-Glei-Wilmoth method. Rate ratios and rate differences among the low and high-educated were estimated and used to estimate the contribution of inequality in smoking-attributable mortality to inequality in total mortality.

Results

In most countries, smoking-attributable mortality decreased in consecutive birth cohorts born between 1906 and 1961 among low- and high-educated men and high-educated women, but not among low-educated women among whom it increased. Relative educational inequalities in smoking-attributable mortality increased among both men and women with no signs of turning points. Absolute inequalities were stable among men but slightly increased among women. The contribution of inequality in smoking-attributable mortality to inequality in total mortality decreased in consecutive generations among men but increased among women.

Conclusions

Smoking might become less important as a driver of inequalities in total mortality among men in the future. However, among women, smoking threatens to further widen inequalities in total mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12963-021-00247-2.

The association between education level and chronic liver disease of any etiology

BACKGROUND

The potential link between educational level and chronic liver diseases (CLD) were explored using the mortality records of liver cirrhosis, which lack accuracy and are unable to identify the different etiological factors of liver cirrhosis. Information on the association of low educational level with the severity of CLD is lacking.

AIM

To evaluate the potential association linking education level to etiology and clinical stage of CLD cases.

METHODS

Consecutive enrolment of 11,107 subjects with CLD aged≥18 years prospectively recruited in two national surveys in 2001 and 2014 at one of the participating Italian liver units throughout the country. Subjects were pooled in two groups: low education level (less than high school) and high education level (completed high school or beyond). The association of demographic, etiological, and clinical stage of subjects with educational level was assessed using logistic regression analysis. In the analysis low educational level was the outcome variable.

RESULTS

A total of 11,107 subjects born in Italy (mean age 55.5 years, sex ratio 1.5) were evaluated. Multiple logistic regression analysis shows that chronic HCV infection (O.R.1,38:95%,C.I.1.23-1.55), risky alcohol intake (O.R.1.96;95%,C.I.1.73-2.21) and liver cirrhosis (O.R.1.65;95%,C.I.1.46-1.85) all resulted independently associated with less than a completed high school education. HBV infection resulted independently associated with high education level (O.R.0.74;95%,C.I.0.64-0.86), reflecting changes in HBV modes of transmission in recent decades. No association was found with CLD related to non-alcoholic fatty liver disease (O.R.1.03;95%, C.I.0.81-1.30).

CONCLUSIONS

These findings show an independent association linking education level with viruses and alcohol-related CLD. Low educational level is associated with the severity of CLD.

The respective parts of incidence and lethality in socioeconomic differences in cancer mortality. An analysis of the French network Cancer registries (FRANCIM) data

Background

To determine relevant public health actions and to guide intervention priorities, it is of great importance to assess the relative contribution of incidence and lethality to social inequalities in cancer mortality.

Methods

The study population comprised 185,518 cases of cancer diagnosed between 2006 and 2009 recorded in the French registries. Survival was known for each patient (endpoint: 30/06/2013). Deprivation was assessed using the European Deprivation Index. We studied the influence of deprivation on mortality, incidence and lethality rates and quantified the respective proportions of incidence and lethality in social inequalities in mortality by calculating attributable deaths.

Results

For cancers with social inequalities both in incidence and lethality, excess mortality in deprived was mainly caused by social inequalities in incidence (e.g. men lung cancer: 87% of excess deaths in the deprived caused by inequalities in incidence). Proportions were more balanced for some cancer sites (e.g. cervical cancer: 56% incidence, 44% lethality). For cancer sites with a higher incidence in the least deprived (e.g. breast cancer), the excess-lethality in deprived leads entirely the higher mortality among the deprived.

Conclusions

Most of the excess mortality in deprived is due to the excess incidence of tobacco-dependent cancers and the excess lethality of screenable cancers.

Progress against inequalities in mortality: register-based study of 15 European countries between 1990 and 2015

Socioeconomic inequalities in mortality are a challenge for public health around the world, but appear to be resistant to policy-making. We aimed to identify European countries which have been more successful than others in narrowing inequalities in mortality, and the factors associated with narrowing inequalities. We collected and harmonised mortality data by educational level in 15 European countries over the last 25 years, and quantified changes in inequalities in mortality using a range of measures capturing different perspectives on inequality (e.g., 'relative' and 'absolute' inequalities, inequalities in 'attainment' and 'shortfall'). We determined which causes of death contributed to narrowing of inequalities, and conducted country- and period-fixed effects analyses to assess which country-level factors were associated with narrowing of inequalities in mortality. Mortality among the low educated has declined rapidly in all European countries, and a narrowing of absolute, but not relative inequalities was seen in many countries. Best performers were Austria, Italy (Turin) and Switzerland among men, and Spain (Barcelona), England and Wales, and Austria among women. Ischemic heart disease, smoking-related causes (men) and amenable causes often contributed to narrowing inequalities. Trends in income inequality, level of democracy and smoking were associated with widening inequalities, but rising health care expenditure was associated with narrowing inequalities. Trends in inequalities in mortality have not been as unfavourable as often claimed. Our results suggest that health care expansion has counteracted the inequalities widening effect of other influences.

Mortality inequalities by occupational class among men in Japan, South Korea and eight European countries: a national register-based study, 1990-2015

BACKGROUND

We compared mortality inequalities by occupational class in Japan and South Korea with those in European countries, in order to determine whether patterns are similar.

METHODS

National register-based data from Japan, South Korea and eight European countries (Finland, Denmark, England/Wales, France, Switzerland, Italy (Turin), Estonia, Lithuania) covering the period between 1990 and 2015 were collected and harmonised. We calculated age-standardised all-cause and cause-specific mortality among men aged 35-64 by occupational class and measured the magnitude of inequality with rate differences, rate ratios and the average inter-group difference.

RESULTS

Clear gradients in mortality were found in all European countries throughout the study period: manual workers had 1.6-2.5 times higher mortality than upper non-manual workers. However, in the most recent time-period, upper non-manual workers had higher mortality than manual workers in Japan and South Korea. This pattern emerged as a result of a rise in mortality among the upper non-manual group in Japan during the late 1990s, and in South Korea during the late 2000s, due to rising mortality from cancer and external causes (including suicide), in addition to strong mortality declines among lower non-manual and manual workers.

CONCLUSION

Patterns of mortality by occupational class are remarkably different between European countries and Japan and South Korea. The recently observed patterns in the latter two countries may be related to a larger impact on the higher occupational classes of the economic crisis of the late 1990s and the late 2000s, respectively, and show that a high socioeconomic position does not guarantee better health.

The Socio-Economic Health Deprivation Index and its association with mortality and attitudes towards influenza vaccination among the elderly in Palermo, Sicily

Introduction

Socio-economic status (SES) seems to be a determinant of health and is associated with vaccination coverage among older and at-risk populations. The aim of this study was to evaluate trends in health outcomes and the Socio-Economic and Health Deprivation Index (SEHDI) among elderly people in the city of Palermo.

Methods

In the 2015 CCM project, the Palermo Unit collected mortality data for use in validating the SEHDI. Italian census data from 2009 to 2015 on overall mortality and causes of death were used. The outcome used to validate the SEHDI was vaccination coverage from the 2009-2010 to 2014-2015 influenza seasons among the elderly in Palermo.

Results

The SEHDI correlated significantly with all-cause mortality (p < 0.05), though this correlation displayed a decreasing trend. Regarding mortality due to influenza or pneumonia, however, the significant correlation (p < 0.05) showed an increasing trend. A linear trend was observed in the inverse correlation between the SEHDI and vaccination coverage rates (p < 0.05), with an overall 27% vaccination coverage among older people. Elderly subjects living in a census district with more regular immigrants, divorced people and single-parent families were more reluctant to undergo influenza vaccination.

Conclusions

This study allowed us to identify subgroups of elderly people who are less likely to adhere to influenza vaccination, and to whom health promotion interventions could be addressed in order to facilitate "healthy aging".

LIFE Med Hiss: An innovative cohort design for public health

The aim of MED HISS methodology was to test the effectiveness of a low-cost approach to study long-term effects of air pollution, applicable in all European countries. This approach is potentially exportable to other environmental issues where a cohort representative of the country population is needed. The cohort is derived from the National Health Interview Survey, compulsory in European countries, which has information on individual lifestyle factors. In Life Med Hiss approach, subjects recruited have been linked at individual level with health data and have been then followed-up for mortality and hospital admissions outcomes. Exposure values of air pollution (PM2.5 and NO2) have been assigned using national dispersion models, enhanced by the information derived from monitoring station with data fusion techniques, and then upscaled at municipality level (highest level of detail achievable for the Italian Survey). Results for mortality have been used to test the effectiveness of this methodology and are encouraging if compared with European ones. The advantages of this technique are summarized below: •It uses a cohort already available and compulsory in European countries•It uses air quality modelling data, available for most of the countries•It permits to implement versatile environmental surveillance systems.

Long term effect of air pollution on incident hospital admissions: Results from the Italian Longitudinal Study within LIFE MED HISS project

BACKGROUND

The LIFE MED HISS project aims at setting up a surveillance system on the long term effects of air pollution on health, using data from National Health Interview Surveys and other currently available sources of information in most European countries. Few studies assessed the long term effect of air pollution on hospital admissions in European cohorts.

OBJECTIVE

The objective of this paper is to estimate the long term effect of fine particulate matter (PM2.5) and nitrogen dioxide (NO₂) on first-ever (incident) cause-specific hospitalizations in Italy.

METHODS

We used data from the Italian Longitudinal Study (ILS), a cohort study based on the 1999-2000 National Health Interview Survey (NHIS), followed up for hospitalization (2001-2008) at individual level. The survey contains information on crucial potential confounders: occupational/educational/marital status, body mass index (BMI), smoking habit and physical activity. Annual mean exposure to PM2.5 and NO₂ was assigned starting from simulated gridded data at spatial resolution of 4 × 4 km² firstly integrated with data from monitoring stations and then up-scaled at municipality level. Statistical analyses were conducted using Cox proportional hazard models with robust variance estimator.

RESULTS

For each cause of hospitalization we estimated the hazard ratios (HRs) adjusted for confounders with 95% Confidence Interval (CI) related to a 10 μg/m³ increase in pollutants. For PM2.5 and NO₂, respectively, we found positive associations for circulatory system diseases [1.05(1.03-1.06); 1.05(1.03-1.07)], myocardial infarction [1.15(1.12-1.18); 1.15(1.12-1.18)], lung cancer [1.18(1.10-1.26); 1.20(1.12-1.28)], kidney cancer [1.24(1.11-1.29); 1.20(1.07-1.33)], all cancers (but lung) [1.06(1.04-1.08); 1.06(1.04-1.08)] and Low Respiratory Tract Infections (LRTI) [1.07 (1.04-1.11); 1.05 (1.02-1.08)].

DISCUSSION

Our results add new evidence on the effects of air pollution on first-ever (incident) hospitalizations, both in urban and rural areas. We demonstrated the feasibility of a low-cost monitoring system based on available data.

Selective serotonin reuptake inhibitor use and mortality, postoperative complications, and quality of care in hip fracture patients: a Danish nationwide cohort study

Purpose

To examine the association between selective serotonin reuptake inhibitor (SSRI) use and mortality, postoperative complications, and quality of in-hospital care in hip fracture patients.

Patients and methods

The study was a nationwide cohort study based on individual-level linked, prospectively collected data from Danish population-based national registries covering all hospitals in Denmark. The health care system in Denmark is tax-funded, and all citizens have equal access to health care services. We included patients with first-time hospitalization due to hip fracture undergoing surgery from 2006–2016. We estimated the risk of 30-day mortality, any unplanned readmission, any reoperation, specific postoperative complications including cardiovascular events and major bleeding, and quality of in-hospital care using Cox and Poisson regression analyses comparing current and former SSRI users with non-users.

Results

In 68,487 hip fracture patients, 13,272 (19%) were current SSRI users, 2,777 (4%) were former SSRI users, and 52,438 (77%) were SSRI non-users. The 30-day mortality risk was 13% in current SSRI users (HR 1.16, 1.10–1.21) and 12% in former (HR 1.15, 1.04–1.27) compared with 10% in non-users. The HR for any unplanned readmission was 1.11 (1.02–1.20) in current and 1.13 (1.01–1.27) in former SSRI users and for any reoperation 1.21 (1.11–1.31) in current and 1.04 (0.84–1.28) in former SSRI users compared with non-users. The risk of venous thromboembolism, myocardial infarction, stroke, and bleeding were similar irrespective of SSRI use. No association between current and former SSRI use and quality of in-hospital care was found.

Conclusion

In patients undergoing hip fracture surgery, 30-day mortality and overall readmission risk were elevated in both current and former SSRI users compared with non-users. Those currently using SSRI had a 26% increased reoperation risk compared with non-users. However, SSRI use was not associated with increased risk of other postoperative complications and lower quality of in-hospital care. A limitation of this study was the inability to control for potential confounding of social deprivation.

Trends In Inequalities In Mortality Amenable To Health Care In 17 European Countries

Little is known about the effectiveness of health care in reducing inequalities in health. We assessed trends in inequalities in mortality from conditions amenable to health care in seventeen European countries in the period 1980-2010 and used models that included country fixed effects to study the determinants of these trends. Our findings show remarkable declines over the study period in amenable mortality among people with a low level of education. We also found stable absolute inequalities in amenable mortality over time between people with low and high levels of education, but widening relative inequalities. Higher health care expenditure was associated with lower mortality from amenable causes, but not from nonamenable causes. The effect of health care expenditure on amenable mortality was equally strong, in relative terms, among people with low levels of education and those with high levels. As a result, higher health care expenditure was associated with a narrowing of absolute inequalities in amenable mortality. Our findings suggest that in the European context, more generous health care funding provides some protection against inequalities in amenable mortality.

Cohort profile: the Italian Network of Longitudinal Metropolitan Studies (IN-LiMeS), a multicentre cohort for socioeconomic inequalities in health monitoring

PURPOSE

The Italian Network of Longitudinal Metropolitan Studies (IN-LiMeS) is a system of integrated data on health outcomes, demographic and socioeconomic information, and represents a powerful tool to study health inequalities.

PARTICIPANTS

IN-LiMeS is a multicentre and multipurpose pool of metropolitan population cohorts enrolled in nine Italian cities: Turin, Venice, Reggio Emilia, Modena, Bologna, Florence, Leghorn, Prato and Rome. Data come from record linkage of municipal population registries, the 2001 population census, mortality registers and hospital discharge archives. Depending on the source of enrolment, cohorts can be closed or open. The census-based closed cohort design includes subjects resident in any of the nine cities at the 2001 census day; 4 466 655 individuals were enrolled in 2001 in the nine closed cohorts. The open cohort design includes subjects resident in 2001 or subsequently registered by birth or immigration until the latest available follow-up (currently 31 December 2013). The open cohort design is available for Turin, Venice, Reggio Emilia, Modena, Bologna, Prato and Rome. Detailed socioeconomic data are available for subjects enrolled in the census-based cohorts; information on demographic characteristics, education and citizenship is available from population registries.

FINDINGS TO DATE

The first IN-LiMeS application was the study of differentials in mortality between immigrants and Italians. Either using a closed cohort design (nine cities) or an open one (Turin and Reggio Emilia), individuals from high migration pressure countries generally showed a lower mortality risk. However, a certain heterogeneity between the nine cities was noted, especially among men, and an excess mortality risk was reported for some macroareas of origin and specific causes of death.

FUTURE PLANS

We are currently working on the linkage of the 2011 population census data, the expansion of geographical coverage and the implementation of the open design in all the participating cohorts.

'Fundamental causes' of inequalities in mortality: an empirical test of the theory in 20 European populations

The 'fundamental causes' theory stipulates that when new opportunities for lowering mortality arise, higher socioeconomic groups will benefit more because of their greater material and non-material resources. We tested this theory using harmonised mortality data by educational level for 22 causes of death and 20 European populations from the period 1980-2010. Across all causes and populations, mortality on average declined by 2.49 per cent (95%CI: 2.04-2.92), 1.83% (1.37-2.30) and 1.34% (0.89-1.78) per annum among the high, mid and low educated, respectively. In 69 per cent of cases of declining mortality, mortality declined faster among the high than among the low educated. However, when mortality increased, less increase among the high educated was found in only 46 per cent of cases. Faster mortality decline among the high educated was more manifest for causes of death amenable to intervention than for non-amenable causes. The difference in mortality decline between education groups was not larger when income inequalities were greater. While our results provide support for the fundamental causes theory, our results suggest that other mechanisms than the theory implies also play a role.

Determinants of the magnitude of socioeconomic inequalities in mortality: A study of 17 European countries

The magnitude of socioeconomic inequalities in mortality differs importantly between countries, but these variations have not been satisfactorily explained. We explored the role of behavioral and structural determinants of these variations, by using a dataset covering 17 European countries in the period 1970-2010, and by conducting multilevel multivariate regression analyses. Our results suggest that between-country variations in inequalities in current mortality can partly be understood from variations in inequalities in smoking, excessive alcohol consumption, and poverty. Also, countries with higher national income, higher quality of government, higher social transfers, higher health care expenditure and more self-expression values have smaller inequalities in mortality. Finally, trends in behavioral risk factors, particularly smoking and excessive alcohol consumption, appear to partly explain variations in inequalities in mortality trends. This study shows that analyses of variations in health inequalities between countries can help to identify entry-points for policy.

Socioeconomic indicators in epidemiologic research: A practical example from the LIFEPATH study

Background

Several social indicators have been used in epidemiological research to describe socioeconomic position (SEP) of people in societies. Among SEP indicators, those more frequently used are education, occupational class and income. Differences in the incidence of several health outcomes have been reported consistently, independently from the indicator employed. Main objectives of the study were to present the socioeconomic classifications of the social indicators which will be employed throughout the LIFEPATH project and to compare social gradients in all-cause mortality observed in the participating adult cohorts using the different SEP indicators.

Methods

Information on the available social indicators (education, own and father’s occupational class, income) from eleven adult cohorts participating in LIFEPATH was collected and harmonized. Mortality by SEP for each indicator was estimated by Poisson regression on each cohort and then evaluated using a meta-analytical approach.

Results

In the meta-analysis, among men mortality was significantly inversely associated with both occupational class and education, but not with father’s occupational class; among women, the increase in mortality in lower social strata was smaller than among men and, except for a slight increase in the lowest education category, no significant differences were found.

Conclusions

Among men, the proposed three-level classifications of occupational class and education were found to predict differences in mortality which is consistent with previous research. Results on women suggest that classifying them through their sole SEP, without considering that of their partners, may imply a misclassification of their social position leading to attenuation of mortality differences.

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.

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.

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.

Education level and chronic liver disease by aetiology: A proportional mortality study

BACKGROUND

Data are lacking on mortality from chronic liver diseases of different aetiology by education level.

AIMS

To investigate the association between education level and mortality from alcoholic, viral, and non-viral/non-alcoholic chronic liver disease.

METHODS

Proportional mortality was investigated in 2011-2013 in the Veneto Region (Italy). Odds ratios were estimated by conditional logistic regression with deaths from liver cirrhosis, liver cancer, and viral hepatitis as cases, and all other deaths as controls. Disease aetiology was determined from all conditions mentioned in the death certificate.

RESULTS

Overall chronic liver disease proportional mortality was higher in males (OR 1.37, 95% CI 1.18-1.60) and females (OR 1.72, 95% CI 1.29-2.30) with primary education than in subjects with higher educational level. The risk for alcohol-related and non-viral/non-alcohol-related disease significantly increased with lower education in both genders.

CONCLUSIONS

Proportional mortality analysis of multiple causes of death records showed an association between education and chronic liver diseases with alcoholic and non-viral/non-alcoholic aetiology.

Inequalities in Alcohol-Related Mortality in 17 European Countries: A Retrospective Analysis of Mortality Registers

BACKGROUND

Socioeconomic inequalities in alcohol-related mortality have been documented in several European countries, but it is unknown whether the magnitude of these inequalities differs between countries and whether these inequalities increase or decrease over time.

METHODS AND FINDINGS

We collected and harmonized data on mortality from four alcohol-related causes (alcoholic psychosis, dependence, and abuse; alcoholic cardiomyopathy; alcoholic liver cirrhosis; and accidental poisoning by alcohol) by age, sex, education level, and occupational class in 20 European populations from 17 different countries, both for a recent period and for previous points in time, using data from mortality registers. Mortality was age-standardized using the European Standard Population, and measures for both relative and absolute inequality between low and high socioeconomic groups (as measured by educational level and occupational class) were calculated. Rates of alcohol-related mortality are higher in lower educational and occupational groups in all countries. Both relative and absolute inequalities are largest in Eastern Europe, and Finland and Denmark also have very large absolute inequalities in alcohol-related mortality. For example, for educational inequality among Finnish men, the relative index of inequality is 3.6 (95% CI 3.3-4.0) and the slope index of inequality is 112.5 (95% CI 106.2-118.8) deaths per 100,000 person-years. Over time, the relative inequality in alcohol-related mortality has increased in many countries, but the main change is a strong rise of absolute inequality in several countries in Eastern Europe (Hungary, Lithuania, Estonia) and Northern Europe (Finland, Denmark) because of a rapid rise in alcohol-related mortality in lower socioeconomic groups. In some of these countries, alcohol-related causes now account for 10% or more of the socioeconomic inequality in total mortality. Because our study relies on routinely collected underlying causes of death, it is likely that our results underestimate the true extent of the problem.

CONCLUSIONS

Alcohol-related conditions play an important role in generating inequalities in total mortality in many European countries. Countering increases in alcohol-related mortality in lower socioeconomic groups is essential for reducing inequalities in mortality. Studies of why such increases have not occurred in countries like France, Switzerland, Spain, and Italy can help in developing evidence-based policies in other European countries.

Education and mortality in Spain: a national study supports local findings

OBJECTIVES

To estimate educational inequalities in mortality in Spain and in three Spanish areas: Madrid, Barcelona, and the Basque country.

METHODS

A national prospective study was carried out including all persons aged 25-74 years living in Spain in 2001 and followed up for mortality over 7 years. The mortality rate ratio and difference from all causes and from leading causes of death were estimated for the entire Spanish population and for the above three geographical areas.

RESULTS

With respect to people with the highest education, the mortality rate ratios in the entire population of Spain in people with the second highest, second lowest and lowest education were, respectively, 1.09, 1.10, 1.39 in women and 1.19, 1.27 and 1.54 in men. The mortality rate differences per 100,000 person-years were, respectively, 24.8, 28.3, 108.2 in women and 116.7, 162.5 and 319.1 in men. These estimates were intermediate in magnitude compared to those seen in the three geographical areas.

CONCLUSIONS

The results provide further evidence that educational inequalities in mortality are smaller in the south of Europe than in other European countries.

Education and Mortality in the Rome Longitudinal Study

Background

A large body of evidence supports an inverse association between socioeconomic status and mortality. We analysed data from a large cohort of residents in Rome followed-up between 2001 and 2012 to assess the relationship between individual education and mortality. We distinguished five causes of death and investigated the role of age, gender, and birthplace.

Methods

From the Municipal Register we enrolled residents of Rome on October 21^st 2001 and collected information on educational level attained from the 2001 Census. We selected Italian citizens aged 30–74 years and followed-up their vital status until 2012 (n = 1,283,767), identifying the cause of death from the Regional Mortality Registry. We calculated hazard ratios (HRs) for overall and cause-specific mortality in relation to education. We used age, gender, and birthplace for adjusted or stratified analyses. We used the inverse probability weighting approach to account for right censoring due to emigration.

Results

We observed an inverse association between education (none vs. post-secondary+ level) and overall mortality (HRs(95%CIs): 2.1(1.98–2.17), males; 1.5(1.46–1.59), females) varying according to demographic characteristics. Cause-specific analysis also indicated an inverse association with education, in particular for respiratory, digestive or circulatory system related-mortality, and the youngest people seemed to be more vulnerable to low education.

Conclusion

Our results confirm the inverse association between education and overall or cause-specific mortality and show differentials particularly marked among young people compared to the elderly. The findings provide further evidence from the Mediterranean area, and may contribute to national and cross-country comparisons in Europe to understand the mechanisms generating socioeconomic differentials especially during the current recession period.

Decreasing educational differences in mortality over 40 years: evidence from the Turin Longitudinal Study (Italy)

BACKGROUND

Recent studies suggest that inequalities in premature mortality have continued to rise over the last decade in most European countries, but not in southern European countries.

METHODS

In this study, we assess long-term trends (1971-2011) in absolute and relative educational inequalities in all-cause and cause-specific mortality in the Turin Longitudinal Study (Turin, Italy), a record-linkage study including all individuals resident in Turin in the 1971, 1981, 1991 and 2001 censuses, and aged 30-99 years (more than 2 million people). We examined mortality for all causes, cardiovascular disease (CVD), all cancers and specific cancers (lung, breast), as well as smoking and alcohol-related mortality.

RESULTS

Overall mortality substantially decreased in all educational groups over the study period, although cancer rates only slightly declined. Absolute inequalities decreased for both genders (SII=962/694 in men/women in 1972-1976 and SII=531/259 in 2007-2011, p<0.01). Among men, absolute inequalities for CVD and alcohol-related causes declined (p<0.05), while remaining stable for other causes of death. Among women, declines in absolute inequalities were observed for CVD, smoking and alcohol-related causes and lung cancer (p<0.05). Relative inequalities in all-cause mortality remained stable for men and decreased for women (RII=1.92/2.03 in men/women in 1972-1976 and RII=2.15/1.32 in 2007-2011). Among men, relative inequalities increased for smoking-related causes, while among women they decreased for all cancers, CVD, smoking-related causes and lung cancer (p<0.05).

CONCLUSIONS

Absolute inequalities in mortality strongly declined over the study period in both genders. Relative educational inequalities in mortality were generally stable among men; while they tended to narrow among women. In general, this study supports the hypothesis that educational inequalities in mortality have decreased in southern European countries.

Variations in the relation between education and cause-specific mortality in 19 European populations: a test of the "fundamental causes" theory of social inequalities in health

Link and Phelan have proposed to explain the persistence of health inequalities from the fact that socioeconomic status is a "fundamental cause" which embodies an array of resources that can be used to avoid disease risks no matter what mechanisms are relevant at any given time. To test this theory we compared the magnitude of inequalities in mortality between more and less preventable causes of death in 19 European populations, and assessed whether inequalities in mortality from preventable causes are larger in countries with larger resource inequalities. We collected and harmonized mortality data by educational level on 19 national and regional populations from 16 European countries in the first decade of the 21st century. We calculated age-adjusted Relative Risks of mortality among men and women aged 30-79 for 24 causes of death, which were classified into four groups: amenable to behavior change, amenable to medical intervention, amenable to injury prevention, and non-preventable. Although an overwhelming majority of Relative Risks indicate higher mortality risks among the lower educated, the strength of the education-mortality relation is highly variable between causes of death and populations. Inequalities in mortality are generally larger for causes amenable to behavior change, medical intervention and injury prevention than for non-preventable causes. The contrast between preventable and non-preventable causes is large for causes amenable to behavior change, but absent for causes amenable to injury prevention among women. The contrast between preventable and non-preventable causes is larger in Central & Eastern Europe, where resource inequalities are substantial, than in the Nordic countries and continental Europe, where resource inequalities are relatively small, but they are absent or small in Southern Europe, where resource inequalities are also large. In conclusion, our results provide some further support for the theory of "fundamental causes". However, the absence of larger inequalities for preventable causes in Southern Europe and for injury mortality among women indicate that further empirical and theoretical analysis is necessary to understand when and why the additional resources that a higher socioeconomic status provides, do and do not protect against prevailing health risks.