Life-course socioeconomic differences and social mobility in preventable and non-preventable mortality: a study of Swedish twins

Socioeconomic inequalities in avoidable mortality in Italy: results from a nationwide longitudinal cohort

BACKGROUND

Disparities in avoidable mortality have never been evaluated in Italy at the national level. The present study aimed to assess the association between socioeconomic status and avoidable mortality.

METHODS

The nationwide closed cohort of the 2011 Census of Population and Housing was followed up for 2012-2019 mortality. Outcomes of preventable and of treatable mortality were separately evaluated among people aged 30-74. Education level (elementary school or less, middle school, high school diploma, university degree or more) and residence macro area (North-West, North-East, Center, South-Islands) were the exposures, for which adjusted mortality rate ratios (MRRs) were calculated through multivariate quasi-Poisson regression models, adjusted for age at death. Relative index of inequalities was estimated for preventable, treatable, and non-avoidable mortality and for some specific causes.

RESULTS

The cohort consisted of 35,708,459 residents (48.8% men, 17.5% aged 65-74), 34% with a high school diploma, 33.5% living in the South-Islands; 1,127,760 deaths were observed, of which 65.2% for avoidable causes (40.4% preventable and 24.9% treatable). Inverse trends between education level and mortality were observed for all causes; comparing the least with the most educated groups, a strong association was observed for preventable (males MRR = 2.39; females MRR = 1.65) and for treatable causes of death (males MRR = 1.93; females MRR = 1.45). The greatest inequalities were observed for HIV/AIDS and alcohol-related diseases (both sexes), drug-related diseases and tuberculosis (males), and diabetes mellitus, cardiovascular diseases, and renal failure (females). Excess risk of preventable and of treatable mortality were observed for the South-Islands.

CONCLUSIONS

Socioeconomic inequalities in mortality persist in Italy, with an extremely varied response to policies at the regional level, representing a possible missed gain in health and suggesting a reassessment of priorities and definition of health targets.

Intra-generational social mobility and mortality among older men in the Concord Health and Ageing in Men Project: A cohort study

Objectives

We examined associations between intra-generational social mobility (reflected in life-course socioeconomic trajectories) and mortality, among older men.

Methods

Data came from a prospective Australian community-based cohort of older men. Social mobility was defined by socioeconomic indicators from three points in the life-course: educational attainment (late adolescence-early adulthood), occupation (mid-life), and current sources of income (older age). We defined indicators of social mobility trajectory (6 categories; reflecting the direction of social mobility) and social mobility status (2 categories; mobile or non-mobile). We used Cox regression to examine associations with mortality, adjusting for age, country of birth, and living arrangement.

Results

We followed 1568 men (mean age 76.8, SD 5.4) for a mean duration of 9.1 years, with 797 deaths recorded. Moving upward was the predominant social mobility trajectory (36.0%), followed by mixed trajectories (25.1%), downward (15.1%), stable low (12.2%), stable high (7.6%), and stable middle (4.0%). Men with downward (Hazard ratio 1.58, 95% CI 1.13 to 2.19) and stable low socioeconomic trajectories (1.77, 1.25 to 2.50) had higher mortality risks than men with stable high socioeconomic trajectories, while men with upward trajectories had similar risks to those with stable high trajectories. 76.2% of the participants were classified as having mobile status; no associations were evident between binary social mobility status and mortality.

Discussions

These findings suggest cumulative and persistent exposure to disadvantaged socioeconomic conditions across the life-course, rather than social mobility, is associated with increased mortality. For each stage of the life-course, addressing socioeconomic disadvantage may reduce inequities in mortality.

Educational Influences on Late-Life Health: Genetic Propensity and Attained Education

OBJECTIVES

The educational gradient in late-life health is well established. Despite this, there are still ambiguities concerning the role of underlying confounding by genetic influences and gene-environment (GE) interplay. Here, we investigate the role of educational factors (attained and genetic propensities) on health and mortality in late life using genetic propensity for educational attainment (as measured by a genome-wide polygenic score, PGSEdu) and attained education.

METHODS

By utilizing genetically informative twin data from the Swedish Twin Registry (n = 14,570), we investigated influences of the educational measures, familial confounding as well as the possible presence of passive GE correlation on both objective and subjective indicators of late-life health, that is, the Frailty Index, Multimorbidity, Self-rated health, cardiovascular disease, and all-cause mortality.

RESULTS

Using between-within models to adjust for shared familial factors, we found that the relationship between educational level and health and mortality later in life persisted despite controlling for familial confounding. PGSEdu and attained education both uniquely predicted late-life health and mortality, even when mutually adjusted. Between-within models of PGSEdu on the health outcomes in dizygotic twins showed weak evidence for passive GE correlation (prGE) in the education-health relationship.

DISCUSSION

Both genetic propensity to education and attained education are (partly) independently associated with health in late life. These results lend further support for a causal education-health relationship but also raise the importance of genetic contributions and GE interplay.

Childhood neighborhoods and cause-specific adult mortality in Sweden 1939-2015

The socioeconomic health gradient has widened in recent decades. We study how childhood socioeconomic neighborhood conditions influence gender- and cause-specific adult mortality. Using uniquely detailed geocoded longitudinal microdata for a Swedish town (1939-1967), with a follow-up in national registers (1968-2015), we apply Cox proportional hazards models and estimate individual neighborhoods at the address-level. We find that childhood neighborhood social class has a lasting influence on male adult mortality (ages 40-69), even when adjusting for class position, class origin, neighborhood physical attributes and school districts. This impact was particularly pronounced for preventable causes of death, pointing to lifestyle and behavioral factors as important mechanisms.

Healthy ageing from birth to age 84 years in the Helsinki Birth Cohort Study, Finland: a longitudinal study

BACKGROUND

The true prevalence of healthy ageing on a population level is unknown. In this study we aimed to examine the upper limit for the prevalence of healthy ageing, by quantifying the probability of surviving and remaining free of chronic diseases that could impact functioning (ie, healthy survival) across adulthood. We also estimated the prevalence of clinically assessed healthy ageing, and the determinants of healthy survival and healthy ageing.

METHODS

In this longitudinal study, we assessed men and women born in 1934-44 from the Helsinki Birth Cohort Study (Helsinki, Finland; n=13 140). We obtained information on chronic diseases, deaths, and early-to-midlife variables from national registers, databases, and health records for the period Jan 1, 1971, to Dec 31, 2017 (follow-up 951 088 person-years). We also collated data from clinical visits conducted in 2001-04 and 2017-18. Healthy ageing was defined on the basis of clinical data according to six criteria covering chronic diseases, cognitive function, physical performance, depressive symptoms, pain interference, and social functioning. We analysed the probability of healthy survival across adulthood using the Kaplan-Meier method, and the determinants of healthy survival using Cox regression models. We assessed the association of healthy ageing status in 2017-18 (n=813 with available data) with late-midlife factors collected in 2001-04 using age-adjusted logistic regression.

FINDINGS

The probability of healthy survival was 42·8% (95% CI 41·6-44·0) in men and 40·1% (38·9-41·4) in women at age 65 years, and 22·5% (21·5-23·6%) in men and 24·4% (23·3-25·6) in women at age 75 years. Healthy survival was associated with socioeconomic position in childhood (adjusted hazard ratio [aHR], upper-middle class vs manual worker, men: 1·21 [1·11-1·31]; women: 1·15 [95% CI 1·05-1·26]) and years of education (aHR per 1 SD increase, men: 1·12 [1·08-1·16]; women: 1·03 [1·00-1·07]). In men, healthy survival was also associated with lower maternal BMI in late pregnancy (aHR per 1 SD increase 0·93 [0·90-0·96]), and in women, with shorter height at age 7 years (aHR per 1 SD increase 0·95 [0·91-0·99]). Among the 813 individuals with relevant clinical assessment data, 159 (19·6%) met all six criteria for healthy ageing at mean age 76 years (SD 3). In addition to age, we found that nutrition (Alternative Healthy Eating Index, age-adjusted odds ratio [aOR] per 1 point increase 1·03 [1·01-1·05]), former smoker status (vs non-smoker status, aOR 0·68 [0·47-0·98], and use of lipid-lowering medication (vs not used, aOR 0·60 [0·42-0·87]) in late midlife (mean age 61 years [SD 3]) were associated with healthy ageing.

INTERPRETATION

The probability of healthy survival, as the upper limit for healthy ageing, was less than 50% from age 65 years. The probability of healthy survival and healthy ageing was influenced by several factors across the life course. Promotion of healthy ageing needs to take a life course approach.

FUNDING

Signe and Ane Gyllenberg Foundation, Samfundet Folkhälsan, Finska Läkaresällskapet, Medicinska Understödsföreningen Liv och Hälsa, European Commission Seventh Framework Programme, EU Horizon 2020, and the Academy of Finland.

Influences of genetically predicted and attained education on geographic mobility and their association with mortality

INTRODUCTION

Both educational attainment and genetic propensity to education (PGSEdu) have been associated with geographic mobility. Socioeconomic conditions are, in turn, associated with individuals' health. Geographic mobility could therefore lead to better health for some since it could provide better opportunities, like education. Our aim was to study how attained education and genetic predisposition for higher education are related to geographic mobility, and how they affect the association between geographic mobility and mortality.

METHODS

We used data from the Swedish Twin Registry (twins born 1926-1955; n = 14,211) in logistic regression models to test if attained education and PGSEdu predicted geographic mobility. Cox regression models were then performed to test if geographic mobility, attained education, and PGSEdu were associated with mortality.

RESULTS

The results show that both attained education and PGSEdu predicted geographic mobility, in both independent and joint effect models, with higher education associated with higher mobility. Geographic mobility was associated with lower mortality in the independent effect model, but joint effect models showed that this association was completely explained by attained education.

CONCLUSIONS

To conclude, both attained education and PGSEdu were associated with geographic mobility. Moreover, attained education explained the relationship between geographic mobility and mortality.

Short-term socioeconomic status shift and long-term cardiovascular outcomes in China: a population-based cohort study

INTRODUCTION

Limited studies have discussed the effect of socioeconomic status (SES) shift on cardiovascular outcomes, especially in less developed regions and countries. We; therefore, explored the association between short-term SES shift and long-term cardiovascular outcomes in China.

METHODS

In participants who had completed China Kadoorie Biobank study resurvey, 18 672 were included in the final analysis after excluding those who had cardiovascular diseases at baseline, and those who had a cardiovascular event before the resurvey. We used education, occupation, household income and healthcare cover as measurement of SES, and generated SES class for each individual at baseline and resurvey using latent class analysis. Outcomes of interest included cardiovascular death, major coronary event (MCE) and stroke. We used accelerated failure time model to obtain survival time ratio for each level of SES shift.

RESULTS

During a mean time gap of 2.6 years, 10 273 (55%) individuals remained stable in SES, 7763 (41.6%) shifted towards higher SES and 636 (3.4%) shifted towards lower SES. Participants were followed up for a mean of 9.8 years. After adjusting for baseline factors, sharp but not moderate SES downshift was significantly associated with shortened event-free survival time before cardiovascular deaths (p=0.02) and MCEs (p<0.001) occurred. Contrarily, moderate and sharp SES upshift was significantly associated with prolonged event-free survival time before cardiovascular deaths (p=0.0027 and p<0.001) and MCEs (p=0.0079 and p=0.009) occurred.

CONCLUSION

Short-term SES improvement is associated with better long-term cardiovascular outcome in China. High baseline SES might buffer out some unfavourable impact brought by moderate SES downshift. More comprehensive strategies should be considered in policy-making for socioeconomic development.

Application of Dance Movement Therapy to Life-Death Education of College Students Under Educational Psychology

The present work aims to efficiently carry out life-death education (LDE) for college students, improve their psychological problems, and reduce suicide accidents by combining LDE with Dance Movement Therapy (DMT). DMT is a psychosomatic cross therapy that treats mental or physical diseases through dance or improvisation. Firstly, this paper introduces LDE and DMT and designs the activities of DMT intervention. Secondly, the relationship between DMT and LDE is analyzed. Finally, a questionnaire survey is conducted on the research objects. The research objects are divided into the experimental group receiving DMT intervention, the control group participating in sports dance courses, and the benchmark group. The research data show no significant difference in interpersonal skills and emotional psychology among the three groups. The DMT intervention group has substantial changes in other factors except for the conflict control ability before and after the intervention. In addition, the questionnaire survey results after the intervention demonstrate that the DMT intervention group gets a significantly higher score in the interpersonal relationship, interpersonal relationship building ability, moderate rejection ability, self-disclosure ability, and emotional support ability. Therefore, DMT intervention positively impacts college students' interpersonal relationships. After the sports dance course, there are differences in the total score of interpersonal ties and scores of interpersonal relationships building ability, self-disclosure ability, and emotional support ability in the control group, but with no significant difference in moderate rejection ability and conflict control ability. Therefore, compared with traditional psychotherapy methods, the DMT method reported here is conducive to releasing pressure and alleviating physical and mental anxiety. The research content provides new ideas for psychological education in colleges and universities and contributes to improving college students' suicidal tendencies and helping college students grow up healthily.

Trends in the shape of the income-mortality association in Sweden between 1995 and 2017: a repeated cross-sectional population register study

OBJECTIVE

We investigate recent trends in income inequalities in mortality and the shape of the association in Sweden. We consider all-cause, preventable and non-preventable mortality for three age groups (30-64, 65-79 and 80+ years).

DESIGN AND SETTING

Repeated cross-sectional design using Swedish total population register data.

PARTICIPANTS

All persons aged 30 years and older living in Sweden 1995-1996, 2005-2006 and 2016-2017 (n=8 084 620).

METHODS

Rate differences and rate ratios for all-cause, preventable and non-preventable mortality were calculated per income decile and age group.

RESULTS

From 1995 to 2017, relative inequalities in mortality by income increased in Sweden in the age groups 30-64 years and 65-79 years. Absolute inequalities increased in the age group 65-79 years. Among persons aged 80+ years, inequalities were small. The shape of the income-mortality association was curvilinear in the age group 30-64 years; the gradient was stronger below the fourth percentile. In the age group 65-79 years, the shape shifted from linear in 1995-1996 to a more curvilinear shape in 2016-2017. In the oldest age group (80+ years), varied shapes were observed. Inequalities were more pronounced in preventable mortality compared with non-preventable mortality. Income inequalities in preventable and non-preventable mortality increased at similar rates between 1995 and 2017.

CONCLUSIONS

The continued increase of relative (ages 30-79 years) and absolute (ages 65-79 years) mortality inequalities in Sweden should be a primary concern for public health policy. The uniform increase of inequalities in preventable and non-preventable mortality suggests that a more complex explanatory model than only social causation is responsible for increased health inequalities.

A retrospective on fundamental cause theory: State of the literature, and goals for the future

Fundamental Cause Theory (FCT) was originally proposed to explain how socioeconomic inequalities in health emerged and persisted over time. The concept was that higher socioeconomic status helped some people to avoid risks and adopt protective strategies using flexible resources - knowledge, money, power, prestige and beneficial social connections. As a sociological theory, FCT addressed this issue by calling on social stratification, stigma, and racism as they affected medical treatments and health outcomes. The last comprehensive review was completed a decade ago. Since then, FCT has been tested, and new applications have extended central features. The current review consolidates key foci in the literature in order to guide future research in the field. Notable themes emerged around types of resources and their usage, approaches used to test the theory, and novel extensions. We conclude that after 25 years of use, there remain crucial questions to be addressed.

SES inequalities in cause-specific adult mortality: a study of the long-term trends using longitudinal individual data for Sweden (1813-2014)

Higher socioeconomic status (SES) is associated with lower mortality, and this correlation has been confirmed using different indicators across several geographical settings. Nevertheless, the timing of the emergence of the SES gradient remains unclear. We used individual-level longitudinal data for a regional population in southern Sweden covering the period between 1813 and 2014, and we applied a cause-specific proportional hazard model. We estimated SES differences in all-cause, nonpreventable, preventable, and cause-specific adult mortality in four subperiods (1813–1921, 1922–1967, 1968–1989, 1990–2014) by gender adjusting for birth year, place of residence, marital status, and migration status. The SES gradient in mortality present today for both genders emerged only around 1970, and with few exceptions, it emerged at approximately the same time for all causes of death. It emerged earlier for women than for men, particularly in infectious diseases. In the nineteenth and early twentieth centuries, we found a positive association between SES and mortality from circulatory diseases for men. SES has not always been a fundamental cause of mortality; it only emerged as such in the second half of the twentieth century. We argue that habits and behaviors embedded in the different social strata played a major role in the emergence of the SES gradient.

The Effects of Education on Mortality: Evidence From Linked U.S. Census and Administrative Mortality Data

Does education change people's lives in a way that delays mortality? Or is education primarily a proxy for unobserved endowments that promote longevity? Most scholars conclude that the former is true, but recent evidence based on Danish twin data calls this conclusion into question. Unfortunately, these potentially field-changing findings-that obtaining additional schooling has no independent effect on survival net of other hard-to-observe characteristics-have not yet been subject to replication outside Scandinavia. In this article, we produce the first U.S.-based estimates of the effects of education on mortality using a representative panel of male twin pairs drawn from linked complete-count census and death records. For comparison purposes, and to shed additional light on the roles that neighborhood, family, and genetic factors play in confounding associations between education and mortality, we also produce parallel estimates of the education-mortality relationship using data on (1) unrelated males who lived in different neighborhoods during childhood, (2) unrelated males who shared the same neighborhood growing up, and (3) non-twin siblings who shared the same family environment but whose genetic endowments vary to a greater degree. We find robust associations between education and mortality across all four samples, although estimates are modestly attenuated among twins and non-twin siblings. These findings-coupled with several robustness checks and sensitivity analyses-support a causal interpretation of the association between education and mortality for cohorts of boys born in the United States in the first part of the twentieth century.

Compared with whom? Reference groups in socio-economic comparisons and self-reported health in 34 countries

BACKGROUND

The association between socio-economic position and health is believed to be mediated, in part, by psycho-social comparison of one's situation with that of others. But with whom? Possibilities include family, friends, elites, or even those in other countries or in previous times. So far, there has been almost no research on whether the reference point matters.

METHODS

We take advantage of a comparative data set that, uniquely, allows us to ask this question. The Life in Transition Survey was conducted in four Southern European and 30 Central and Eastern European and Eurasian countries. We sought differences in the probability of good self-reported health among those using different reference groups, including own family, friends and neighbours, domestic elites, people living in other countries and those living prior to a major politico-economic transition. We used multivariable and multilevel mixed-effects Poisson regressions and estimated treatment effects via the regression adjustment of Poisson models.

RESULTS

In most cases the choice of reference group did not matter but in some it did. Among men in Eastern European and Eurasian societies, those who compared themselves with their parents and their own families before the start of transition were less likely to report good health compared with those who did not compare their own economic situation with any specific reference group.

CONCLUSIONS

For some individuals, the choice of who to compare one's situation with does seem to matter, pointing to an area for future investigation in research on psycho-social determinants of health.