Global trends in lifespan inequality: 1950-2015

Ranking Age-at-Death Distributions Using Dominance: Robust Evaluation of United States Mortality Trends, 2006-2021

Diverging mortality trends at different ages motivate the monitoring of lifespan inequality alongside life expectancy. Conclusions are ambiguous when life expectancy and lifespan inequality move in the same direction or when inequality measures display inconsistent trends. We propose using nonparametric dominance analysis to obtain a robust ranking of age-at-death distributions. Application to U.S. period life tables for 2006-2021 reveals that, until 2014, more recent years generally dominate earlier years, implying improvement if longer lifespans that are less unequally distributed are considered better. Improvements were more pronounced for non-Hispanic Black and Hispanic individuals than for non-Hispanic White individuals. Since 2014, for all subpopulations-particularly Hispanics-earlier years often dominate more recent years, indicating worsening age-at-death distributions if shorter and more unequal lifespans are considered worse. Dramatic deterioration of the distributions in 2020-2021 during the COVID-19 pandemic is most evident for Hispanic individuals.

Cross-sectional Average Length of Life Entropy ( H CAL ): International Comparisons and Decompositions

Keyfitz and Leser's life table entropy was proposed to serve as a relative inequality in mortality measure. Entropy considers the variation around the age at death relative to the length of lifespan in a population, allowing comparisons across time and populations. It is used widely in period and cohort applications. Here, we propose extending this measure and present an index that incorporates the history of survival of all cohorts present at a given time, namely the cross-sectional average length of life entropy, or CAL-entropy ( H CAL ). We decompose cross-population differences of CAL-entropy into the contribution of longevity and lifespan variation, and the change of those differences across time. Our illustrations show that populations are converging regarding lifespan inequality. Lifespan variation holds a noticeable share in the CAL-entropy gap among selected European populations. Longevity held once a pronounced share in CAL-entropy differences and their change, but its influence has receded over the years. The US demonstrates a unique trend where it performs worse across time compared to the selected European populations, and lifespan variation has played a major role in this process. This study signals the importance of lifespan variation in reducing inequality in mortality among developed and longevous populations.

The Lifespan Disparity Dataset: An open repository on inequality and polarization in length of life (1950-2021)

Monitoring health is key for identifying priorities in public health planning and improving healthcare services. Life expectancy has conventionally been regarded as a valuable indicator to compare the health status of different populations. However, this measure is simply the mean of the distribution of the length of life and, as such, neglects individual disparities in health outcomes. In this paper, we use life tables from the UN World Population Prospects to develop the most comprehensive dataset of lifespan inequality and polarization for 258 countries and areas for the period 1950-2021. These extensive series on lifespan distributions provide access to crucial information for researchers, practitioners, and the general public, thus contributing to a better understanding of health differences within and between nations.

Global trends in incidence and prevalence of achalasia, 1925-2021: A systematic review and meta-analysis

BACKGROUND

Achalasia poses a significant socioeconomic burden, yet global trends remain undocumented. This study aims to describe the worldwide trends in the incidence and prevalence of achalasia from 1925 to 2021 and explore their correlation with various factors through a comprehensive systematic review.

METHODS

We searched the PubMed/MEDLINE, Embase, and Cochrane databases from inception to 30 June 2023, to identify studies reporting the incidence or prevalence of achalasia in the general population. This study utilized pooled estimates with 95% confidence intervals (CI) to estimate the incidence and prevalence of achalasia, and conducted various subgroup analyses.

RESULTS

A total of 26 eligible studies covering approximately 269 million participants and 20,873 patients from 14 countries across five continents were included. Global pooled incidence and prevalence of achalasia were estimated to be 0.78 cases per 100,000 person-years (95% CI, 0.64-0.93; number of studies, 26; sample population, 269,315,171) and 10.82 cases per 100,000 person-years (95% CI, 8.15-13.48; number of studies, 14; sample population, 192,176,076), respectively. The incidence of achalasia was higher in Oceania (than Asia and Africa) and in adults (than children) after the introduction of the Chicago classification. Prevalence followed a similar pattern. The pooled incidence of achalasia showed an overall upward trend from 1925 to 2021 (1925-1999; 0.40 [0.32-0.49] vs. 2018-2021; 1.64 [1.33-1.95] cases per 100,000 person-years).

CONCLUSIONS

The incidence and prevalence of achalasia have notably increased, particularly with advancements in diagnosis, and show significant variation worldwide, despite the large heterogeneity within the sample population. Further studies are necessary to accurately assess the global incidence and prevalence of achalasia.

Cause-of-Death Determinants of Lifespan Inequality

We propose a novel decomposition approach that breaks down the levels and trends of lifespan inequality as the sum of cause-of-death contributions. The suggested method shows whether the levels and changes in lifespan inequality are attributable to the levels and changes in (1) the extent of inequality in the cause-specific age-at-death distribution (the "Inequality" component), (2) the total share of deaths attributable to each cause (the "Proportion" component), or (3) the cause-specific mean age at death (the "Mean" component). This so-called Inequality-Proportion-Mean (or IPM) method is applied to 10 low-mortality countries in Europe. Our findings suggest that the most prevalent causes of death (in our setting, "circulatory system" and "neoplasms") do not necessarily contribute the most to overall levels of lifespan inequality. In fact, "perinatal and congenital" causes are the strongest drivers of lifespan inequality declines. The contribution of the IPM components to changes in lifespan inequality varies considerably across causes, genders, and countries. Among the three components, the Mean one explains the least lifespan inequality dynamics, suggesting that shifts in cause-specific mean ages at death alone contributed little to changes in lifespan inequality.

On the measurement of cause of death inequality

BACKGROUND

Attempts at assessing heterogeneity in countries' mortality profiles often rely on measures of cause of death (CoD) diversity. Unfortunately, such indicators fail to take into consideration the degree of (dis)similarity among pairs of causes (e.g. 'transport injuries' and 'unintentional injuries' are implicitly assumed to be as dissimilar as 'transport injuries' and 'Alzheimer's disease')－an unrealistic and unduly restrictive assumption.

DEVELOPMENT

We extend diversity indicators proposing a broader class of heterogeneity measures that are sensitive to the similarity between the causes of death one works with. The so-called 'CoD inequality' measures are defined as the average expected 'dissimilarity between any two causes of death'. A strength of the approach is that such measures are decomposable, so that users can assess the contribution of each cause to overall CoD heterogeneity levels-a useful property for the evaluation of public health policies.

APPLICATION

We have applied the method to 15 low-mortality countries between 1990 and 2019, using data from the Global Burden of Disease project. CoD inequality and CoD diversity generally increase over time across countries and sex, but with some exceptions. In several cases (notably, Finland), both indicators run in opposite directions.

CONCLUSIONS

CoD inequality and diversity indicators capture complementary information about the heterogeneity of mortality profiles, so they should be analysed alongside other population health metrics, such as life expectancy and lifespan inequality.

Contributions of age groups and causes of death to the sex gap in lifespan variation in Europe

Much less is known about the sex gap in lifespan variation, which reflects inequalities in the length of life, than about the sex gap in life expectancy (average length of life). We examined the contributions of age groups and causes of death to the sex gap in lifespan variation for 28 European countries, grouped into five European regions. In 2010-15, males in Europe displayed a 6.8-year-lower life expectancy and a 2.3-year-higher standard deviation in lifespan than females, with clear regional differences. Sex differences in lifespan variation are attributable largely to higher external mortality among males aged 30-39, whereas sex differences in life expectancy are due predominantly to higher smoking-related and cardiovascular disease mortality among males aged 60-69. The distinct findings for the sex gap in lifespan variation and the sex gap in life expectancy provide additional insights into the survival differences between the sexes.

The Burden of Urologic Diseases in a Tertiary Hospital in South-eastern Nigeria: A Three-Year Review

Background

Urological diseases are an integral part of the surgical burden of diseases. There are national, regional, and global variations. Characterisation of the burden of disease in this specialty is important for the registry and in allocation of the already scarce resource in this sub-region.

Objective

This study was aimed at characterising the burden of urological diseases in our teaching hospital as a means towards addressing the gap between resources and urological needs.

Materials and Methods

It was a retrospective study of new patients seen over 3 years from January 2019 to December 2021 at the urology clinics of Alex-Ekwueme Federal University Teaching Hospital Abakaliki. Data collected included sex, age, and diagnosis. Data analysis was done using SPSS version 26.

Results

A total of 2893 patients were available for analysis, of which 2777 (96%) were male patients whereas 116 (4%) were female patients with a male-to-female ratio of 23.9:1. The mean age of the patients was 58.11 ± 16.76 years. The common presentations were benign prostatic enlargement (BPE) 1515 (52.4%), cancer of the prostate (CAP) 349 (12.1%), urethral stricture disease 268 (9.3%), and urinary tract infection (UTI) 192 (6.6%). In men, the three most common diagnoses were prostate-related diseases 1864 (67.1%), urethral stricture disease 268 (9.70%), and UTI 170 (6.1%), whereas, in women, urolithiasis, urinary tract infection, and hydronephrosis accounted for 50 (43.1%), 22 (19%), and 20 (17.2%), respectively.

Conclusion

BPE, CAP, and urethral stricture disease were the most common presentations in men whereas urolithiasis, UTI, and hydronephrosis were common in women. This knowledge can be used to channel hospital resources appropriately.

Healthy lifespan inequality: morbidity compression from a global perspective

Current measures of population health lack indicators capturing the variability in age-at-morbidity onset, an important marker to assess the timing patterns of individuals' health deterioration and evaluate the compression of morbidity. We provide global, regional, and national estimates of the variability in morbidity onset from 1990 to 2019 using indicators of healthy lifespan inequality (HLI). Using data from the Global Burden of Disease Study 2019, we reconstruct age-at-death distributions to calculate lifespan inequality (LI), and age-at-morbidity onset distributions to calculate HLI. We measure LI and HLI with the standard deviation. Between 1990 and 2019, global HLI decreased from 24.74 years to 21.92, and has been decreasing in all regions except in high-income countries, where it has remained stable. Countries with high HLI are more present in sub-Saharan Africa and south Asia, whereas low HLI values are predominant in high-income countries and central and eastern Europe. HLI tends to be higher for females than for males, and HLI tends to be higher than LI. Globally, between 1990 and 2019 HLI at age 65 increased from 6.83 years to 7.44 for females, and from 6.23 to 6.96 for males. Improvements in longevity are not necessarily accompanied by further reductions in HLI among longevity vanguard countries. Morbidity is compressing, except in high-income countries, where it stagnates. The variability in the ages at morbidity onset tends to be larger than the variability in lifespans, and such divergence broadens over time. As longevity increases worldwide, the locus of health inequality is moving from death-related inequalities to disease- and disability-centered ones.

Levels, trends, and determinants of cause-of-death diversity in a global perspective: 1990-2019

BACKGROUND

While much is known about the leading causes of death (CoD) and how they have evolved over time, much less is known about the diversity of such causes of death. CoD diversity is an important marker of population health heterogeneity that has been largely overlooked in the study of contemporary health dynamics.

METHODS

We provide regional and national estimates of CoD diversity from 1990 to 2019. We rely on data from the Global Burden of Disease project, using information on 21 CoD. Results are presented for 204 countries and territories, for women and men separately. CoD diversity is measured with the index of Fractionalization. Results are disaggregated by age and cause of death.

RESULTS

CoD diversity has declined across world regions, except for Latin America and the Caribbean, the region of High-income countries and women in Central Europe, Eastern Europe, and Central Asia. Changes in mortality at adult and older ages have been mostly responsible for CoD diversity dynamics, except for the regions of South Asia and Sub-Saharan Africa, where infant and child mortality still play a non-negligible role. The relationship between CoD diversity, life expectancy, and lifespan inequality is strongly non-monotonic, with turning points differing by sex and indicator. Among longevity vanguard countries, further increases in life expectancy are associated with decreasing lifespan inequality but increasing CoD diversity.

CONCLUSION

As mortality declines, there is no universal pathway toward low CoD diversity, thus casting doubts on the ability of Epidemiological Transition Theory to predict prospective CoD dynamics among high- and middle-mortality countries. Despite the postponement and increasing predictability of the ages at which individuals die, low-mortality populations are composed of an increasingly heterogenous mix of robust and frail individuals, thus increasing the diversity of health profiles among older persons - an issue that could potentially complicate further improvements in longevity.

Acetylsalicylic Acid Effect in Colorectal Cancer Taking into Account the Role of Tobacco, Alcohol and Excess Weight

Excess weight, smoking and risky drinking are preventable risk factors for colorectal cancer (CRC). However, several studies have reported a protective association between aspirin and the risk of CRC. This article looks deeper into the relationships between risk factors and aspirin use with the risk of developing CRC. We performed a retrospective cohort study of CRC risk factors and aspirin use in persons aged >50 years in Lleida province. The participants were inhabitants with some medication prescribed between 2007 and 2016 that were linked to the Population-Based Cancer Registry to detect CRC diagnosed between 2012 and 2016. Risk factors and aspirin use were studied using the adjusted HR (aHR) with 95% confidence intervals (CI) using a Cox proportional hazard model. We included 154,715 inhabitants of Lleida (Spain) aged >50 years. Of patients with CRC, 62% were male (HR = 1.8; 95% CI: 1.6-2.2), 39.5% were overweight (HR = 2.8; 95% CI: 2.3-3.4) and 47.3% were obese (HR = 3.0; 95% CI: 2.6-3.6). Cox regression showed an association between aspirin and CRC (aHR = 0.7; 95% CI: 0.6-0.8), confirming a protective effect against CRC and an association between the risk of CRC and excess weight (aHR = 1.4; 95% CI: 1.2-1.7), smoking (aHR = 1.4; 95% CI: 1.3-1.7) and risky drinking (aHR = 1.6; 95% CI: 1.2-2.0). Our results show that aspirin use decreased the risk of CRC and corroborate the relationship between overweight, smoking and risky drinking and the risk of CRC.

Top and bottom longevity of nations: a retrospective analysis of the age-at-death distribution across 18 OECD countries

BACKGROUND

Similar to the study of the distribution of income within countries, population-level health disparities can be examined by analyzing the distribution of age at death.

METHODS

We sourced period-specific death counts for 18 OECD countries over 1900-2020 from the Human Mortality Database. We studied the evolution of country-year-specific distributions of age at death, with an examination of the lower and upper tails of these distributions. For each country-year, we extracted the 1st, 5th, 10th, 90th, 95th and 99th percentiles of the age-at-death distribution. We then computed the corresponding shares of longevity-the sum of the ages weighted by the age-at-death distribution as a fraction of the sum of the ages weighted by the distribution-for each percentile. For example, for the 10th percentile, this would correspond to how much longevity accrues to the bottom 10% of the age-at-death distribution in a given country-year.

RESULTS

We expose a characterization of the age-at-death distribution across populations with a focus on the lower and upper tails of the distribution. Our metrics, specifically the gap measures in age and share across the 10th and 90th percentiles of the distribution, enable a systematic comparison of national performances, which yields information supplementary to the cross-country differences commonly pointed by traditional indicators of life expectancy and coefficient of variation.

CONCLUSIONS

Examining the tails of age-at-death distributions can help characterize the comparative situations of the better- and worse-off individuals across nations, similarly to depictions of income distributions in economics.

Cause-of-Death Diversity From a Multiple-Cause Perspective in the United States

Cause-of-death diversity captures the variability of deaths across causes and is an important marker of heterogeneity in a population's health. We contribute to the debate of cause-of-death diversity dynamics by following a novel multiple causes of death (MCOD) approach and applying it to the U.S. context between 2003 and 2018 and across education groups. Results show that cause-of-death diversity increased over this period, especially up to 2012. These trends were mainly driven by increases in the groups aged 65 years or more. The inclusion of MCOD resulted in higher increases in cause-of-death diversity over time compared with merely using underlying causes of death, except for the 85 or more age group, where no difference was observed for males and a reverted gradient was observed for females. Results by educational attainment reveal lower diversity among the highest educated groups and widening differences across groups from around 2012 onward. The clear educational gradient observed at ages 30-64 diminished at older ages. The observed increases in cause-of-death diversity should be monitored to better understand mortality dynamics in aging populations. Our new MCOD diversity measures suggest that traditional approaches relying on single causes of death might be underestimating cause-of-death diversity dynamics, particularly for males.

National and subnational burden of brain and central nervous system cancers in Iran, 1990-2019: Results from the global burden of disease study 2019

INTRODUCTION

Central nervous system cancers (CNS cancers) impose a significant burden upon healthcare systems worldwide. Currently, the lack of a comprehensive study to assess various epidemiological indexes of CNS cancers on national and subnational scales in Iran can hamper healthcare planning and resource allocation in this regard. This study aims to fill this gap by providing estimates of CNS cancer epidemiological measures on national and subnational levels in Iran from 1990 to 2019.

MATERIALS AND METHODS

This study is a part of Global Burden of Disease (GBD) 2019 that contains epidemiological measures including prevalence, incidence, mortality, Disability-Adjusted Life Years (DALYs), Years Lived with Disability (YLDs), and Years of Life Lost (YLLs) of CNS cancers. Age standardization was utilized for comparing different provinces.

RESULTS

In 2019, 5811 (95% Uncertainty Interval: 2942-7046) national new cases and 3494 (1751-4173) deaths due to CNS cancers were reported. National age-standardized incidence (ASIR), deaths (ASDR), and DALYs rates were 7.3 (3.7-8.8), 4.6 (2.3-5.5), and 156.4 (82.0-187.0) per 100,000 in 2019, respectively. Subnational results revealed that ASDR and ASIR have increased in the past 30 years in all provinces. Although incidence rates have increased in all age groups and genders since 1990, death rates have remained the same for most age groups and genders except for young patients aged under 15, where a decrease in mortality and YLLs can be observed.

CONCLUSION

The incidence, deaths, and DALYs of CNS cancers increased at national and subnational levels. These findings should be considered for planning and resource allocation.

Health, income, and the preston curve: A long view

Well-being is increasingly viewed as a multidimensional phenomenon, of which income is only one facet. In this paper I focus on another one, health, and look at its synthetic measure, life expectancy at birth, and its relationship with per capita income. International trends of life expectancy and per capita GDP differed during the past 150 years. Life expectancy gains depended on economic growth but also on the advancement in medical knowledge. The pace and breadth of the health transitions drove life expectancy aggregate tendencies and distribution. The new results confirm the relationship between life expectancy and per capita income and its outward shift over time as put forward by Samuel Preston. However, the association between nonlinearly transformed life expectancy and the log of per capita income does not flatten out over time, but becomes convex suggesting more than proportional increases in life expectancy at higher per capita income levels.

On the emergence of the correlation between life expectancy and the variance in the age at death

Recent empirical studies have found various patterns in the correlations between lifespan inequality and life expectancy in modern human populations. However, it is unclear how general these regularities are. Here we establish three theorems that provide theoretical foundations for such regularities. We show that for populations with a finite maximum lifespan ω, and under certain continuity assumptions, the variance in the age at death is bounded by a function of lifespan that has a maximum and tends to zero as life expectancy tends to zero and ω. We show how the change in said variance is determined by a particular interplay between the coefficient of variation and the mean age in the population. These results lead to three hypotheses-a three-phased pattern of change for the correlation between the variance and life expectancy, a particular shape of the associated variance function, and that survival curve Type is one driver of the pattern. We illustrate those hypotheses empirically via a study of the 10 countries in the Human Mortality Database with the oldest available data. Our results elucidate the emergence of the aforementioned correlation patterns and provide demographically meaningful conditions under which those correlations reverse.

Drewnowski's index to measure lifespan variation: Revisiting the Gini coefficient of the life table

The Gini coefficient of the life table is a concentration index that provides information on lifespan variation. Originally proposed by economists to measure income and wealth inequalities, it has been widely used in population studies to investigate variation in ages at death. We focus on the complement of the Gini coefficient, Drewnowski's index, which is a measure of equality. We study its mathematical properties and analyze how changes over time relate to changes in life expectancy. Further, we identify the threshold age below which mortality improvements are translated into decreasing lifespan variation and above which these improvements translate into increasing lifespan inequality. We illustrate our theoretical findings simulating scenarios of mortality improvement in the Gompertz model, and showing an example of application to Swedish life table data. Our experiments demonstrate how Drewnowski's index can serve as an indicator of the shape of mortality patterns. These properties, along with our analytical findings, support studying lifespan variation alongside life expectancy trends in multiple species.

Probability of males to outlive females: an international comparison from 1751 to 2020

OBJECTIVE

To measure sex differences in lifespan based on the probability of males to outlive females.

DESIGN

International comparison of national and regional sex-specific life tables from the Human Mortality Database and the World Population Prospects.

SETTING

199 populations spanning all continents, between 1751 and 2020.

PRIMARY OUTCOME MEASURE

We used the outsurvival statistic ( φ ) to measure inequality in lifespan between sexes, which is interpreted here as the probability of males to outlive females.

RESULTS

In random pairs of one male and one female at age 0, the probability of the male outliving the female varies between 25% and 50% for life tables in almost all years since 1751 and across almost all populations. We show that φ is negatively correlated with sex differences in life expectancy and positively correlated with the level of lifespan variation. The important reduction of lifespan inequality observed in recent years has made it less likely for a male to outlive a female.

CONCLUSIONS

Although male life expectancy is generally lower than female life expectancy, and male death rates are usually higher at all ages, males have a substantial chance of outliving females. These findings challenge the general impression that 'men do not live as long as women' and reveal a more nuanced inequality in lifespans between females and males.

The comparative mortality of an elite group in the long run of history: an observational analysis of politicians from 11 countries

This study aims to compare the mortality rate and life expectancy of politicians with those of the age and gender-matched general populations. This was an observational analysis of mortality rates of politicians (i.e. members of national parliaments with available data on dates of birth, death and election, gender, and life tables) in 11 developed countries. Politicians were followed from date of first election until either death or the last available year with life table data. Relative mortality differences were estimated using standardised mortality ratios (SMRs). Absolute inequalities were quantified as the difference in survival by deducting a population’s remaining life expectancy from politicians’ remaining life expectancy at age 45, estimated using Gompertz parametric proportional hazards models. We included 57,561 politicians (with follow-up ranging from 1816–2016 for France to 1949–2017 for Germany). In almost all countries politicians had similar rates of mortality to the general population in the early part of the twentieth century. Relative mortality and survival differences (favouring politicians) increased considerably over the course of the twentieth century, with recent SMRs ranging from 0.45 (95%CI 0.41–0.50) in Italy to 0.82 (95%CI 0.69–0.95) in New Zealand. The peak life expectancy gaps ranged from 4.4 (95% CI, 3.5–5.4) years in the Netherlands to 7.8 (95% CI, 7.2–8.4) years in the US. Our results show large relative and absolute inequalities favouring politicians in every country. In some countries, such as the US, relative inequalities are at the greatest level in over 150 years.

Modeling Years of Life Lost Due to COVID-19, Socioeconomic Status, and Nonpharmaceutical Interventions: Development of a Prediction Model

Background

Research in the COVID-19 pandemic focused on the health burden, thereby largely neglecting the potential harm to life from welfare losses.

Objective

This paper develops a model that compares the years of life lost (YLL) due to COVID-19 and the potential YLL due to the socioeconomic consequences of its containment.

Methods

It improves on existing estimates by conceptually disentangling YLL due to COVID-19 and socioeconomic status. By reconciling the normative life table approach with socioeconomic differences in life expectancy, it accounts for the fact that people with low socioeconomic status are hit particularly hard by the pandemic. The model also draws on estimates of socioeconomic differences in life expectancy to ascertain potential YLL due to income loss, school closures, and extreme poverty.

Results

Tentative results suggest that if only one-tenth of the current socioeconomic damage becomes permanent in the future, it may carry a higher YLL burden than COVID-19 in the more likely pandemic scenarios. The model further suggests that the socioeconomic harm outweighs the disease burden due to COVID-19 more quickly in poorer and more unequal societies. Most urgently, the substantial increase in extreme poverty needs immediate attention. Avoiding a relatively minor number of 4 million unemployed, 1 million extremely poor, and 2 million students with a higher learning loss may save a similar amount of life years as saving 1 million people from dying from COVID-19.

Conclusions

Primarily, the results illustrate the urgent need for redistributive policy interventions and global solidarity. In addition, the potentially high YLL burden from income and learning losses raises the burden of proof for the efficacy and necessity of school and business closures in the containment of the pandemic, especially where social safety nets are underdeveloped.

Normalized lifespan inequality: disentangling the longevity-lifespan variability nexus

Previous studies have documented a historically strong and negative association between countries’ life expectancy (i.e., average longevity) and length-of-life inequality (i.e., variability in ages at death). The relationship between both variables might be partially explained by life expectancy increasing at a faster pace than maximal length of life, a phenomenon that mechanically compresses the age-at-death distribution and has not been taken into consideration in previous studies. In this paper, we propose a new approach to lifespan inequality measurement that accounts for the (uncertainly) bounded nature of length-of-life. Applying the new approach to the countries of the Human Mortality Database, we observe that the decline in overall lifespan variability typically associated with increases in longevity seems to stop and even reverse at higher levels of life expectancy. This suggests the emergence of worrying ethical dilemmas, whereby higher achievements in longevity would only be possible at the expense of higher lifespan variability.

From convergence to divergence: Lifespan variation in US states, 1959-2017

BACKGROUND

Large disparities in life expectancy exist across US states and the gaps have been widening in recent decades. Less is known about the lifespan variability - a measure that can provide important insights into mortality inequalities both between and within states.

METHOD

Using yearly lifetables from the United States Mortality Database, we explore geographic and temporal patterns in lifespan variation (unconditional and conditional on survival to age 10, 35 and 65) across US states between 1959 and 2017. We also examine the contribution of state differences in life expectancy to overall lifespan variation using standard decomposition techniques.

RESULTS

Despite overall convergence in lifespan variation across states over the last six decades, in more recent years there has been notable divergence. Gender-specific analyses show that lifespan variation was generally greater among males than among females; but this pattern reverses for mortality past age 65. Much of the state disparities in lifespan variation, unconditional and conditional on survival to age 10 and 35, were due to mortality differences under the age 65. Decomposition analysis shows that while within-state variability remains the primary driver of overall lifespan variation, the contribution of cross-state differences in life expectancy is growing.

CONCLUSIONS

Variation in longevity is greater within US States than between them, yet cross-states disparities in mortality are increasing. This likely reflects the long-term consequences of rising social, economic, and political stratification for health inequalities both within and across states.

The Cross-sectional Average Inequality in Lifespan (CAL†): A Lifespan Variation Measure That Reflects the Mortality Histories of Cohorts

Lifespan variation is a key metric of mortality that describes both individual uncertainty about the length of life and heterogeneity in population health. We propose a novel and timely lifespan variation measure, which we call the cross-sectional average inequality in lifespan, or CAL†. This new index provides an alternative perspective on the analysis of lifespan inequality by combining the mortality histories of all cohorts present in a cross-sectional approach. We demonstrate how differences in the CAL† measure can be decomposed between populations by age and cohort to explore the compression or expansion of mortality in a cohort perspective. We apply these new methods using data from 10 low-mortality countries or regions from 1879 to 2013. CAL† reveals greater uncertainty in the timing of death than the period life table-based indices of variation indicate. Also, country rankings of lifespan inequality vary considerably between period and cross-sectional measures. These differences raise intriguing questions as to which temporal dimension is the most relevant to individuals when considering the uncertainty in the timing of death in planning their life courses.

Socioeconomic Inequalities in Mortality After Age 67: The Contribution of Psychological Factors

Diverging trends of longer lives and increased inequalities in age-at-death invite to updated research on late-life mortality. Earlier studies have identified health behavior, childhood, psychosocial, and material conditions as key determinants of life expectancy, but the role of psychological factors remains a topic of debate. The current study is framed in a life course developmental perspective and assesses the mediating role of secondary control strategies (subjective age) and primary control capacity (perceived control) to socioeconomic (wealth and education) inequality in mortality after age 67. Data are derived from the second wave of the Norwegian Life Course, Ageing and Generation study (N=1,432 and age 67–85). All in all, 366 deaths were observed over a mean follow-up of 9.6years. Perceived control was measured by the Pearlin and Schooler Mastery Scale. SA was measured with proportional discrepancy scores in felt age and ideal age. Stepwise Cox proportional hazards regression analyses were conducted to analyze the relative contribution of SES (education and accumulated wealth), felt age, and ideal age discrepancies and perceived control on 11-year mortality. Findings show that lower levels of wealth and perceived control independently predict increased elderly mortality over an 11-year period. Feeling younger and smaller ideal age discrepancies are positively associated with perceived control, but do not account for additional variability in longevity among older adults. Findings add to the interdisciplinary field of socioeconomic inequalities in elderly mortality and underline the specific importance of structural conditions (wealth) and the continued importance of (perceived) primary control capacity for longevity also after age 67. Future research may assess in more detail how wealth and perceived control complement each other in contributing to healthy aging and longevity, for example, by longitudinal research including the role of significant life events in the second half of life in different welfare state contexts.

Progress of Inequality in Age at Death in India: Role of Adult Mortality

India has seen a reduction in infant and child mortality rates for both the sexes since the early 1980s. However, a decline in mortality at adult ages is marked by significant differences in the subgroups of sex and regions. This study assesses the progress of inequality in age at death with the advances in mortality transition during 36 years period between 1981-1985 and 2012-2016 in India, using the Gini coefficients at the age of zero (G ₀ ). The Gini coefficients show that in the mid-2000s, women outpaced men in G ₀ . The reduction in inequality in age at death is a manifestation of the process of homogeneity in mortality. The low G ₀ is concomitant of high life expectancy at birth (e ₀ ) in India. The results show the dominance of adult mortality over child mortality in the medium-mortality and low-mortality regimes. Varying adult mortality in the subgroups of sex and variance in the mortality levels of regions are the predominant factors for the variation in inequality in age at death. By lowering of the mortality rates in the age group of 15-29 years, India can achieve a high e ₀ that appears at high demographic development and the narrow sex differentials in e ₀ and G ₀ in a short time. Men in the age group of 15-29 years are the most vulnerable subgroup with respect to mortality. There is an immediate need for health policies in India to prioritise the aversion of premature deaths in men aged 15-29 years.

Nationwide evidence that education disrupts the intergenerational transmission of disadvantage

We leveraged a three-generation approach in 2.1 million Danes to measure the transmission and disruption of multiple health and social disadvantages: poor physical health, poor mental health, social welfare dependency, criminal offending, and protective services involvement. Health and social disadvantages clustered within a small segment of families: Adults who relied disproportionately on multiple, different health and social services tended to have parents who relied disproportionately on multiple, different health and social services and tended to have children who appeared in protective services records. Education disrupted these statistical associations between and within generations and between and within families. If associations are causal, investing in young people’s education potential could interrupt the multigenerational cycle of disadvantage and reduce health and social inequalities.

Despite overall improvements in health and living standards in the Western world, health and social disadvantages persist across generations. Using nationwide administrative databases linked for 2.1 million Danish citizens, we leveraged a three-generation approach to test whether multiple, different health and social disadvantages—poor physical health, poor mental health, social welfare dependency, criminal offending, and Child Protective Services involvement—were transmitted within families and whether education disrupted these statistical associations. Health and social disadvantages concentrated, aggregated, and accumulated within a small, high-need segment of families: Adults who relied disproportionately on multiple, different health and social services tended to have parents who relied disproportionately on multiple, different health and social services and tended to have children who evidenced risk for disadvantage at an early age, through appearance in protective services records. Intra- and intergenerational comparisons were consistent with the possibility that education disrupted this transmission. Within families, siblings who obtained more education were at a reduced risk for later-life disadvantage compared with their cosiblings who obtained less education, despite shared family background. Supporting the education potential of the most vulnerable citizens might mitigate the multigenerational transmission of multiple disadvantages and reduce health and social disparities.

Development and psychometric properties of the general public's attitudes toward advance care directives scale in Portugal

Background: To date, no instrument in Portugal has evaluated the attitudes of the population about advance care directives. This paper describes the development and testing of the General Public's Attitudes Toward Advance Care Directives (GPATACD) Scale. Design and Methods: Methodological study. The development of the instrument was based on a literature review, updated in 2018. Face and content validity were verified by an expert panel and piloted among six participants. Data were collected in an online survey of 1024 Portuguese adults. The obtained data were analyzed using Varimax rotation, while the reliability was evaluated by calculating Cronbach's alpha. Results: The scale achieves good Item-Content Validity Index (I-CVI) values, between 0.89 and 1.00, and scale-CVI values of 0.91. A principal component analysis generated four dimensions with 26 items as a final scale, with overall Cronbach's alpha of 0.848. Conclusions: The findings demonstrate that the scale is valid and reliable as a vehicle for assessment of the general public's attitudes toward advance care directives.

A global, regional, and national survey on burden and Quality of Care Index (QCI) of brain and other central nervous system cancers; global burden of disease systematic analysis 1990-2017

Primary brain and other central nervous system (CNS) cancers cause major burdens. In this study, we introduced a measure named the Quality of Care Index (QCI), which indirectly evaluates the quality of care given to patients with this group of cancers. Here we aimed to compare different geographic and socioeconomic patterns of CNS cancer care according to the novel measure introduced. In this regard, we acquired age-standardized primary epidemiologic measures were acquired from the Global Burden of Disease (GBD) study 1990-2017. The primary measures were combined to make four secondary indices which all of them indirectly show the quality of care given to patients. Principal Component Analysis (PCA) method was utilized to calculate the essential component named QCI. Further analyses were made based on QCI to assess the quality of care globally, regionally, and nationally (with a scale of 0-100 which higher values represent better quality of care). For 2017, the global calculated QCI was 55.0. QCI showed a desirable condition in higher socio-demographic index (SDI) quintiles. Oppositely, low SDI quintile countries (7.7) had critically worse care quality. Western Pacific Region with the highest (76.9) and African Region with the lowest QCIs (9.9) were the two WHO regions extremes. Singapore was the country with the maximum QCI of 100, followed by Japan (99.9) and South Korea (98.9). In contrast, Swaziland (2.5), Lesotho (3.5), and Vanuatu (3.9) were countries with the worse condition. While the quality of care for most regions was desirable, regions with economic constraints showed to have poor quality of care and require enforcements toward this lethal diagnosis.

Marked Disparities in Life Expectancy by Education, Poverty Level, Occupation, and Housing Tenure in the United States, 1997-2014

OBJECTIVES

Socioeconomic disparities in life expectancy in the United States (US) are marked and have widened over time. However, there is limited research using individual-level socioeconomic variables as such information is generally lacking or unreliable in vital records used for life table construction. Using longitudinal cohort data, we computed life expectancy for US adults by social determinants such as education, income/poverty level, occupation, and housing tenure.

METHODS

We analyzed the 1997-2014 National Health Interview Survey prospectively linked to mortality records in the National Death Index (N=1,146,271). Standard life table methodologies were used to compute life expectancy and other life table functions at various ages according to socioeconomic variables stratified by sex and race/ethnicity.

RESULTS

Adults with at least a Master's degree had 14.7 years higher life expectancy at age 18 than those with less than a high school education and 8.3 years higher life expectancy than those with a high school education. Poverty was inversely related to life expectancy. Individuals living in poverty had 10.5 years lower life expectancy at age 18 than those with incomes ≥400% of the poverty threshold. Laborers and those employed in craft and repair occupations had, respectively, 10.9 years and 8.6 years lower life expectancy at age 18 than those with professional and managerial occupations. Male and female renters had, respectively, 4.0 years and 4.6 years lower life expectancy at age 18 than homeowners. Women in the most advantaged socioeconomic group outlived men in the most disadvantaged group by 23.5 years at age 18.

CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS

Marked socioeconomic gradients in US life expectancy were found across all sex and racial/ethnic groups. Adults with lower education, higher poverty levels, in manual occupations, and with rental housing had substantially lower life expectancy compared to their counterparts with higher socioeconomic position.