High life expectancy and reversed socioeconomic gradients of elderly people in Mexico and Costa Rica

Educational Disparities in Preventable Deaths: Do They Explain the Longevity Gap Between Mexico and Spain?

OBJECTIVE

Determine how preventable causes of death contribute to the life expectancy gap between Mexico and Spain.

METHODS

We used a linear integral decomposition to analyze the impact of preventable mortality on life expectancy between ages 30-75 (temporary life expectancy) between Mexico and Spain in 2018. Additionally, we computed cause-deleted life tables to estimate potential gains in temporary life expectancy. Analyses were stratified by educational attainment, sex, and age.

RESULTS

Low-educated Mexicans showed the largest gains in temporary life expectancy from removing preventable deaths (3.4 years for males, 1.6 for females), partially explaining the gap with Spain. Removing these deaths would close the gap almost entirely due to a higher relative decrease for middle- and high-educated individuals.

DISCUSSION

While access to adequate healthcare is crucial for improving population health, appropriate non-medical public policies can significantly reduce mortality disparities between Mexico and Spain, especially for individuals from higher educational backgrounds.

Health inequalities in a middle-income country: a systematic review of the Costa Rican case

Objective

This study systematically reviews evidence of socioeconomic health disparities in Costa Rica, a middle-income country, to elucidate the relationship between socioeconomic status and health outcomes.

Methods

Published studies were identified through a systematic review of PubMed (English) and Scielo (Spanish) databases from December 2023 to January 2024, following PRISMA guidelines. Search terms included socioeconomic status, social determinants, social gradient in health, and health inequalities.

Results

Of 236 identified references, 55 met the inclusion criteria. Findings were categorized into health inequalities in mortality (among the general population, infants, and older adults), life expectancy, cause-specific mortality, and health determinants or risk factors mediating the association between the social environment and health. The studies indicate higher mortality among the most disadvantaged groups, including deaths from respiratory diseases, violence, and infections. Higher socioeconomic status was associated with lower mortality rates in the 1990s, indicating a positive social gradient in health (RII = 1.3, CI [1.1-1.5]). Disparities were less pronounced among older adults. Urban areas exhibited concentrated wealth and increased risky behaviors, while rural areas, despite greater socioeconomic deprivation, showed a lower prevalence of risky behaviors. Regarding smoking, people living in rural areas smoked significantly less than those in urban areas (7% vs. 10%). Despite the relatively equitable distribution of public primary healthcare, disparities persisted in the timely diagnosis and treatment of chronic diseases. Cancer survival rates post-diagnosis were positively correlated with the wealth of districts (1.23 [1.12-1.35] for all cancers combined).

Conclusion

The study highlights the existence of social health inequalities in Costa Rica. However, despite being one of the most unequal OECD countries, Costa Rica shows relatively modest social gradients in health compared to other middle and high-income nations. This phenomenon can be attributed to distinctive social patterns in health behaviors and the equalizing influence of the universal healthcare system.

Inequalities in Disability-Free and Disabling Multimorbid Life Expectancy in Costa Rica, Mexico, and the United States

OBJECTIVES

To better understand variations in multimorbidity severity over time, we estimate disability-free and disabling multimorbid life expectancy (MMLE), comparing Costa Rica, Mexico, and the United States (US). We also assess MMLE inequalities by sex and education.

METHODS

Data come from the Costa Rican Study on Longevity and Healthy Aging (2005-2009), the Mexican Health and Aging Study (2012-2018), and the Health and Retirement Study (2004-2018). We apply an incidence-based multistate Markov approach to estimate disability-free and disabling MMLE and stratify models by sex and education to study within-country heterogeneity. Multimorbidity is defined as a count of 2 or more chronic diseases. Disability is defined using limitations in activities of daily living.

RESULTS

Costa Ricans have the lowest MMLE, followed by Mexicans, then individuals from the US. Individuals from the US spend about twice as long with disability-free multimorbidity compared with individuals from Costa Rica or Mexico. Females generally have longer MMLE than males, with particularly stark differences in disabling MMLE. In the US, higher education was associated with longer disability-free MMLE and shorter disabling MMLE. We identified evidence for cumulative disadvantage in Mexico and the US, where sex differences in MMLE were larger among the lower educated.

DISCUSSION

Substantial sex and educational inequalities in MMLE exist within and between these countries. Estimating disability-free and disabling MMLE reveals another layer of health inequality not captured when examining disability and multimorbidity separately. MMLE is a flexible population health measure that can be used to better understand the aging process across contexts.

Rural and urban differences in lifetime occupation and its influence on mortality among Mexican adults

OBJECTIVE

To determine how primary lifetime occupation type is associated with mortality, and how the relationship varies by rural and urban dwelling.

MATERIALS AND METHODS

Data come from 2001-2018 Mexican Health and Aging Study (adults aged 50+, n=11 094). We created five occupation categories. Cox proportional hazard models predicted mortality using baseline covariates.

RESULTS

In both rural and urban settings, participants with manual jobs, such as agriculture and production/industrial jobs, had an increased risk of mortality compared to those with administrative/professional jobs. In urban settings, participants in the domestic/service and no main job categories had higher risk of mortality than those in the administrative/professional category. For men these differences remained, but not for women.

CONCLUSION

In a context of rural and urban demographic shifts, it is crucial to consider the implications that occupation as a socioeconomic factor can have on health and to identify the most vulnerable groups.

Health inequalities in cause-specific mortality in Costa Rica: a population-based cohort study

OBJECTIVE

To analyze health inequalities in cause-specific mortality in Costa Rica from 2010 to 2018, observing the main causes for inequality in the country.

METHODS

The National Electoral Rolls were used to follow-up all Costa Rican adults aged 20 years or older from 2010 to 2018 (n = 2,739,733) in an ecological study. A parametric survival model based on the Gompertz distribution was performed and the event death was classified according to the ICD-10.

RESULTS

After adjustment for urbanicity, the poorest districts had a higher mortality than the wealthier districts for most causes of death except neoplasms, mental and behavioral disorders, and diseases of the nervous system. Urban districts showed significantly higher mortality than mixed and rural districts after adjustment for wealth for most causes except mental and behavioral disorders, diseases of the nervous system, and diseases of the respiratory system. Differences according to wealth were more frequent in women than men, whereas differences according to urbanicity were more frequent in men than in women.

CONCLUSIONS

The study's findings were consistent, but not fully similar, to the international literature.

What have we learned about mortality patterns over the past 25 years?

In this paper, I examine progress in the field of mortality over the past 25 years. I argue that we have been most successful in taking advantage of an increasingly data-rich environment to improve aggregate mortality models and test pre-existing theories. Less progress has been made in relating our estimates of mortality risk at the individual level to broader mortality patterns at the population level while appropriately accounting for contextual differences and compositional change. Overall, I find that the field of mortality continues to be highly visible in demographic journals, including Population Studies. However much of what is published today in field journals could just as easily appear in neighbouring disciplinary journals, as disciplinary boundaries are shrinking.

The Importance of Education for Middle- and Old-Age Mortality in Chile: Estimates From Panel Data Linked to Death Records

OBJECTIVES

To examine the association between education and mortality by age and gender in Chile.

METHODS

We drew data from 10,147 adults aged 40 years and over from the Chilean Social Protection Survey linked to the national death records. We specify five Cox regression models to estimate the main and interaction effects for education levels, age, sex, and mortality.

RESULTS

The hazard ratios reduce with increasing education. Secondary and tertiary education levels are associated, respectively, with 34% and 41% lower hazard rates than 0-4 years of schooling. Also, the educational gradient in mortality is significantly weaker at older ages, and it does not differ by gender.

DISCUSSION

Our findings endorse the negative association of formal education with adult mortality, uncovering Chile's structural problems despite the economic improvements underway. It also corroborates the importance of novel longitudinal data for mortality analyses in Latin America.

Social inequality in incidence and mortality of malignant neoplasms of lip, oral cavity and pharynx: Is Costa Rica an international paradox?

OBJECTIVES

Low socioeconomic position (SEP) has been associated with higher incidences and mortality of lip, oral cavity and pharynx (LOP) cancers in the vast majority of countries with available data. The origins of health inequalities in cancer are socioeconomic, although they vary by time and country. Evidence from Low-and Middle-income Countries (LMICs) remains scarce. This study aims to identify and describe socioeconomic inequalities in LOP cancers incidence and mortality in Costa Rica. The hypothesis tested is that people leaving in low-SEP districts in Costa Rica have greater incidence and mortality rates of lip, oral cavity and pharynx cancers.

METHODS

The 10th revision of the International Classification of Diseases (ICD-10) was used to define cancer sites. Data come from a national population-based Cancer Registry with 100% completeness to study incidence. Incidence rate included all new cases of LOP cancer diagnosed from January 1, 2011, and December 31, 2015, for a total of 2 798 517 individuals, 13 832 524 years of follow-up and 601 LOP cases. Mortality rate was extracted from the National Death Index, including 2 739 733 individuals, 23 950 240 person-years of follow-up and 586 LOP cancer deaths, from January 1, 2010, to December 31, 2018. The 2011 Census (with 94% of Costa Rican inhabitants) was used to characterize the urbanicity and wealth of 477 districts. Survival models were performed for both incidence and mortality, allowing to consider existing competitive risks. Cox models were used for incidence, and parametric survival models based on a Gompertz distribution for mortality.

RESULTS

The study found that people who lived in the most socioeconomically disadvantaged areas had lower probabilities of developing LOP cancers than people in the richest districts. The same pattern for mortality, however, was not significant.

CONCLUSIONS

The hypothesis that incidence and mortality of LOP cancers will show a positive social gradient was not confirmed in this study, contradicting the existing literature. This could be explained by the social distribution of risky health behaviours, more frequent in socially advantaged populations.

The contribution of social participation to differences in life expectancy and healthy years among the older population: A comparison between Chile, Costa Rica and Spain

We study the health trajectories of the population aged over 60, comparing between one European and two Latin American countries (Spain, Chile and Costa Rica) which have similar longevity patterns. Our focus is on functional limitation and mortality risks, considering differences by gender, education and social participation. Data come from national panel surveys (EPS, CRELES, SHARE). Multistate modelling is used to estimate transition probabilities between two health states: healthy to unhealthy, unhealthy to healthy as well as the transition to death from healthy or unhealthy states, to estimate the duration of stay in a specific state (computing healthy and unhealthy life expectancies) and the effect of the selected covariates. Results show that older Costa Ricans have the smallest gender gap in life expectancy but women have a lower healthy life expectancy compared to those in Chile and Spain. Participation in social activities leads to higher healthy life expectancy among the elderly in Costa Rica and Spain, whilst there were no relevant educational differences observed in longevity in the analysed countries. To conclude: despite the different patterns observed in health transitions and survival across the three countries, social participation is associated with greater health and longevity among people of old age, with little effect coming from educational attainment. Public policies should therefore be aimed at reducing unhealthy life years and dependency at advanced ages by promoting more engagement in social activities, especially among vulnerable groups who are more likely to experience impairment from a younger age.

Life expectancy and mortality in 363 cities of Latin America

The concept of a so-called urban advantage in health ignores the possibility of heterogeneity in health outcomes across cities. Using a harmonized dataset from the SALURBAL project, we describe variability and predictors of life expectancy and proportionate mortality in 363 cities across nine Latin American countries. Life expectancy differed substantially across cities within the same country. Cause-specific mortality also varied across cities, with some causes of death (unintentional and violent injuries and deaths) showing large variation within countries, whereas other causes of death (communicable, maternal, neonatal and nutritional, cancer, cardiovascular disease and other noncommunicable diseases) varied substantially between countries. In multivariable mixed models, higher levels of education, water access and sanitation and less overcrowding were associated with longer life expectancy, a relatively lower proportion of communicable, maternal, neonatal and nutritional deaths and a higher proportion of deaths from cancer, cardiovascular disease and other noncommunicable diseases. These results highlight considerable heterogeneity in life expectancy and causes of death across cities of Latin America, revealing modifiable factors that could be amenable to urban policies aimed toward improving urban health in Latin America and more generally in other urban environments.

City-level analysis of data from the SALURBAL project shows vast heterogeneity in life expectancy across cities within the same country, in addition to substantive differences in causes of death among nine Latin American countries, revealing modifiable factors that could be leveraged by municipal-level policies aimed toward improving health in urban environments.

Education and adult mortality in middle-income countries: Surprising gradients in six nationally-representative longitudinal surveys

Background

There are large differences in adult mortality across schooling groups in many high-income countries (HICs). An important open question is whether there are similar gradients in adult mortality in middle-income countries (MICs), where schooling and healthcare quality tends to be lower and health-related behaviors are often not strongly patterned by schooling.

Methods

We present one of the first international-comparative studies on schooling differences in adult mortality across MICs using harmonizedlongitudinal data on adults ages 50+ from China, Costa Rica, Indonesia, Mexico, South Africa, and South Korea. We use Cox proportional hazards models to estimate differences in the hazard of mortality across schooling groups overall and separately by sex and broad age groups. We also estimate schooling gradients in smoking and body mass index to determine whether risk factor gradients potentially explain mortality patterns.

Results

Only adults with tertiary schooling have a consistent adult mortality advantage compared to those with no schooling. We do not find evidence that individuals with primary schooling have a lower hazard of mortality compared to individuals with no schooling in five of the six countries. The mortality advantage for individuals with secondary schooling is mixed, with evidence of lower mortality relative to those with no schooling in Mexico, South Africa, and South Korea. Gradients in BMI and smoking are inconsistent across countries and unlikely to explain mortality differences.

Conclusions

We find that adult mortality and risk factor gradients in MICs can be much different than the established patterns seen in modern HICs. Our results highlight that adult mortality gradients are not an inevitability and are not found in all populations. Understanding what factors give rise to inequalities in adult mortality and what can be done to minimize gradients while still ensuring continued mortality improvements in MICs is a crucial focus for research and policy.

Calloused hands, shorter life? Occupation and older-age survival in Mexico

BACKGROUND

Inequalities in mortality are often attributed to socioeconomic differences in education level, income, and wealth. Low socioeconomic status (SES) is generally related to worse health and survival across the life course. Yet, disadvantaged people are also more likely to hold jobs requiring heavy physical labor, repetitive movement, ergonomic strain, and safety hazards.

OBJECTIVE

We examine the link between primary lifetime occupation, together with education and net worth, on survival among older adults in Mexico.

METHODS

We use data from four waves (2001, 2003, 2012, and 2015) of the Mexican Health and Aging Study (MHAS). We estimate age-specific mortality rates for ages 50 and over using a hazards model based on a two-parameter Gompertz function.

RESULTS

Primary lifetime occupations have a stronger association with survival for women than men. Women with higher socioeconomic status have significantly lower mortality rates than lower status women, whether SES is assessed in terms of schooling, wealth, or occupation. Occupational categories are not jointly related to survival among men, even without controls for education and wealth. There are significant survival differences by wealth among men, but no disparities in mortality by education.

CONCLUSIONS

Consistent with recent studies of the Mexican population, we fail to find the expected gradient in the association between some measures of SES and better survival among men.

CONTRIBUTION

Our estimates extend this anomalous pattern among Mexican men to another dimension of SES, occupation. SES differentials in mortality are substantially larger for Mexican women, highlighting an important gender disparity.

Inequalities in life expectancy in six large Latin American cities from the SALURBAL study: an ecological analysis

BACKGROUND

Latin America is one of the most unequal regions in the world, but evidence is lacking on the magnitude of health inequalities in urban areas of the region. Our objective was to examine inequalities in life expectancy in six large Latin American cities and its association with a measure of area-level socioeconomic status.

METHODS

In this ecological analysis, we used data from the Salud Urbana en America Latina (SALURBAL) study on six large cities in Latin America (Buenos Aires, Argentina; Belo Horizonte, Brazil; Santiago, Chile; San José, Costa Rica; Mexico City, Mexico; and Panama City, Panama), comprising 266 subcity units, for the period 2011-15 (expect for Panama city, which was for 2012-16). We calculated average life expectancy at birth by sex and subcity unit with life tables using age-specific mortality rates estimated from a Bayesian model, and calculated the difference between the ninth and first decile of life expectancy at birth (P90-P10 gap) across subcity units in cities. We also analysed the association between life expectancy at birth and socioeconomic status at the subcity-unit level, using education as a proxy for socioeconomic status, and whether any geographical patterns existed in cities between subcity units.

FINDINGS

We found large spatial differences in average life expectancy at birth in Latin American cities, with the largest P90-P10 gaps observed in Panama City (15·0 years for men and 14·7 years for women), Santiago (8·9 years for men and 17·7 years for women), and Mexico City (10·9 years for men and 9·4 years for women), and the narrowest in Buenos Aires (4·4 years for men and 5·8 years for women), Belo Horizonte (4·0 years for men and 6·5 years for women), and San José (3·9 years for men and 3·0 years for women). Higher area-level socioeconomic status was associated with higher life expectancy, especially in Santiago (change in life expectancy per P90-P10 change unit-level of educational attainment 8·0 years [95% CI 5·8-10·3] for men and 11·8 years [7·1-16·4] for women) and Panama City (7·3 years [2·6-12·1] for men and 9·0 years [2·4-15·5] for women). We saw an increase in life expectancy at birth from east to west in Panama City and from north to south in core Mexico City, and a core-periphery divide in Buenos Aires and Santiago. Whereas for San José the central part of the city had the lowest life expectancy and in Belo Horizonte the central part of the city had the highest life expectancy.

INTERPRETATION

Large spatial differences in life expectancy in Latin American cities and their association with social factors highlight the importance of area-based approaches and policies that address social inequalities in improving health in cities of the region.

FUNDING

Wellcome Trust.

Costa Rican Mortality 1950-2013: An Evaluation of Data Quality and Trends Compared with Other Countries

Background

Mortality estimates from various sources suggest that Costa Ricans experience record-high life expectancy at birth in Latin America and higher longevity than the populations of many high-income countries, although there is some uncertainty as to the reliability of those estimates.

Objective

We construct a life table series for Costa Rica to assess the quality of national demographic statistics for the period 1950-2013 and to determine whether reliable mortality estimates can be directly calculated from these data.

Methods

We apply the methods from the Human Mortality Database (HMD) to national statistics to construct the Costa Rica life table series without adjusting for data quality, and we validate our results through internal consistency by evaluating the plausibility of the mortality patterns and its change over time and through external consistency by comparing our results with those from other sources.

Results

Our mortality estimates for Costa Rica tend to be lower than others, especially for the period before 1970. They also produce a suspicious age pattern of mortality, with low adult and old-age mortality relative to the infant and child mortality, casting doubt on the quality of national demographic data.

Conclusions

Other organizations have produced mortality estimates for Costa Rica that are higher than our unadjusted estimates, but it is difficult to evaluate the accuracy of the available estimates.

Contribution

This analysis provides a more thorough evaluation of data quality issues regarding Costa Rica mortality than previously available. Unadjusted life tables by sex for 1950-2013 are included as supplemental material, together with the raw data upon which those life tables are based and with links to the detailed methods protocol implemented.