Bilevel Parameter Learning for Higher-Order Total Variation Regularisation Models

We consider a bilevel optimisation approach for parameter learning in higher-order total variation image reconstruction models. Apart from the least squares cost functional, naturally used in bilevel learning, we propose and analyse an alternative cost based on a Huber-regularised TV seminorm. Differentiability properties of the solution operator are verified and a first-order optimality system is derived. Based on the adjoint information, a combined quasi-Newton/semismooth Newton algorithm is proposed for the numerical solution of the bilevel problems. Numerical experiments are carried out to show the suitability of our approach and the improved performance of the new cost functional. Thanks to the bilevel optimisation framework, also a detailed comparison between TGV 2 and ICTV is carried out, showing the advantages and shortcomings of both regularisers, depending on the structure of the processed images and their noise level.

Acceleration of the PDHGM on Partially Strongly Convex Functions

We propose several variants of the primal-dual method due to Chambolle and Pock. Without requiring full strong convexity of the objective functions, our methods are accelerated on subspaces with strong convexity. This yields mixed rates, O ( 1 / N 2 ) with respect to initialisation and O(1 / N) with respect to the dual sequence, and the residual part of the primal sequence. We demonstrate the efficacy of the proposed methods on image processing problems lacking strong convexity, such as total generalised variation denoising and total variation deblurring.

Phase reconstruction from velocity-encoded MRI measurements--a survey of sparsity-promoting variational approaches

In recent years there has been significant developments in the reconstruction of magnetic resonance velocity images from sub-sampled k-space data. While showing a strong improvement in reconstruction quality compared to classical approaches, the vast number of different methods, and the challenges in setting them up, often leaves the user with the difficult task of choosing the correct approach, or more importantly, not selecting a poor approach. In this paper, we survey variational approaches for the reconstruction of phase-encoded magnetic resonance velocity images from sub-sampled k-space data. We are particularly interested in regularisers that correctly treat both smooth and geometric features of the image. These features are common to velocity imaging, where the flow field will be smooth but interfaces between the fluid and surrounding material will be sharp, but are challenging to represent sparsely. As an example we demonstrate the variational approaches on velocity imaging of water flowing through a packed bed of solid particles. We evaluate Wavelet regularisation against Total Variation and the relatively recent second order Total Generalised Variation regularisation. We combine these regularisation schemes with a contrast enhancement approach called Bregman iteration. We verify for a variety of sampling patterns that Morozov's discrepancy principle provides a good criterion for stopping the iterations. Therefore, given only the noise level, we present a robust guideline for setting up a variational reconstruction scheme for MR velocity imaging.

Psychosocial stress and sociodemographic differentials in mortality from ischaemic heart disease in Finland

This report describes differences in mortality from ischaemic heart disease (IHD) and other selected causes of death according to region, marital status, language group (Finnish vs Swedish), social group and rural-urban divisions in Finland. The data include all deaths in Finland during 1971-75 in the cohorts of men aged 35-64 and women aged 35-74 on January 1st 1971 (33,862 IHD deaths). The sociodemographic characteristics of the decreased were obtained through computerized linkage from the records of the 1970 census by means of personal identification codes. IHD mortality was found to be higher than average in Eastern Finland, in the Finnish speaking population and in lower social groups. There was a higher mortality in non-married than in married categories among men, but among women the differences were smaller. The findings are discussed in the light of differences in stressrelated mortality.

Socioeconomic status and ischaemic heart disease mortality in 10 western European populations during the 1990s

OBJECTIVE

To assess the association between socioeconomic status and ischaemic heart disease (IHD) mortality in 10 western European populations during the 1990s.

DESIGN

Longitudinal study.

SETTING

10 European populations (95,009,822 person years).

METHODS

Longitudinal data on IHD mortality by educational level were obtained from registries in Finland, Norway, Denmark, England/Wales, Belgium, Switzerland, Austria, Turin (Italy), Barcelona (Spain), and Madrid (Spain). Age standardised rates and rate ratios (RRs) of IHD mortality by educational level were calculated by using Poisson regression.

RESULTS

IHD mortality was higher in those with a lower socioeconomic status than in those with a higher socioeconomic status among men aged 30-59 (RR 1.55, 95% confidence interval (CI) 1.51 to 1.60) and 60 years and over (RR 1.22, 95% CI 1.21 to 1.24), and among women aged 30-59 (RR 2.13, 95% CI 1.98 to 2.29) and 60 years and over (RR 1.36, 95% CI 1.33 to 1.38). Socioeconomic disparities in IHD mortality were larger in the Scandinavian countries and England/Wales, of moderate size in Belgium, Switzerland, and Austria, and smaller in southern European populations among men and younger women (p < 0.0001). For elderly women the north-south gradient was smaller and there was less variation between populations. No socioeconomic disparities in IHD mortality existed among elderly men in southern Europe.

CONCLUSIONS

Socioeconomic disparities in IHD mortality were larger in northern than in southern European populations during the 1990s. This partly reflects the pattern of socioeconomic disparities in cardiovascular risk factors in Europe. Population wide strategies to reduce risk factor prevalence combined with interventions targeted at the lower socioeconomic groups can contribute to reduce IHD mortality in Europe.

Education level inequalities and transportation injury mortality in the middle aged and elderly in European settings

OBJECTIVE

To study the differential distribution of transportation injury mortality by educational level in nine European settings, among people older than 30 years, during the 1990s.

METHODS

Deaths of men and women older than 30 years from transportation injuries were studied. Rate differences and rate ratios (RR) between high and low educational level rates were obtained.

RESULTS

Among men, those of low educational level had higher death rates in all settings, a pattern that was maintained in the different settings; no inequalities were found among women. Among men, in all the settings, the RR was higher in the 30-49 age group (RR 1.46, 95% CI 1.32 to 1.61) than in the age groups 50-69 and > or = 70 years, a pattern that was maintained in the different settings. For women for all the settings together, no differences were found among educational levels in the three age groups. In the different settings, only three had a high RR in the youngest age group, Finland (RR 1.33, 95% CI 1.01 to 1.74), Belgium (RR 1.38; 95% CI 1.13 to 1.67), and Austria (RR 1.49, 95% CI 0.75 to 2.96).

CONCLUSION

This study provides new evidence on the importance of socioeconomic inequalities in transportation injury mortality across Europe. This applies to men, but not to women. Greater attention should be placed on opportunities to select intervention strategies tailored to tackle socioeconomic inequalities in transportation injuries.

Neighbourhood unemployment and all cause mortality: a comparison of six countries

STUDY OBJECTIVE

Studies have shown that living in more deprived neighbourhoods is related to higher mortality rates, independent of individual socioeconomic characteristics. One approach that contributes to understanding the processes underlying this association is to examine whether the relation is modified by the country context. In this study, the size of the association between neighbourhood unemployment rates and all cause mortality was compared across samples from six countries (United States, Netherlands, England, Finland, Italy, and Spain).

DESIGN

Data from three prospective cohort studies (ARIC (US), GLOBE (Netherlands), and Whitehall II (England)) and three population based register studies (Helsinki, Turin, Madrid) were analysed. In each study, neighbourhood unemployment rates were derived from census, register based data. Cox proportional hazard models, taking into account the possible correlation of outcomes among people of the same neighbourhood, were used to assess the associations between neighbourhood unemployment and all cause mortality, adjusted for education and occupation at the individual level.

RESULTS

In men, after adjustment for age, education, and occupation, living in the quartile of neighbourhoods with the highest compared with the lowest unemployment rates was associated with increased hazards of mortality (14%-46%), although for the Whitehall II study associations were not statistically significant. Similar patterns were found in women, but associations were not statistically significant in two of the five studies that included women.

CONCLUSIONS

Living in more deprived neighbourhoods is associated with increased all cause mortality in the US and five European countries, independent of individual socioeconomic characteristics. There is no evidence that country substantially modified this association.

Trends in socioeconomic disparities in stroke mortality in six european countries between 1981-1985 and 1991-1995

This study assesses whether stroke mortality trends have been less favorable among lower than among higher socioeconomic groups. Longitudinal data on mortality by socioeconomic status were obtained for Finland, Norway, Denmark, Sweden, England/Wales, and Turin, Italy. Data covered the entire population or a representative sample. Stroke mortality rates were calculated for the period 1981-1995. Changes in stroke mortality rate ratios were analyzed using Poisson regression and compared with rate ratios in ischemic heat disease mortality. Trends in stroke mortality were generally as favorable among lower as among higher socioeconomic groups, such that socioeconomic disparities in stroke mortality persisted and remained of a similar magnitude in the 1990s as in the 1980s. In Norway, however, occupational disparities in stroke mortality significantly widened, and a nonsignificant increase was observed in some countries. In contrast, disparities in ischemic heart disease mortality widened throughout this period in most populations. Improvements in hypertension prevalence and treatment may have contributed to similar stroke mortality declines in all socioeconomic groups in most countries. Socioeconomic disparities in stroke mortality generally persisted and may have widened in some populations, which fact underlines the need to improve preventive and secondary care for stroke among the lower socioeconomic groups.

Socioeconomic inequalities in mortality among elderly people in 11 European populations

STUDY OBJECTIVE

To describe mortality inequalities related to education and housing tenure in 11 European populations and to describe the age pattern of relative and absolute socioeconomic inequalities in mortality in the elderly European population.

DESIGN AND METHODS

Data from mortality registries linked with population census data of 11 countries and regions of Europe were acquired for the beginning of the 1990s. Indicators of socioeconomic status were educational level and housing tenure. The study determined mortality rate ratios, relative indices of inequality (RII), and mortality rate differences. The age range was 30 to 90+ years. Analyses were performed on the pooled European data, including all populations, and on the data of populations separately. Data were included from Finland, Norway, Denmark, England and Wales, Belgium, France, Austria, Switzerland, Barcelona, Madrid, and Turin.

MAIN RESULTS

In Europe (populations pooled) relative inequalities in mortality decreased with increasing age, but persisted. Absolute educational mortality differences increased until the ages 90+. In some of the populations, relative inequalities among older women were as large as those among middle aged women. The decline of relative educational inequalities was largest in Norway (men and women) and Austria (men). Relative educational inequalities did not decrease, or hardly decreased with age in England and Wales (men), Belgium, Switzerland, Austria, and Turin (women).

CONCLUSIONS

Socioeconomic inequalities in mortality among older men and women were found to persist in each country, sometimes of similar magnitude as those among the middle aged. Mortality inequalities among older populations are an important public health problem in Europe.

Effects of the characteristics of neighbourhoods and the characteristics of people on cause specific mortality: a register based follow up study of 252,000 men

STUDY OBJECTIVE

To assess the strength of the associations between neighbourhood characteristics and mortality, after adjusting for individual characteristics.

DESIGN AND SETTING

1990 census records of over 25 year old men in the Helsinki Metropolitan area linked to death records in 1991-1995; almost 1.22 million person years and 15 000 deaths. Individual characteristics were education, occupation based social class, housing tenure, housing density, and living arrangements. Proportion of manual workers, proportion of over 60 year olds, and social cohesion were measured for 55 small areas, and SAS Glimmix was used to fit multilevel models.

MAIN RESULTS

Men in areas with high proportion of manual workers and low social cohesion have high mortality, particularly among 25-64 year olds. About 70% of this excess mortality is explained by compositional differences of people living in these areas. Accidents and violence, circulatory diseases, and alcohol related causes contribute most to these area effects. Area characteristics do not consistently modify or mediate the effects of individual socioeconomic characteristics on mortality.

CONCLUSIONS

As compared with individual characteristics neighbourhood characteristics have modest independent effects on male mortality. Furthermore, individual socioeconomic characteristics are associated with mortality independently of area characteristics. Rather than the characteristics of areas, other social contexts, such as peer groups and family settings may be more fruitful targets for further research and policy on contextual effects on mortality.

Trends in regional and socio-economic mortality differentials in Finland

Trends in mortality in Finland are reviewed over the past 20 years. The author notes that "Finnish female life expectancy has increased more than five years since 1965-1969 and it is now slightly higher than the average in Western Europe. It is also almost five years higher than the average life expectancy in Eastern Europe. The male life expectancy has also risen by more than five years...." However, the author also states that regional differences in mortality have not diminished over this period, despite prevention programs designed to reduce such differences. Furthermore "socio-economic differences in mortality have increased during the same period among men, but had been relatively stable among the women."

Income differences in mortality: a register-based follow-up study of three million men and women

OBJECTIVES

We analyse whether the relationship between net household income and mortality form a continuous linear gradient or is curvilinear, assess the attenuation of this association after adjusting for confounding and reverse causality, and assess the strength of the association by age and cause of death.

DESIGN AND SETTING

Prospective study of mortality in Finland among all men and women over 30 years old. Information on household income and sociodemographic factors was from the records of the Finnish tax authorities and the 1990 census. Income data were available for more than 95% of the cohort. Follow-up was by record linkage to death certificates in 1991-1996; altogether about 261 000 deaths.

RESULTS

The all-cause mortality ratio between the lowest and the highest household income decile is 2.37 (95% CI : 2.30-2.44) among men and 1.73 (95% CI : 1.67-1.80) among women. Adjusting for household structure, spouse's economic activity, social class, education and own economic activity attenuates the relationship by 61% among men and 52% among women. The association between income and mortality is mainly linear before and after adjusting for confounding, and the association is strong for all 5-year age groups below 60-64 years, after which it declines rapidly in strength.

CONCLUSIONS

The mainly linear nature of the relationship and the strong attenuation after adjustment for other socioeconomic factors and economic activity status, and the age pattern of the relationship indicate that a large part of the relationship is unlikely to be due to direct causal effects of poverty and material hardship. Rather, income seems to be related to accumulation of factors that increase mortality over the whole range of incomes.

Change in male and female life expectancy by social class: decomposition by age and cause of death in Finland 1971-95

STUDY OBJECTIVE

To quantify the contribution of different causes of death and age groups for trends in life expectancy for two major social classes.

DESIGN AND SETTING

Prospective study of mortality in Finland among all over 35 year old men and women. Baseline social class (manual/non-manual) was from the 1970, 1975, 1980, 1985 and 1990 census records, and follow up was by computerised record linkage to death certificates for 1971-1995.

MAIN RESULTS

From the early 1970s to the early 1990s life expectancy at age 35 increased by about five and four years among Finnish men and women respectively, with largest gains among 55-74 year old men and 65-84 year old women. Life expectancy increase was 5.1 years among non-manual and 3.8 years among manual men; corresponding figures for women were 3.6 and 3.0 years. In the 1980s, when differences in life expectancy increased most rapidly, decline in cardiovascular disease mortality was more rapid in the non-manual than the manual class. Furthermore, increasing mortality for alcohol associated causes, "other diseases", and accidents and violence were most prominent in the manual class.

CONCLUSIONS

Explanations of increasing social inequalities in mortality that are based on one underlying factor are difficult to reconcile with the variability in the cause specific trends in social inequalities in mortality. The contribution of older ages to social inequalities in mortality should be more widely recognised.

Mortality differences by parental social class from childhood to adulthood

STUDY OBJECTIVE

To examine mortality differences by parental social class and cause of death from age 5 to age 34.

DESIGN

Register-based follow up study based on census records for 1985 and 1990 linked with death records for the period 1987-95.

SETTING AND SUBJECTS

The study covers all males and females in non-manual and manual classes in Finland aged 5-34 years in 1987-95 (8135 deaths). Parental social class is defined on the basis of the occupation of the head of household at the time the child was 0-14 years.

MAIN OUTCOME MEASURES

All cause mortality, mortality from diseases, mortality from accidents and violence, and alcohol related mortality during the period 1987-95.

MAIN RESULTS

At ages 5-14 there is no systematic gradient in mortality by parental social class. Both absolute and relative differences increase with age. The relative rate of male all cause mortality among manual class descendants at ages 25-29 compared with that of upper non-manual class descendants is 1.60 (95% CI 1.37, 1.86). At ages 30-34 the relative rate among males is 1.95 (95 % CI 1.58, 2.42) and among females 1.47 (95% CI 1. 03, 2.10). Among males alcohol related causes of death account for 70% of the excess mortality of sons of manual class parents compared with sons of upper non-manual class parents at ages 25-34. At ages 25-34, both among females and males, the contribution of diseases to the mortality difference increases.

CONCLUSIONS

Parental social class has an impact on mortality after childhood mainly through health related behaviours and lifestyles up to age 34.

Diminishing educational differences in breast cancer mortality among Finnish women: a register-based 25-year follow-up

OBJECTIVES

This study examined trends in breast cancer mortality by education, age, and birth cohort.

METHODS

Census records of Finnish women 35 years and older were linked with death records for 1971 through 1995.

RESULTS

Excess breast cancer mortality of more-educated women has declined rapidly, mainly because of increasing mortality among less-educated women and stable or decreasing mortality among more-educated 35- to 64-year-old women. During the 1990s, mortality among more-educated 50- to 64-year-old women declined particularly fast.

CONCLUSIONS

The causes of declining differences by education in breast cancer mortality are difficult to verify, but they may be due in part to narrowing differences in reproductive behavior among the younger birth cohorts and to a period effect possibly associated with the introduction of breast cancer screening in the late 1980s.

Socioeconomic inequalities in mortality among women and among men: an international study

OBJECTIVES

This study compared differences in total and cause-specific mortality by educational level among women with those among men in 7 countries: the United States, Finland, Norway, Italy, the Czech Republic, Hungary, and Estonia.

METHODS

National data were obtained for the period ca. 1980 to ca. 1990. Age-adjusted rate ratios comparing a broad lower-educational group with a broad upper-educational group were calculated with Poisson regression analysis.

RESULTS

Total mortality rate ratios among women ranged from 1.09 in the Czech Republic to 1.31 in the United States and Estonia. Higher mortality rates among lower-educated women were found for most causes of death, but not for neoplasms. Relative inequalities in total mortality tended to be smaller among women than among men. In the United States and Western Europe, but not in Central and Eastern Europe, this sex difference was largely due to differences between women and men in cause-of-death pattern. For specific causes of death, inequalities are usually larger among men.

CONCLUSIONS

Further study of the interaction between socioeconomic factors, sex, and mortality may provide important clues to the explanation of inequalities in health.

Bias related to the exclusion of the economically inactive in studies on social class differences in mortality

BACKGROUND

To assess how the exclusion of the economically inactive affects levels and trends in social class differences in mortality among men and women at different durations of follow-up.

METHODS

Records of the 1970, 1975, 1980 and 1985 censuses on Finnish men and women aged 35-64 linked with records of all deaths during 1971-1990.

RESULTS

Exclusion of the economically inactive population underestimates the class differences in the total population by about 25% among men and 60% among women. The bias does not disappear if the first 5 years of follow-up are excluded and the bias can lead to erroneous conclusions about the trends in social class differences in mortality.

CONCLUSIONS

Analyses based on the economically active population may lead to significant underestimation of social class differences in mortality, introduce biases in international comparison and may only partially capture the causal mechanisms underlying these mortality differences. Our results further show that although the bias diminishes during the follow-up, it is by no means eliminated after the first 5 years. The underestimation of social class differences in mortality created by the exclusion of the inactive should be more widely recognized and more accurate data on previous occupations should be collected.

Occupational class and ischemic heart disease mortality in the United States and 11 European countries

OBJECTIVES

Twelve countries were compared with respect to occupational class differences in ischemic heart disease mortality in order to identify factors that are associated with smaller or larger mortality differences.

METHODS

Data on mortality by occupational class among men aged 30 to 64 years were obtained from national longitudinal or cross-sectional studies for the 1980s. A common occupational class scheme was applied to most countries. Potential effects of the main data problems were evaluated quantitatively.

RESULTS

A north-south contrast existed within Europe. In England and Wales, Ireland, and Nordic countries, manual classes had higher mortality rates than nonmanual classes. In France, Switzerland, and Mediterranean countries, manual classes had mortality rates as low as, or lower than, those among nonmanual classes. Compared with Northern Europe, mortality differences in the United States were smaller (among men aged 30-44 years) or about as large (among men aged 45-64 years).

CONCLUSIONS

The results underline the highly variable nature of socioeconomic inequalities in ischemic heart disease mortality. These inequalities appear to be highly sensitive to social gradients in behavioral risk factors. These risk factor gradients are determined by cultural as well as socioeconomic developments.

The effects of differential unemployment rate increases of occupation groups on changes in mortality

OBJECTIVES

This study estimated the effects of changes in unemployment rates of occupation groups on changes in mortality in a period of increasing unemployment.

METHODS

Census records for all 20- to 64-year-old economically active Finnish men in 1985 were linked to information on unemployment and deaths in 1987 through 1993.

RESULTS

Change in mortality was similar in occupation groups in which unemployment rates increased at a different pace. These relationships were similar for all age groups and for mortality from diseases as well as accidents and violence.

CONCLUSIONS

Unemployment does not seem to cause mortality in the short term. Excess mortality rates among unemployed individuals observed in previous studies may have been due in part to selection.

Socio-economic inequalities in mortality. Methodological problems illustrated with three examples from Europe

BACKGROUND

Studies from most European countries have been able to demonstrate that lower socioeconomic groups have higher risks of disease, disability and premature death. Uncertain is, however, whether these studies have also been able to estimate the precise magnitude of these inequalities, their patterns and their trends over time. The purpose of this paper is to illustrate the extent to which results of descriptive studies can be biased due to problems with the data that are commonly available to European countries.

METHODS

Three illustrations are presented from a project on socio-economic inequalities in premature morbidity and mortality in Europe. These illustrations concern three problems often encountered in data on social class differences in mortality among middle aged men: the numerator/denominator bias in cross-sectional studies (illustrated for France), the exclusion of economically inactive men (illustrated for 4 countries), and the use of approximate social class schemes (illustrated for Sweden).

RESULTS

In each illustration, inequalities in mortality among middle aged men could be demonstrated, but data problems appeared to bias estimates of the precise magnitude of inequalities in mortality, their patterns by social class and cause of death, and their trends over time. The bias was substantial in most cases. Usually, it was difficult to predict in which ways and to what extent inequality estimates would have been biased.

CONCLUSIONS

When the aim of a study is to determine the precise magnitude, patterns or time trends of health inequalities, the results should be evaluated carefully against a number of potential data problems. Investments are needed, e.g. in data sources and in the measurement of socio-economic status, to secure that future studies can describe socio-economic inequalities in health in Europe in more detail and with more reliability.

Do education and income buffer the effects of death of spouse on mortality?

In this paper, we estimate the effects of the death of a spouse on the mortality of the survivor in different education and income groups. These socioeconomic resources may buffer the harmful effects of the stressful life event of the loss of one's spouse. The data come from a prospective study of mortality among all 35- to 74-year-old married Finnish persons. Follow-up was established by record linkage to death certificate registers for 1986-1991 (about 86,000 deaths, of which almost 5,500 occurred among the bereaved). The relative mortality after the death of one's spouse was broadly similar in different education and income groups. Absolute differences in mortality rates between bereaved and nonbereaved persons were larger in the lower end of the social spectrum, however. This pattern held for four broad categories of death: both sexes and two age groups (35-64 years and 65-74 years). The degree to which socioeconomic resources buffer the effects of death of spouse depends on whether it is assessed in terms of rate differences or rate ratios. Nevertheless, regardless of measurement choice, the effects of bereavement exist in all socioeconomic groups analyzed in this study. Furthermore, because of the high absolute level of mortality, the burden of excess mortality experienced after the death of one's spouse is heavier in the lower social strata.

Socioeconomic inequalities in health expectancy in Finland and Norway in the late 1980s

Studies on health inequalities have usually focused either on mortality or on morbidity. This concerns national studies as well as international comparisons of health inequalities. This paper seeks to bridge the gap by applying health expectancy as a synthetic overall measure of health. The purpose of the study is to compare socioeconomic inequalities in health expectancy in Finland and Norway in the late 1980s. Additionally, the major methodological issues in the use of health expectancy in the study of health inequalities are identified. Data on mortality by level of education derive from linked national follow-up studies (1986-1990) of population censuses. Data on the prevalence of morbidity by level of education derive from nationally representative surveys of the noninstitutionalised adult population in 1985/87. Persons aged 25-74 years were included. Four measures of morbidity were used: limiting long-standing illness, extremely limiting long-standing illness, functional disabilities and perceived less than good health. The association between mortality/morbidity and level of education in each 5-year age/sex group was determined by a regression-based method. Partial life expectancies and partial health expectancies for ages 25-74 were then calculated by using the mortality quotients and morbidity prevalences predicted by the regression model for those at the top and the bottom of the educational hierarchy in each 5-year age group, using an application of the method first presented by Sullivan. Although various measures of health expectancy were used, the result were consistent. In absolute terms the size of socioeconomic inequalities in health expectancy in Finland and Norway is on the same level. In relative terms, however, the size of inequalities in health expectancy is greater in Norway. If one considers premature mortality to be more severe than any indicator of morbidity, the mortality morbidity mix of the health inequalities is less favourable to Finland, since the size of absolute inequalities in mortality is greater in Finland. Health expectancy measures provide a promising measure for assessing and comparing the pattern and the size of health inequalities.

Mortality in a large population-based cohort of patients with drug-treated diabetes mellitus

OBJECTIVES

This paper presents detailed cause-specific data about excess mortality among diabetic persons in Finland, by age and sex.

METHODS

Five-year follow-up data on the Finnish population aged 30 through 74 years were analyzed. During these 5 years, 11,215 persons with diabetes and 102,843 persons without diabetes died. The diabetic population was defined as people who were entitled to free medication for diabetes at the beginning of the follow-up period, that is, at the end of 1980.

RESULTS

The relative mortality of persons with drug-treated diabetes compared with nondiabetic persons was higher among women (3.4) than among men (2.4). Almost three quarters of the mortality excess was due to circulatory diseases. For most other causes of death, too, diabetic persons had higher than average mortality. The exceptions were lung cancer, chronic obstructive pulmonary disease, and alcohol poisoning.

CONCLUSIONS

Diabetes is a general risk factor for untimely death and makes a significant contribution to overall national death rates, particularly for circulatory diseases. Lower than average mortality from smoking-related diseases and alcohol poisoning, however, warrant optimism about the effects of health education among diabetic persons.

Sociodemographic mortality differences among the oldest old in Finland

This study examined mortality differences and trends by several sociodemographic characteristics among the Finnish elderly aged 80 years or over during the period of 1971-90. The analyses were based on comprehensive data sets compiled by means of linking individual death records and census records for the entire population of Finland. Poisson regression was applied as the main statistical tool. For both sexes, life expectancy at age 80 was about 1 year longer among those with a higher education than among those with basic education. A similar difference was found between former upper nonmanual workers and manual workers. Slightly lower than average mortality was observed among the married, among those living in Western Finland, and among the Swedish-speaking population. Mortality declined during the study period in all subgroups, with no consistent signs of either convergence or divergence of mortality levels. The results suggest that at least some further decline of mortality even among the oldest old is possible.

Estimated numbers of deaths from coronary heart disease "caused" and "prevented" by alcohol: an example from Finland

OBJECTIVE

Epidemiological studies show that moderate alcohol consumption rather than abstention is associated with a lower risk of coronary heart disease (CHD) mortality. Our objective was to adjust established methods for calculating attributable fractions to a situation where the risk function is J-shaped and to estimate the number of CHD deaths "caused" and "prevented" by alcohol in Finland.

METHOD

Point estimates of relative risk were obtained by a meta-analysis. They were pooled by fitting a nonparametric cubic smoothing spline to the data. Alcohol consumption distribution was estimated from survey data (N = 4,818; 2,488 women). The consequences of various assumptions about changes in alcohol consumption distribution on CHD mortality were estimated. The most detailed analyses are presented for men aged 30-69. The results for the men and women aged 30-79 are summarized.

RESULTS

Among men aged 30-69, the beneficial effects of light to moderate alcohol consumption "prevent" some 400 CHD deaths each year which corresponds to 12-14% of the observed CHD deaths. Around 20 CHD deaths are "caused" by alcohol consumption exceeding the estimated optimum level. Among men aged 70-79 and women aged 30-79, the numbers of CHD deaths "prevented" by alcohol consumption were approximately 200 and 100, respectively, whereas there were only a few CHD deaths "caused" by alcohol.

CONCLUSIONS

Our best estimates suggest that approximately one-tenth of the observed number of CHD deaths among middle-aged men in Finland is "prevented" by alcohol, while the relative effect is considerably smaller among older men and all women.

Contribution of deaths related to alcohol use to socioeconomic variation in mortality: register based follow up study

OBJECTIVE

To estimate the contribution of excessive alcohol use to socioeconomic variation in mortality among men and women in Finland.

DESIGN

Register based follow up study.

SUBJECTS

The population covered by the 1985 and 1990 censuses, aged > or = 20 in the follow up period 1987-93.

MAIN OUTCOME MEASURES

Total mortality and alcohol related mortality from all causes, from diseases, and from accidents and violence according to socioeconomic position. The excess mortality among other classes compared with upper non-manual employees and differences in life expectancy between the classes were used to measure mortality differentials.

RESULTS

Alcohol related mortality constituted 11% of all mortality among men aged > or = 20 and 2% among women and was higher among manual workers than among other classes. It accounted for 14% of the excess all cause mortality among manual workers over upper non-manual employees among men and 4% among women and for 24% and 9% of the differences in life expectancy, respectively. Half of the excess mortality from accidents and violence among male manual workers and 38% among female manual workers was accounted for by alcohol related deaths, whereas in diseases the role of alcohol was modest. The contribution of alcohol related deaths to relative mortality differentials weakened with age.

CONCLUSIONS

Class differentials in alcohol related mortality are an important factor in the socioeconomic mortality differentials in Finland, especially among men, among younger age groups, and in mortality from accidents and violence.

Health expectancy by level of education in Finland

Using the method first presented by Sullivan, the article presents results on health expectancy by level of education and gender in the late 1980s in Finland. The life tables by level of education cover the years 1986-90. Indicators of disability and poor health were based on three variables from the nationwide 1986 Survey on Living Conditions (N = 12,057): limiting long-standing illness, functional disability or poor self-perceived health. Two cutting points indicating different levels of severity of disability or poor health were used for each measure, giving six dichotomous indicators. Disability-free life expectancy and life expectancy with disability were found to depend strongly on the indicator of disability, but the patterns of differences both between genders and between educational categories were largely independent of the indicators used. Life expectancy as well as disability-free life expectancy showed a systematic relationship with level of education: the higher the level of education, the higher the life expectancy and disability-free life expectancy. The differences between educational categories in disability-free life expectancy were markedly larger than in total life expectancy. Life expectancy with disability was shortest among the more educated and longest among the less educated. Due to the higher life expectancy and the higher prevalence of disability among women, life expectancy with disability was longer among women than men according to all indicators.

Socioeconomic differences in mortality among diabetic people in Finland: five year follow up

OBJECTIVE

To compare socioeconomic differences in mortality (by cause of death) among diabetic people with those in the rest of the population.

DESIGN

Five year follow up of mortality in the population of Finland, comparing people with diabetes and those without diabetes.

SETTING

Finland.

SUBJECTS

All residents of Finland aged 30 to 74 included in the 1980 census. Subjects were classified as diabetic (230,000 person years) or other (12,400,000 person years) according to whether they were exempted from charges for medication for diabetes. During 1981-5 there were 114,058 deaths, of which 11,215 were in people with diabetes.

MAIN OUTCOME MEASURES

Age standardised mortality by sex, social class, and cause of death for the diabetic and non-diabetic populations.

RESULTS

No significant social class differences in mortality were found among women with diabetes. Among diabetic men there was a slight increasing trend in mortality from the upper while collar group to the unskilled blue collar workers but it was much less steep than that of non-diabetic men.

CONCLUSIONS

Among people with diabetes in Finland the quality of treatment and compliance with treatment probably do not vary by socioeconomic status. Health education for diabetic people seems to be effective in all socioeconomic strata; in people from the lower strata this leads to greater changes because their health behavior was originally less good.

Excess mortality of unemployed men and women during a period of rapidly increasing unemployment

BACKGROUND

Previous studies have found evidence of higher mortality rates among unemployed people than among those in employment, but the effect of changes in national unemployment rates on this association is unclear. We studied mortality in both men and women during a period of rapidly increasing unemployment in Finland.

METHODS

In this prospective study of mortality in the Finnish population aged 25-59 years (2.5 million people), baseline sociodemographic data were obtained from the 1990 census and information on employment status in 1987-92 from Statistics Finland's labour force data files. Mortality follow-up was established by record linkage to death certificates from 1991 to 1993.

FINDINGS

Individuals who experienced unemployment between 1987 and 1992 had greater mortality than those in employment after control for age, education, occupational class, and marital status. The mortality ratios for men and women unemployed for the first time in 1990, at a time of low national unemployment were 2.11 (95% CI 1.76-2.53) and 1.61 (1.09-2.36), respectively. These values were lower for those who were unemployed for the first time in 1992 when the national unemployment rate was very high (men 1.35 [1.16-1.56], women 1.30 [0.97-1.75]). The jobless who were re-employed had higher mortality than those who were continuously employed, but not as high as those who remained unemployed.

INTERPRETATION

We have found that the association between unemployment and mortality weakens as the general unemployment rate increases. Studies that took place when the unemployment rate was low may thus overestimate the effect of unemployment on mortality because of unaccounted confounding.

Mortality after the death of a spouse: rates and causes of death in a large Finnish cohort

OBJECTIVES

This study examines excess mortality among Finnish persons after the death of a spouse, by sex, the subject's cause of death, duration of bereavement, and age.

METHODS

The subjects were 1580000 married Finnish persons aged 35 through 84 years who were followed up from 1986 through 1991.

RESULTS

Excess mortality among the bereaved was high from accidental, violent, and alcohol-related causes (50% to 150%), moderate for chronic ischemic heart disease and lung cancer (20% to 35%), and small for other causes (5% to 15%). Excess mortality was greater at short ( < 6 months) rather than long durations of bereavement and among younger rather than older bereaved persons for most causes of death; it was also greater among men that women.

CONCLUSIONS

The results are consistent with the hypothesis that excess mortality after the death of a spouse is partly caused by stress. The loss of social support or the inability to cope with stress may explain why men suffer from bereavement more than do women.

Mortality after death of spouse in relation to duration of bereavement in Finland

STUDY OBJECTIVES

(1) To assess the extent to which death of a spouse causes excess mortality by controlling for the effects of confounding and other sources of bias. Three possible sources of bias are considered: accidents common to spouses, common socioeconomic environment, and common lifestyles. (2) To assess the duration specific effects of death of a spouse on mortality.

DESIGN AND SETTING

Prospective study of mortality in Finland among all 35-84 year old married Finnish men and women (1,580,000 people). Baseline sociodemographic measurement from the 1985 census records. Follow up by computerised record linkage to death certificate registers for the period 1986-91 (about 116,000 deaths, of which almost 10,000 among the bereaved) using personal identification codes.

RESULTS

(1) After controlling for confounding effects, excess mortality was 17% in men and 6% in women. (2) Excess mortality was higher for short durations than long durations of bereavement. (3) Excess mortality after bereavement was higher in men than women.

CONCLUSIONS

Controlling for confounding does not seem to have a crucial modifying effect on the relationship between spousal bereavement and mortality. It seems that death of a spouse has a causal effect on mortality. However, although spousal bereavement is a major stressful life event, this causal effect seems to be relatively small and short lived.

Coronary risk factor levels: differences between educational groups in 1972-87 in eastern Finland

STUDY OBJECTIVE

To compare differences in coronary heart disease (CHD) risk factor levels between educational groups in the 1970s and 1980s in eastern Finland.

DESIGN AND PARTICIPANTS

Independent, cross sectional population surveys were undertaken in 1972, 1977, 1982, and 1987 of randomly selected men and women aged 30-59 living in two provinces in eastern Finland. Altogether 20,096 subjects participated. The lowest observed level of participation in either sex or province in any year was 77%. Serum cholesterol values and blood pressure measurements, body mass index, smoking, and the level of education were determined in each survey using comparable methodology.

MAIN RESULTS

More poorly educated men and women had higher levels of all risk factors at the end of the study period (1987). There was no change between 1972 and 1987 in differences between educational groups in mean serum cholesterol values and the diastolic blood pressure level in either sex, and in smoking in men. In women, the proportion of smokers was highest in the better educated in the 1970s but lowest in this group in the 1980s (interaction between year of examination and educational level p < 0.01). Differences between educational groups in mean body mass index increased with time in both men (p < 0.001) and women (p = 0.06).

CONCLUSIONS

Relative differences between socioeconomic groups in CHD mortality have increased in Finland in the 1970s and 1980s. Present results from eastern Finland show no reduction in differences between educational groups in risk factor levels, and even some evidence of increasing differences. Although a comparison between mortality trends and risk factor trends is problematic, trends in the risk factors analysed do not seem to be a major cause for the increasing differences in CHD mortality in Finland, at least in men. On the other hand, the risk factor trends analysed show no progress towards reducing inequalities in health, a major goal of public health policy.

Problems in the measurement and international comparisons of socio-economic differences in mortality

The opportunities for research of socio-economic differences in mortality are best in countries where a system of personal identification numbers makes the computerised linkage of census and death records possible. The first part of this study is an example of the use of such linked records. It presents results on the development of mortality differences by level of education and occupational class in Finland in the period 1971-1985. Socio-economic mortality differences among middle-aged and elderly men increased in Finland during the study period. The increase was mainly due to the rapid decline of mortality from cardiovascular diseases among upper white-collar employees and men with more than secondary education. Relative socio-economic mortality differences were smaller among women than among men and remained unchanged in 1971-1985. The second part of the article discusses the problems in international comparisons of socio-economic mortality differences and summaries results from two comparative studies. The results are inconsistent: differences by level of education among men were found to be similar in six countries included in the comparison, whereas marked variation was found in the ratios of the mortality of manual workers to the mortality of non-manual workers.

Health and social inequities in Finland and elsewhere

This review summarizes results of a number of studies on health and social inequities in Finland in comparison with other countries. Comparisons over time have been made when possible. Inequities in mortality in Finland can be compared with data from Denmark, Norway and Sweden as well as England and Wales plus Hungary. All countries show a similar relationship between mortality and level of education. No major changes in this relationship can be observed during the 1970s. Data on morbidity and perceived health complete the picture obtained on the basis of mortality data. Inequities concern various dimensions of health. Taken as a whole, the data suggest that the pattern of health inequities is more accentuated in Finland than in other Nordic countries.

Male mortality from ischaemic heart disease in Finland: Relation to region of birth and region of residence

"The purpose of the study is to shed light on the causes of the large difference in mortality from ischaemic heart disease (IHD) between East and West Finland. The study is based on the death certificate records on deaths from IHD in 1971-1975 among Finnish men aged 35-64. These records were linked with the records on persons in the 1970 census. Mortality from IHD is analyzed simultaneously by region of birth and region of residence, controlling for several socio-economic and demographic variables, by means of log-linear models. The analysis shows that being born in East Finland and living there both increase the risk of IHD, but that being born in East Finland is a more important risk factor than is living there." (SUMMARY IN FRE)

Mortality of doctors: do doctors benefit from their medical knowledge?

Official population and mortality statistics show that overall mortality of male doctors in Finland in 1971-80 was lower than that of all economically active men. Doctors had lower death rates from cardiovascular disease, tumours, other diseases, causes of death amenable to medical interventions, and accidents and violence, but not suicide. Except for tumours, mortality of male doctors was at the same level or higher than that of men in other professions. Risk of suicide was twice as high for male doctors as for other professions. The numbers of women doctors were too small for firm conclusions about their mortality to be drawn. It is concluded either that doctors do not use their professional knowledge and skills in a way that reduces their own mortality risk or that they are exposed to occupational hazards that cancel out such an effect. Possible hazards are more likely to be mental than physical or chemical.

Trends in coronary heart disease mortality and morbidity and related factors in Finland

A marked increase in the coronary heart disease (CHD) mortality of working-age men and women occurred in Finland from the 1950s until the 1960s. Around the year 1970, CHD mortality started to decline and this decline still continues. In the age group 35-64 years the average annual decline of CHD mortality in the 1970s was 1.8% for men and 3.4% for women. Limited data available on trends in CHD morbidity show that the decline in CHD mortality is accompanied by a decline in the incidence of non-fatal myocardial infarction. CHD mortality and incidence are higher in east Finland than in west Finland and this east-west difference has so far persisted during the declining trend. The decline in CHD mortality and incidence in the 1970s has been preceded and paralleled by changes into favourable direction in dietary fat consumption and population mean levels for serum cholesterol, prevalence of smoking among adult Finnish men, control of hypertension by antihypertensive drug therapy, and management of patients with symptomatic CHD. Both the changes in life-styles and CHD risk factor levels, as well as changes in the management of patients with CHD, appear to have been contributing to the decline in CHD mortality and incidence in Finland.