Elsevier

The Lancet

Volume 365, Issue 9458, 5–11 February 2005, Pages 493-500
The Lancet

Articles
Educational inequalities in cause-specific mortality in middle-aged and older men and women in eight western European populations

https://doi.org/10.1016/S0140-6736(05)17867-2Get rights and content

Summary

Background

Studies of socioeconomic disparities in patterns of cause of death have been limited to single countries, middle-aged people, men, or broad cause of death groups. We assessed contribution of specific causes of death to disparities in mortality between groups with different levels of education, in men and women, middle-aged and old, in eight western European populations.

Methods

We analysed data from longitudinal mortality studies by cause of death, between Jan 1, 1990, and Dec 31, 1997. Data were included for more than 1 million deaths in 51 million person years of observation.

Findings

Absolute educational inequalities in total mortality peaked at 2127 deaths per 100 000 person years in men, and at 1588 deaths per 100 000 person years in women aged 75 years and older. In this age-group, rate ratios were greater than 1·00 for total mortality and all specific causes of death, apart form prostate cancer in men and lung cancer in women, showing increased mortality in low versus high eductational groups. In men, cardiovascular diseases accounted for 39% of the difference between low and high eductational groups in total mortality, cancer for 24%, other diseases for 32%, and external causes for 5%. Among women, contributions were 60%, 11%, 30%, and 0%, respectively. The contributions of cerebrovascular disease, other cardiovascular diseases, pneumonia, and COPD strongly increased by age, whereas those of cancer and external causes declined. Although relative inequalities in total mortality were closely similar in all populations, we noted striking differences in the contribution of specific causes to these inequalities.

Interpretation

Research needs to be broadened to include older populations, other diseases, and populations from different parts of Europe. Effective interventions should be developed and implemented to reduce exposure to cardiovascular risk factors in low-educational groups.

Introduction

Variations in patterns of cause of death between socioeconomic groups provide valuable clues for the explanation of disparities in health because they point to the specific mechanisms linking low socioeconomic position to ill health. Most studies of socioeconomic variations in patterns of cause of death have been done in only one country,1, 2, 3 and international comparisons have been done before the 1990s4, 5 or in single groups of specific causes of death, such as cardiovascular mortality.6, 7 Some of these international comparative studies yielded important results. Kunst and colleagues4 showed that during the 1980s the contribution of broad groups of causes of death to inequalities in overall mortality by occupation in middle-aged men varied strongly between northern European and southern European countries.4

Here, we use the most recent data for mortality by cause of death for a broad range of male and female populations from various regions in western Europe. We distinguish detailed causes of death and, because the burden of mortality is highest in older people (⩾65 years), we include data for older populations. Our aim was to broaden the scope of the evidence base for European public-health policies,9, 10 by assessing the contribution of specific causes of death to differences in mortality by socioeconomic level.

Section snippets

Data retrieval

Data from longitudinal mortality studies that were based on linkage of vital registries to population censuses were acquired for European populations in Finland, Norway, England and Wales, Belgium, Switzerland, Austria, Turin, Barcelona, and Madrid. All data consisted of total national, regional (Madrid), and urban (Turin and Barcelona) populations, except for England and Wales where the data cover a representative sample of 1% of the English and Welsh populations and for Switzerland where the

Results

Table 1 shows the results of the pooled analyses for men. After weighting to equalise sample sizes between populations, this dataset consisted of 304 410 deaths in 11 030 032 person years at risk (see also webtable 3 at http://image.thelancet.com/extras/03art12304webtable3.pdf). These results can be interpreted as roughly representing the situation in western Europe as a whole, perhaps with the exception of rural Mediterranean areas. Rate ratios were greater than 1·00 for total mortality and

Discussion

We have shown that differences in mortality by educational level persisted into old age in both men and women in western Europe. Cardiovascular diseases contributed the most to these differences in mortality. In men, the top five specific contributory causes were ischaemic heart disease, lung cancer, COPD, other cardiovascular diseases, and cerebrovascular disease. In women they were ischaemic heart disease, other cardiovascular diseases, cerebrovascular disease, pneumonia, and COPD. Relative

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