Widening socioeconomic inequalities in mortality in six Western European countries

Objectives: During the past decades a widening of the relative gap in death rates between upper and lower socioeconomic groups has been reported for several European countries. Although differential mortality decline for cardiovascular diseases has been suggested as an important contributory factor, it is not known what its quantitative contribution was, and to what extent other causes of death have contributed to the widening gap in total mortality. Methods: We collected data on mortality by educational level and occupational class among men and women from national longitudinal studies in Finland, Sweden, Norway, Denmark, England/Wales, and Italy (Turin), and analysed age-standardized death rates in two recent time periods (1981–1985 and 1991–1995), both total mortality and by cause of death. For simplicity, we report on inequalities in mortality between two broad socioeconomic groups (high and low educational level, non-manual and manual occupations). Results: Relative inequalities in total mortality have increased in all six countries, but absolute differences in total mortality were fairly stable, with the exception of Finland where an increase occurred. In most countries, mortality from cardiovascular diseases declined proportionally faster in the upper socioeconomic groups. The exception is Italy (Turin) where the reverse occurred. In all countries with the exception of Italy (Turin), changes in cardiovascular disease mortality contributed about half of the widening relative gap for total mortality. Other causes also made important contributions to the widening gap in total mortality. For these causes, widening inequalities were sometimes due to increasing mortality rates in the lower socioeconomic groups. We found rising rates of mortality from lung cancer, breast cancer, respiratory disease, gastrointestinal disease, and injuries among men and/or women in lower socioeconomic groups in several countries. Conclusions: Reducing socioeconomic inequalities in mortality in Western Europe critically depends upon speeding up mortality declines from cardiovascular diseases in lower socioeconomic groups, and countering mortality increases from several other causes of death in lower socioeconomic groups

Own education, current conditions, parental material circumstances, and risk of myocardial infarction in a former communist country

OBJECTIVE—To study the association between own education, adult and parental circumstances and the risk of myocardial infarction in a former communist country.
DESIGN—Population based case-control study.
SETTING—General population of five districts of the Czech Republic in the age group 25-64 years.
PARTICIPANTS—Random sample of population (938 men and 1048 women, response rate 77%) served as controls to 282 male and 80 female cases of non-fatal first myocardial infarctions.
MAIN OUTCOME MEASURES—Myocardial infarction was defined by the WHO MONICA criteria based on ECG, enzymes and symptoms. The following socioeconomic indicators were studied: own education, crowded housing conditions (more than one person per room), car ownership, and education and occupation of mother and father.
RESULTS—There was a weak correlation between education and car ownership, and a strong association between own education and parental education and occupation. Crowding was not related to other socioeconomic factors. The risk of myocardial infarction was inversely related to education, and was unrelated to material conditions and parental education and occupation. The age-sex-district adjusted odds ratios for apprenticeship, secondary, and university education, compared with primary education, were 0.87, 0.74 and 0.46, respectively (p for trend 0.009); odds ratios for car ownership and crowding were 1.01 (95% confidence intervals 0.77, 1.34) and 0.92 (0.76,( )1.12), respectively. Further adjustment for parental circumstances and adult height did not change these estimates but adjustment for coronary risk factors reduced the gradient. Increased height seemed, anomalously, to confer a small increased risk.
CONCLUSIONS—In this population, the social gradient in non-fatal myocardial infarction is only apparent for own education. Materialist explanations for this gradient seem unlikely but behaviours seem responsible for a part of the gradient.


Keywords: myocardial infarction; ischaemic heart disease; socioeconomic factors; epidemiology; Eastern Europ