Income and Mortality - The Dynamics of Disparity : A Study on the Changing Association Between Income and Mortality in Finland

Disparity in longevity by income level has been reported in numerous studies. However, few studies have focused on the possible changes over time in the association between income and mortality. The main aim in this thesis was to describe mortality trends in Finland by income quintiles, and to investigate the age- and cause-of-death structure of any changes among these groups in 1988-2012. A further aim was to investigate the income-mortality association independently of the individual socio-demographic factors that are present in childhood and adulthood, and how this association has changed over time in all-cause and cause-specific mortality. The data originated from administrative registers containing individual-level annual information on socio-demographic characteristics linked to cause-specific mortality records in 1971-2012, and also included data linking these registers to 1950 census. Disparities in mortality among those aged over 35 were analysed by calculating life expectancies and their decomposition, and fitting survival regression models to the data. Life expectancy among the highest four income quintiles increased substantially in 1988-2007, but stagnation among men and minor increase among women caused the disparity with other quintiles to increase markedly in the lowest quintile. Mortality relative to the highest quintile among 35-64-year-olds increased between 1988-91 and 2004-07 in all other quintiles even following adjustment for individual socio-demographic characteristics including education, occupation, economic activity, and living alone. Changes in the socio-demographic composition of the income quintiles did not explain the increasing or stagnating mortality level in the lowest quintile among men and women. The disparity in mortality by income in 1971-2007 also persisted following adjustment for observed and unobserved factors of childhood family background shared by siblings. The disparity in mortality remained even when adult socio-demographic factors were controlled for. This observation was consistent over cause-of-death groups. Alcohol-related causes of death were the main drivers of the adverse mortality trend in the lowest quintile because of substantial rise in mortality to these causes among those with low income. Disparities in cancer mortality and ischaemic heart diseases among men also widened the gap in life expectancy. Socio-demographic characteristics explained 50-60 per cent of the excess alcohol-related mortality in the lowest quintile among men. Among women the proportion explained by these factors declined over the study period, from roughly 70 to 30 per cent. The change in the cause-of-death composition of the disparity in mortality towards alcohol-related causes emphasizes addressing mental and behavioural problems such as alcohol abuse in tackling increasing disparity in mortality.Tuloryhmien välisiä eroja elinajassa on havaittu useissa tutkimuksissa Suomessa ja muualla, mutta tulojen ja kuolleisuuden välisen yhteyden muutoksista ajassa tiedetään kansainvälisestikin varsin vähän. Tämä tutkimus kartoittaa eri tuloviidennesten kuolleisuuden kehitystä Suomessa vuosina 1988-2012 sekä sitä, minkälaisista ikä- ja kuolemansyyryhmistä muutokset kumpuavat. Lisäksi tutkimus tarkastelee tulojen ja kuolleisuuden yhteyttä ottaen huomioon yksilön sosiodemografisia tekijöitä lapsuudessa ja aikuisuudessa. Samoin tutkittiin, missä määrin nämä tekijät selittävät tulojen yhteyttä eri kuolinsyihin ja onko niiden rooli kuolleisuuserojen selittäjinä muuttunut ajassa. Tilastokeskuksen yhdistämistä rekistereistä tuotettu aineisto sisälsi tietoa yksilöiden sosiodemografisista ominaisuuksista ja kuolemansyistä vuosina 1971 2012. Aineistoon on yhdistetty myös tietoja vuoden 1950 väestönlaskennasta. Kuolleisuuden kehitystä ja erojen muutoksia yli 35-vuotiailla analysoitiin laskemalla elinajanodotteita tuloviidenneksittäin, dekomponoimalla näiden muutoksia sekä sovittamalla aineistoon regressiomalleja. Neljän ylimmän tuloviidenneksen elinajanodote kasvoi selvästi 1988 2007, mutta alimman viidenneksen kasvun pysähtyminen miehillä ja vaatimaton kasvu naisilla johtivat erojen selvään lisääntymiseen. Suhteellinen ero korkeimpaan viidennekseen kasvoi muissa tuloryhmissä 35 64-vuotiailla jaksojen 1988 91 ja 2004 07 välillä, vaikka tuloryhmien koostumus koulutuksen, ammattiaseman, pääasiallisen toiminnan ja yksin asumisen suhteen huomioitiin. Näiden sosiodemografisten tekijöiden huomiointi ei selittänyt alimman viidenneksen pysähtynyttä kuolleisuuskehitystä miehillä eikä kuolleisuuden kasvua naisilla. Tulojen ja kuolleisuuden välillä havaittiin yhteys myös vuosina 1971 2007, vaikka havaitut ja havaitsemattomat sisarusten jakamat lapsuuden perheen ominaisuudet huomioitiin. Yhteys säilyi, vaikka malliin lisättiin aikuisuudessa havaitut yksilön ominaisuudet ja yhteyttä tarkasteltiin eri kuolemansyyryhmissä. Lisääntynyt kuolleisuus alkoholiperäisiin syihin oli vaatimattoman kuolleisuuskehityksen taustalla alimmassa tuloviidenneksessä molemmilla sukupuolilla. Myös erot kuolleisuudessa syöpiin ja sepelvaltimotautiin lisäsivät eroa elinajanodotteessa tuloryhmien välillä miehillä. Miehillä sosiodemografiset tekijät selittivät noin 50 60 prosenttia suhteellisesta kuolleisuuserosta alkoholisyihin ylimmän ja alimman tuloryhmän välillä 1988 2012. Naisilla näiden tekijöiden selittämä osuus suhteellisesta erosta laski 70:stä 30 prosenttiin. Alkoholin kasvava rooli tuloryhmittäisten kuolleisuuserojen kasvussa alleviivaa tarvetta puuttua terveyskäyttäytymiseen ja mielenterveyteen liittyviin ongelmiin terveyserojen kaventamiseksi

Asuinalueen tulotason vaikutus asukkaiden sosiaalisiin verkostoihin pääkaupunkiseudulla

Only abstract. Paper copies of master’s theses are listed in the Helka database (http://www.helsinki.fi/helka). Electronic copies of master’s theses are either available as open access or only on thesis terminals in the Helsinki University Library.Vain tiivistelmä. Sidottujen gradujen saatavuuden voit tarkistaa Helka-tietokannasta (http://www.helsinki.fi/helka). Digitaaliset gradut voivat olla luettavissa avoimesti verkossa tai rajoitetusti kirjaston opinnäytekioskeilla.Endast sammandrag. Inbundna avhandlingar kan sökas i Helka-databasen (http://www.helsinki.fi/helka). Elektroniska kopior av avhandlingar finns antingen öppet på nätet eller endast tillgängliga i bibliotekets avhandlingsterminaler.Pääkaupunkiseudulla on havaittu viitteitä lievästä huono-osaisuuden keskittymisestä pienille alueille. Työttömyyden ja sosiaalisten ongelmien väheneminen laman jälkeen ei ole ollut yhtä nopeaa kaikilla seudun asuinalueilla. Yhdeksi selitysmalliksi tällaiseen kehitykseen on mainittu mahdolliset erityisyydet huono-osaisten alueiden asukkaiden verkostoitumisen tavassa. Tutkielmassa pyritään kvantitatiivisin menetelmin selvittämään sitä, onko asuinalueen keskimääräisellä tulotasolla vaikutusta asukkaiden verkostojen laajuuteen ja paikallisuuteen. Erityisenä kiinnostuksen kohteena on asukkaiden ns. heikkojen sosiaalisten suhteiden eli tuttavuussuhteiden määrä. Nämä nähdään teoreettisessa keskustelussa tärkeinä juuri työmarkkinoilla menestymisen kannalta. Tutkielman teoreettinen pohja rakentuu myös aluevaikutuksista käytävälle keskustelulle ja erityisesti sille, mitkä ilmiöt ja minkälaisten väestöryhmien läsnäolo alueella saattaa vaikuttaa asukkaiden verkostoitumiseen. Sekä yksilö- että aluetasolla aineistona käytetään Helsingin kaupungin tietokeskuksen ja STAKESin keväällä 2002 keräämää nk. Syreeni-kyselyaineistoa. Aineiston otanta on ositettu siten, että pääkaupunkiseutu on kartalla jaettu 250m kertaa 250m karttaruutuihin ja ruuduille on laskettu asukkaiden keskitulo. Yksi otos on otettu keskituloiltaan ylimpään kvintiiliin kuuluvista ruuduista, toinen alimpaan kvintiiliin kuuluvista ja kolmas kaikista ruuduista satunnaisesti. Yli 18-vuotiaita vastaajia kaikissa kolmessa otoksessa on yhteensä 10 555. Tutkielma perustuu näiden otosten vertailuun elaboraatioasetelmassa. Otostavalla pyritään tavoittamaan pääkaupunkiseudun alueellisesti hajautunut huono-osaisuus. Monitasoista regressioanalyysiä käyttämällä vakioidaan vastaajien yksilöllisten ominaisuuksien vaikutus heidän verkostoilleen ja näin selvitetään alueen tulotason vaikutuksen osuus verkostoihin. Lähialueen tulotasolla näyttää pääkaupunkiseudulla olevan merkitsevä yhteys asukkaiden sosiaaliseen verkostoitumiseen. Suurituloisilla alueilla asukkaiden verkostot ovat hieman laajempia ja heillä on enemmän heikkoja sosiaalisia suhteita muihin alueisiin verrattuna vaikka yksilötason tekijät on vakioitu. Kaikki sosioekonomiset ryhmät hyötyvät sosiaalisten suhteiden muodossa asumisesta suurituloisilla alueilla ja toisaalta kaikki ryhmät kärsivät hieman asumisesta pienituloisella alueella. Yleisesti ottaen korkea sosioekonominen asema, lapsiperhetyyppi ja nuoruus vaikuttavat positiivisesti verkoston kokoon. Ikä vaikuttaa kaikilla alueilla negatiivisesti verkoston kokoon, mutta pienituloisilla alueilla iän myötä tapahtuva suhteiden väheneminen on jyrkempää verrattuna suurituloisiin alueisiin. Pieni- ja suurituloisilla alueilla asuvien verkostot ovat aavistuksen paikallisempia kuin pääkaupunkiseudulla keskimäärin. Erot ovat tosin varsin pieniä. Yksin asuminen ja matala sosioekonominen asema vaikuttavat verkostoon paikallisuutta lisäävästi. Iän karttuessa pienituloisilla alueilla verkoston paikallisuus kasvaa, mutta suurituloisilla alueilla ikä ei vaikuta samoin tavoin paikallisuuteen. Asuinalueen verkostoitumiseen vaikuttavaa piirrettä ei kuitenkaan tutkimuksen perusteella voida määrittää tarkasti, sillä alueen tulotaso, pientalovaltaisuus, asukasrakenne ja sosiaalisen disorganisaation vähäisyys ovat aineistossa vahvasti sidoksissa toisiinsa

Heavy metal toxicity and mortality—association between density of heavy metal bands and cause specific hospital admissions and mortality : population based cohort study

Peer reviewe

Changes in regional variation in mortality over five decades – The contribution of age and socioeconomic population composition

Existing evidence suggests that within-country area variation in mortality has increased in several high-income countries. Little is known about the role of changes in the population composition of areas in these trends. In this study, we look at mortality variation across Finnish municipalities over five decades. We examine trends by sex, age categories and two broad cause of death groups and assess the role of individual-level compositional factors. Analyses rely on individual-level register data on the total Finnish population aged 30 years and over. We estimated two-level Weibull survival-models with individuals nested in areas for 10 periods between 1972 and 2018 to assess municipal-level variation in mortality. Median hazard ratio (MHR) was used as our summary measure and analyses were adjusted for age and socioeconomic characteristics. The results show a clear overall growth in area variation in mortality with MHR increasing from 1.14 (95% CI 1.12–1.15) to 1.28 (CI 1.26–1.30) among men and 1.17 (CI 1.15–1.18) to 1.30 (CI 1.27–1.32) among women. This growth, however, was fully attenuated by adjustment for age. Area differentials were largest and increased most among men at ages 30–49, and particularly for external causes. This increase was largely due to increasing differentiation in the socioeconomic composition of municipalities. In conclusion, our study shows increases in mortality differentials across municipalities that are mostly attributable to increasing differentiation between municipalities in terms of individual compositional factors.Peer reviewe

The impact of income definitions on mortality inequalities

Income is a strong predictor of adult mortality. Measuring income is not as simple as it may sound. It can be conceptualized at the individual or the household level, with the former better reflecting an individual's earning ability, and the latter better capturing living standards. Furthermore, respondents are often grouped into income categories based on their positions in the income distribution, and this operationalization can be done on the basis of age-specific or total population income distributions. In this study, we look at how four combinations of different conceptualizations (individual vs. household) and operationalizations (age-specific vs. total population) of income can affect mortality inequality estimates. Using Finnish registry data, we constructed period life tables for ages 25+ from 1996 to 2017 by gender and for four income definitions. The results indicated that the slope index of inequality for life expectancy varied by 1.1-5.7 years between income definitions, with larger differences observed for women than for men. The overall age patterns of relative index of inequality for mortality rates yielded by the four definitions were similar, but the levels differed. The period trends across income definitions were consistent for men, but not for women. We conclude that researchers should pay particular attention to the choice of the income definitions when analyzing the association between income and mortality, and when comparing the magnitude of inequality across studies and over time.Peer reviewe

Dimensions of Social Stratification and Their Relation to Mortality : A Comparison Across Gender and Life Course Periods in Finland

Differences in mortality between groups with different socioeconomic positions (SEP) are well-established, but the relative contribution of different SEP measures is unclear. This study compares the correlation between three SEP dimensions and mortality, and investigates differences between gender and age groups (35-59 vs. 60-84). We use an 11% random sample with an 80% oversample of deaths from the Finnish population with information on education, occupational class, individual income, and mortality (n=496,658; 274,316 deaths between 1995 and 2007). We estimate bivariate and multivariate Cox proportional hazard models and population attributable fractions. The total effects of education are substantially mediated by occupation and income, and the effects of occupation is mediated by income. All dimensions have their own net effect on mortality, but income shows the steepest mortality gradient (HR 1.78, lowest vs. highest quintile). Income is more important for men and occupational class more important among elderly women. Mortality inequalities are generally smaller in older ages, but the relative importance of income increases. In health inequality studies, the use of only one SEP indicator functions well as a broad marker of SEP. However, only analyses of multiple dimensions allow insights into social mechanisms and how they differ between population subgroups.Peer reviewe

Excess winter mortality in Finland, 1971–2019: a register-based study on long-term trends and effect modification by sociodemographic characteristics and pre-existing health conditions

OBJECTIVES: Excess winter mortality is a well-established phenomenon across the developed world. However, whether individual-level factors increase vulnerability to the effects of winter remains inadequately examined. Our aim was to assess long-term trends in excess winter mortality in Finland and estimate the modifying effect of sociodemographic and health characteristics on the risk of winter death. DESIGN: Nationwide register study. SETTING: Finland. PARTICIPANTS: Population aged 60 years and over, resident in Finland, 1971-2019. OUTCOME MEASURES: Age-adjusted winter and non-winter death rates, and winter-to-non-winter rate ratios and relative risks (multiplicative interaction effects between winter and modifying characteristics). RESULTS: We found a decreasing trend in the relative winter excess mortality over five decades and a drop in the series around 2000. During 2000-2019, winter mortality rates for men and women were 11% and 14% higher than expected based on non-winter rates. The relative risk of winter death increased with age but did not vary by income. Compared with those living with at least one other person, individuals in institutions had a higher relative risk (1.07, 95% CI 1.05 to 1.08). Most pre-existing health conditions did not predict winter death, but persons with dementia emerged at greater relative risk (1.06, 95% CI 1.04 to 1.07). CONCLUSIONS: Although winter mortality seems to affect frail people more strongly-those of advanced age, living in institutions and with dementia-there is an increased risk even beyond the more vulnerable groups. Protection of high-risk groups should be complemented with population-level preventive measures

Association between a history of clinical depression and dementia, and the role of sociodemographic factors: population-based cohort study

Background Depression is associated with an increased dementia risk, but the nature of the association in the long-term remains unresolved, and the role of sociodemographic factors mainly unexplored. Aims To assess whether a history of clinical depression is associated with dementia in later life, controlling for observed sociodemographic factors and unobserved factors shared by siblings, and to test whether gender, educational level and marital status modify the association. Method We conducted a national cohort study of 1 616 321 individuals aged 65 years or older between 2001 and 2018 using administrative healthcare data. A history of depression was ascertained from the national hospital register in the period 15-30 years prior to dementia follow-up. We used conventional and sibling fixed-effects Cox regression models to analyse the association between a history of depression, sociodemographic factors and dementia. Results A history of depression was related to an adjusted hazard ratio of 1.27 (95% CI 1.23-1.31) for dementia in the conventional Cox model and of 1.55 (95% CI 1.09-2.20) in the sibling fixed-effects model. Depression was related to an elevated dementia risk similarly across all levels of education (test for interaction, P = 0.84), but the association was weaker for the widowed than for the married (P = 0.003), and stronger for men than women (P = 0.006). The excess risk among men attenuated following covariate adjustment (P = 0.10). Discussion This study shows that a history of depression is consistently associated with later-life dementia risk. The results support the hypothesis that depression is an aetiological risk factor for dementia.Peer reviewe

Associations Between Cohabitation, Marriage, and Suspected Crime : a Longitudinal Within-Individual Study

The effects of marriage on criminal behavior have been studied extensively. As marriages today are typically preceded by cohabiting relationships, there is a growing need to clarify how different relationship types are associated with criminality, and how these effects may be modified by relationship duration, partner's criminality, and crime type. We used Finnish longitudinal register data and between- and within-individual analyses to examine how cohabitation and marriage were associated with suspected crime. The data included 638,118 residents of Finland aged 0-14 in 2000 and followed for 17 years for a suspected crime: having been suspected of violent, drug, or any crime. Between-individual analyses suggested that those who were cohabiting or married had a 40-65% lower risk of being suspected of a crime compared to those who were single, depending on the type of crime. The within-individual analysis showed a 25-50% lower risk for suspected crime when people were cohabiting or married compared to time periods when they were single. Those in a relationship with a criminal partner had 11 times higher risk for suspected crime than those in a relationship with a non-criminal partner. Forming a cohabiting relationship with a non-criminal partner was associated with reduced criminality. The risk reduction was not fully explained by selection effects due to between-individual differences. Marriage did not introduce further reduction to criminality. Our findings demonstrate that selection effects partly explain the association between relationship status and criminality but are also compatible with a causal effect of cohabitation on reduced risk of being suspected of a crime.Peer reviewe

Midlife socioeconomic position and old-age dementia mortality: a large prospective register-based study from Finland

Objectives To assess the association between multiple indicators of socioeconomic position and dementia-related death, and to estimate the contribution of dementia to socioeconomic differences in overall mortality at older ages. Design Prospective population-based register study. Setting Finland. Participants 11% random sample of the population aged 70-87 years resident in Finland at the end of year 2000 (n=54 964). Main outcome measure Incidence rates, Kaplan-Meier survival probabilities and Cox regression HRs of dementia mortality in 2001-2016 by midlife education, occupational social class and household income measured at ages 53-57 years. Results During the 528 387 person-years at risk, 11 395 individuals died from dementia (215.7 per 10 000 person-years). Lower midlife education, occupational social class and household income were associated with higher dementia mortality, and the differences persisted to the oldest old ages. Compared with mortality from all other causes, however, the socioeconomic differences emerged later. Dementia accounted for 28% of the difference between low and high education groups in overall mortality at age 70+ years, and for 21% of the difference between lowest and highest household income quintiles. All indicators of socioeconomic position were independently associated with dementia mortality, low household income being the strongest independent predictor (HR=1.24, 95% CI 1.16 to 1.32), followed by basic education (HR=1.14, 1.06 to 1.23). Manual occupational social class was related to a 6% higher hazard (HR=1.06, 1.01 to 1.11) compared with non-manual social class. Adjustment for midlife economic activity, baseline marital status and chronic health conditions attenuated the excess hazard of low midlife household income, although significant effects remained. Conclusion Several indicators of socioeconomic position predict dementia mortality independently and socioeconomic inequalities persist into the oldest old ages. The results demonstrate that dementia is among the most important contributors to socioeconomic inequalities in overall mortality at older ages.Peer reviewe