Economic fluctuations and urban-rural differences in educational inequalities in mortality in the Baltic countries and Finland in 2000-2015: a register-based study.

We examined urban-rural differences in educational inequalities in mortality in the Baltic countries (Estonia, Latvia, Lithuania) and Finland in the context of macroeconomic changes. Educational inequalities among 30-74 year olds were examined in 2000-2003, 2004-2007, 2008-2011 and 2012-2015 using census-linked longitudinal mortality data. We estimated age-standardized mortality rates and the relative and slope index of inequality. Overall mortality rates were larger in rural areas except among Finnish women. Relative educational inequalities in mortality were often larger in urban areas among men but in rural areas among women. Absolute inequalities were mostly larger in rural areas excepting Finnish men. Between 2000-2003 and 2012-2015 relative inequalities increased in most countries while absolute inequalities decreased except in Lithuania. In the Baltic countries the changes in both relative and absolute inequalities tended to be more favorable in urban areas; in Finland they were more favorable in rural areas. The overall pattern changed during the reccessionary period from 2004-2007 to 2008-2011 when relative inequalities often diminished or the increase slowed, while the decrease in absolute inequalities accelerated with larger improvements observed in urban areas. Despite substantial progress in reducing overall mortality rates in both urban and rural areas in all countries, low educated men and women in rural areas in the Baltic countries are becoming increasingly disadvantaged in terms of mortality reduction.

Large variation in predictors of mortality by levels of self-rated health: Results from an 18-year follow-up study.

OBJECTIVES: To analyze the variation in factors associated with mortality risk at different levels of self-rated health (SRH). STUDY DESIGN: Retrospective cohort study. METHODS: Cox regression analysis was used to examine the association between mortality and demographic, socioeconomic and health-related predictors for respondents with good, average, and poor SRH in a longitudinal data set from Estonia with up to 18 years of follow-up time. RESULTS: In respondents with good SRH, male sex, older age, lower income, manual occupation, ever smoking, and heavy alcohol consumption predicted higher mortality. These covariates, together with marital status, illness-related limitations, and underweight predicted mortality in respondents with average SRH. For poor SRH, only being never married and having illness-related limitations predicted mortality risk in addition to older age and male sex. CONCLUSIONS: The predictors of all-cause mortality are not universal but depend on the level of SRH. The higher mortality of respondents with poor SRH could to a large extent be attributed to health problems, whereas in the case of average or good SRH, factors other than the presence of illness explained outcome mortality.

The turn of the gradient? Educational differences in breast cancer mortality in 18 European populations during the 2000s.

This study aims to investigate the association between educational level and breast cancer mortality in Europe in the 2000s. Unlike most other causes of death, breast cancer mortality tends to be positively related to education, with higher educated women showing higher mortality rates. Research has however shown that the association is changing from being positive over non-existent to negative in some countries. To investigate these patterns, data from national mortality registers and censuses were collected and harmonized for 18 European populations. The study population included all women aged 30-74. Age-standardized mortality rates, mortality rate ratios, and slope and relative indexes of inequality were computed by education. The population was stratified according to age (women aged 30-49 and women aged 50-74). The relation between educational level and breast cancer mortality was predominantly negative in women aged 30-49, mortality rates being lower among highly educated women and higher among low educated women, although few outcomes were statistically significant. Among women aged 50-74, the association was mostly positive and statistically significant in some populations. A comparison with earlier research in the 1990s revealed a changing pattern of breast cancer mortality. Positive educational differences that used to be significant in the 1990s were no longer significant in the 2000s, indicating that inequalities have decreased or disappeared. This evolution is in line with the "fundamental causes" theory which stipulates that whenever medical insights and treatment become available to combat a disease, a negative association with socio-economic position will arise, independently of the underlying risk factors.

Inequalities in tuberculosis mortality: long-term trends in 11 European countries.

SETTING: Previous studies in many countries have shown that mortality due to tuberculosis (TB) is higher among people of lower socio-economic status. OBJECTIVE: To assess the magnitude and direction of trends in educational inequalities in TB mortality in 11 European countries. DESIGN: Data on TB mortality between 1980 and 2011 were collected among persons aged 35-79 years. Age-standardised mortality rates by educational level were calculated. Inequalities were estimated using the relative and slope indices of inequality. RESULTS: In the first decade of the twenty-first century, educational inequalities in TB mortality occurred in all countries in this study. The largest absolute inequalities were observed in Lithuania, and the smallest in Denmark. In most countries, relative inequalities have remained stable since the 1980s or 1990s, while absolute inequalities remained stable or went down. In Lithuania and Estonia, however, absolute inequalities increased substantially. CONCLUSION: The reduction in absolute inequalities in TB mortality, as seen in many European countries, is a major achievement; however, inequalities persist and are still a major cause for concern in the twenty-first century. Interventions aimed at preventing TB disease and reducing TB case fatality in lower socio-economic groups should be intensified, especially in the Baltic countries.

Loneliness and health in Eastern Europe: findings from Moscow, Russia.

OBJECTIVES: To examine which factors are associated with feeling lonely in Moscow, Russia, and to determine whether loneliness is associated with worse health. STUDY DESIGN: Cross-sectional study. METHODS: Data from 1190 participants were drawn from the Moscow Health Survey. Logistic regression analysis was used to examine which factors were associated with feeling lonely and whether loneliness was linked to poor health. RESULTS: Almost 10% of the participants reported that they often felt lonely. Divorced and widowed individuals were significantly more likely to feel lonely, while not living alone and having greater social support reduced the risk of loneliness. Participants who felt lonely were more likely to have poor self-rated health (odds ratio [OR]: 2.28; 95% confidence interval [CI]: 1.38-3.76), and have suffered from insomnia (OR: 2.43; CI: 1.56-3.77) and mental ill health (OR: 2.93; CI: 1.88-4.56). CONCLUSIONS: Feeling lonely is linked to poorer health in Moscow. More research is now needed on loneliness and the way it affects health in Eastern Europe, so that appropriate interventions can be designed and implemented to reduce loneliness and its harmful impact on population well-being in this setting.

Educational inequalities in tuberculosis mortality in sixteen European populations.

OBJECTIVE: To describe the magnitude of socioeconomic inequalities in tuberculosis (TB) mortality by level of education in male, female, urban and rural populations in several European countries. DESIGN: Data were obtained from the Eurothine Project, covering 16 populations between 1990 and 2003. Age- and sex-standardised mortality rates, the relative index of inequality and the slope index of inequality were used to assess educational inequalities. RESULTS: The number of TB deaths reported was 8530, with a death rate of 3 per 100 000 per year, of which 73% were males. Educational inequalities in TB mortality were present in all European populations. Inequalities in TB mortality were greater than in total mortality. Relative and absolute inequalities were large in Eastern European and Baltic countries but relatively small in Southern European countries and in Norway, Finland and Sweden. Inequalities in mortality were observed among both men and women, and in both rural and urban populations. CONCLUSIONS: Socio-economic inequalities in TB mortality exist in all European countries. Firm political commitment is required to reduce inequalities in the social determinants of TB incidence. Targeted public health measures are called for to improve access to treatment of vulnerable groups and thereby reduce TB mortality.

Avoidable mortality in Estonia: exploring the differences in life expectancy between Estonians and non-Estonians in 2005-2007.

OBJECTIVES: A considerable increase in social inequalities in mortality was observed in Eastern Europe during the post-communist transition. This study evaluated the contribution of avoidable causes of death to the difference in life expectancy between Estonians and non-Estonians in Estonia. STUDY DESIGN: Descriptive study. METHODS: Temporary life expectancy (TLE) was calculated for Estonian and non-Estonian men and women aged 0-74 years in 2005-2007. The ethnic TLE gap was decomposed by age and cause of death (classified as preventable or treatable). RESULTS: The TLE of non-Estonian men was 3.53 years less than that of Estonian men, and the TLE of non-Estonian women was 1.36 years less than that of Estonian women. Preventable causes of death contributed 2.19 years to the gap for men and 0.78 years to the gap for women, while treatable causes contributed 0.67 and 0.33 years, respectively. Cardiorespiratory conditions were the major treatable causes of death, with ischaemic heart disease alone contributing 0.29 and 0.08 years to the gap for men and women, respectively. Conditions related to alcohol and substance use represented the largest proportion of preventable causes of death. CONCLUSIONS: Inequalities in health behaviours underlie the ethnic TLE gap in Estonia, rather than inequalities in access to health care or the quality of health care. Public health interventions should prioritize primary prevention aimed at alcohol and substance use, and should be implemented in conjunction with wider social policy measures.

Socioeconomic inequalities in lung cancer mortality in 16 European populations.

OBJECTIVES: This paper aims to describe socioeconomic inequalities in lung cancer mortality in Europe and to get further insight into socioeconomic inequalities in lung cancer mortality in different European populations by relating these to socioeconomic inequalities in overall mortality and smoking within the same or reference populations. Particular attention is paid to inequalities in Eastern European and Baltic countries. METHODS: Data were obtained from mortality registers, population censuses and health interview surveys in 16 European populations. Educational inequalities in lung cancer and total mortality were assessed by direct standardization and calculation of two indices of inequality: the Relative Index of Inequality (RII) and the Slope Index of Inequality (SII). SIIs were used to calculate the contribution of inequalities in lung cancer mortality to inequalities in total mortality. Indices of inequality in lung cancer mortality in the age group 40-59 years were compared with indices of inequalities in smoking taking into account a time lag of 20 years. RESULTS: The pattern of inequalities in Eastern European and Baltic countries is more or less similar as the one observed in the Northern countries. Among men educational inequalities are largest in the Eastern European and Baltic countries. Among women they are largest in Northern European countries. Whereas among Southern European women lung cancer mortality rates are still higher among the high educated, we observe a negative association between smoking and education among young female adults. The contribution of lung cancer mortality inequalities to total mortality inequalities is in most male populations more than 10%. Important smoking inequalities are observed among young adults in all populations. In Sweden, Hungary and the Czech Republic smoking inequalities among young adult women are larger than lung cancer mortality inequalities among women aged 20 years older. CONCLUSIONS: Important socioeconomic inequalities exist in lung cancer mortality in Europe. They are consistent with the geographical spread of the smoking epidemic. In the next decades socioeconomic inequalities in lung cancer mortality are likely to persist and even increase among women. In Southern European countries we may expect a reversal from a positive to a negative association between socioeconomic status and lung cancer mortality. Continuous efforts are necessary to tackle socioeconomic inequalities in lung cancer mortality in all European countries.

Socioeconomic inequalities in diabetes mellitus across Europe at the beginning of the 21st century.

AIMS/HYPOTHESIS: The aim of this study was to determine and quantify socioeconomic position (SEP) inequalities in diabetes mellitus in different areas of Europe, at the turn of the century, for men and women. METHODS: We analysed data from ten representative national health surveys and 13 mortality registers. For national health surveys the dependent variable was the presence of diabetes by self-report and for mortality registers it was death from diabetes. Educational level (SEP), age and sex were independent variables, and age-adjusted prevalence ratios (PRs) and risk ratios (RRs) were calculated. RESULTS: In the overall study population, low SEP was related to a higher prevalence of diabetes, for example men who attained a level of education equivalent to lower secondary school or less had a PR of 1.6 (95% CI 1.4-1.9) compared with those who attained tertiary level education, whereas the corresponding value in women was 2.2 (95% CI 1.9-2.7). Moreover, in all countries, having a disadvantaged SEP is related to a higher rate of mortality from diabetes and a linear relationship is observed. Eastern European countries have higher relative inequalities in mortality by SEP. According to our data, the RR of dying from diabetes for women with low a SEP is 3.4 (95% CI 2.6-4.6), while in men it is 2.0 (95% CI 1.7-2.4). CONCLUSIONS/INTERPRETATION: In Europe, educational attainment and diabetes are inversely related, in terms of both morbidity and mortality rates. This underlines the importance of targeting interventions towards low SEP groups. Access and use of healthcare services by people with diabetes also need to be improved.

Effect of nationwide tobacco control policies on smoking cessation in high and low educated groups in 18 European countries.

BACKGROUND: Recently a scale was introduced to quantify the implementation of tobacco control policies at country level. Our study used this scale to examine the potential impact of these policies on quit ratios in European countries. Special attention was given to smoking cessation among lower educational groups. METHODS: Cross-sectional data were derived from national health surveys from 18 European countries. In the analyses we distinguished between country, sex, two age groups (25-39 and 40-59 years) and educational level. Age-standardised quit ratios were calculated as total former-smokers divided by total ever-smokers. In regression analyses we explored the correlation between national quit ratios and the national score on the Tobacco Control Scale (TCS). RESULTS: Quit ratios were especially high (>45%) in Sweden, England, The Netherlands, Belgium and France and relatively low (<30%) in Lithuania and Latvia. Higher educated smokers were more likely to have quit smoking than lower educated smokers in all age-sex groups in all countries. National score on the tobacco control scale was positively associated with quit ratios in all age-sex groups. The association of quit ratios with score on TCS did not show consistent differences between high and low education. Of all tobacco control policies of which the TCS is constructed, price policies showed the strongest association with quit ratios, followed by an advertising ban. CONCLUSION: Countries with more developed tobacco control policies have higher quit ratios than countries with less developed tobacco control policies. High and low educated smokers benefit about equally from the nationwide tobacco control policies.

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.

Time trends in cause-specific mortality in Estonia from 1965 to 1989.

BACKGROUND: During the last 30 years, in most developed countries, life expectancy has increased considerably. In Estonia, over the past half century, health and social policy was dictated by the Soviet socioeconomic system. In order to evaluate the consequences to health and to evaluate trends in health, cause-specific mortality was studied in Estonia. METHODS: The study was based on national death records from 1965 to 1989. Mortality rates were computed for all causes of death combined and for 16 cause groups. Age-standardization (European population) was performed using 5-year age groups. RESULTS: From 1965-1969 to 1985-1989, the age-standardized mortality rate for all causes combined increased by 4.0% for males and decreased by 1.5% for females. The greatest increase was observed for ages 45-54 among males (26.3%) and for ages 55-64 among females (7.0%). Very high death rates from circulatory diseases and high mortality from injuries and poisoning are of specific concern, particularly for males. Mortality from circulatory diseases continues to rise for ages 45-74 among males and for ages 55-64 among females. Mortality rates for neoplasms and endocrine disorders are also increasing; however, the mortality rates from respiratory and infectious diseases have shown a substantial decrease. CONCLUSIONS: Chronic diseases, together with injuries and poisoning, remain a serious public health problem in Estonia. Preventive measures, including earlier detection of diseases as well as changes in social security and individual health behaviour are needed to improve the health of the population.

Lung cancer in Estonia in 1968-87: time trends and public health implications.

Changes in lung cancer incidence and mortality in Estonia were studied for 20 years (1968-87). A steady upward trend was observed for men and women. The 1983-87/1968-72 age-standardized incidence rate ratio was 1.22 (95% confidence interval (CI) 1.15-1.29) in men and 1.34 (95% CI 1.16-1.54) in women. The corresponding mortality rate ratio was 1.26 (95% CI 1.18-1.34) in men and 1.35 (95% CI 1.16-1.57) in women. The age-specific incidence and mortality rates increased clearly towards the younger birth cohorts. For men and women, the increase was most evident for the age group 45-64 years. In women there was a more rapid increase in incidence and mortality than in men. It may be a result of a substantial increase of tobacco smoking, particularly among women, after the World War II. The high and still rising occurrence of lung cancer is closely related to the high prevalence of smoking; in addition, high tar yields in domestic cigarettes could have been responsible for an elevated lung cancer risk during the past decades. There is not tobacco control programme in Estonia, and existing legislation and regulations do not defend the non-smoking population.

Time trends in cancer mortality in Estonia, 1965-1989.

Mortality rates for cancer of all sites combined and for 12 selected sites or site groups in Estonia from 1965 to 1989 were studied to assess overall progress in controlling cancer. Between 1965-1969 and 1985-1989, age-standardized mortality (world population) increased by 12.0% among males and decreased by 5.1% among females. The changes in mortality for the age-groups 20-44, 45-64, and 65 and over were -0.3%, 23.5% and 5.8% among males and 0.9%, -7.0% and -4.4% among females, respectively. In males, the most marked rise in mortality occurred for cancers of the oral cavity and pharynx, intestine and larynx. In females, the most rapid increase was observed for cancers of the lung, oral cavity and pharynx and breast. The decline in stomach cancer and cervical cancer mortality reflects worldwide trends. However, the noticeable increase in mortality rates for most of the sites indicates a need for strong preventive measures, particularly anti-smoking campaigns. In general, the time trends in mortality from all cancers combined demonstrate that in Estonia, over the last 25 years, no progress against cancer has been achieved.