Change in marital status structure as an obstacle for health improvement: evidence from six developed countries.

The aim of this study is to estimate the contributions of changes in population distribution by marital status to the changes in adult mortality in six developed countries. The change in total mortality was decomposed into the contributions of: (i) mortality changes within each marital status category; and (ii) changes in population composition by marital status. The study provides evidence that changes in population composition contributed to increases in male mortality in Russia and Lithuania, whereas in the remaining male populations this was a significant obstacle for faster health improvements. The compositional changes had only small impacts on female mortality.

Increasing absolute mortality disparities by education in Finland, Norway and Sweden, 1971-2000.

BACKGROUND AND OBJECTIVES: Studies on socioeconomic health disparities often suffer from a lack of uniform data and methodology. Using high quality, census-linked data and sensible inequality measures, this study documents the changes in absolute and relative mortality differences by education in Finland, Norway and Sweden over the period 1971 to 2000. METHODS: The age-standardised mortality rates and the population exposures for three educational categories were computed from detailed data provided by the national statistical offices. Mortality disparities by education were assessed using two range measures (rate differences and rate ratios), and two Gini-like measures (the average inter-group difference (AID) and the Gini coefficient (G)). The formulae for the decomposition of the change in the AID into (1) the contribution of change in population composition by education, and (2) the contribution of mortality change were introduced. RESULTS: Mortality decreases were often greater for high than for medium and low education. Both relative and absolute mortality disparities tend to increase over time. The magnitude and timing of the increases in absolute disparities vary by country. Both the rate differences and the AIDs have increased since the 1970s in Norway and Sweden, and since the 1980s in Finland. The contributions of the changes in population composition to the total AID increase were substantial in all countries, and for both sexes. The mortality contributions were substantial for males in Norway and Sweden. CONCLUSIONS: The study reports increases in absolute mortality disparity, and its components. This trend needs to be further studied and addressed by policies.

The changing relation between education and life expectancy in central and eastern Europe in the 1990s.

BACKGROUND: The political and social transition in central and eastern Europe has been generally associated with widening educational differences in life expectancy. However, interpretation of these findings is complicated because the size of educational categories within the population has also changed. It is therefore important to disentangle these two phenomena. SETTING: The Czech Republic, Estonia, the Russian Federation and, as a western European reference, Finland, in two periods, 1988-89 and 1998-99. METHODS: Life tables were calculated in three categories: university; secondary; and less than secondary education. Changes in life expectancy were decomposed into contributions of population composition and within-category mortality. RESULTS: In Finland and the Czech Republic improvements are seen in all educational groups, with only a slight widening of the educational differences. Over 80% of the total life expectancy increase is attributable to improved mortality within educational categories. In Estonia and Russia, less favourable overall trends coincide with a dramatic widening of the educational gap. A decrease in life expectancy in those with low and middle education has been compensated for, to a small degree in Russia but a greater extent in Estonia, by improvements among those with higher education and by the improved population composition. For highly educated Estonians, the gains were seen at all ages, the greatest at age > or =60 years. In Russia mortality increased in those <60 years although compensated for by improvements at older ages. CONCLUSIONS: Russia and Estonia exhibit much less equitable transitions compared with the Czech Republic. Analyses of trends in health inequalities should capture the changing population composition. In Russia and Estonia an improved educational structure prevented an even greater decline in life expectancy. The highly educated Estonians can potentially catalyse a wider health progress.

The peculiar pattern of mortality of Jews in Moscow, 1993-95.

Russian Jews, particularly men, have a large mortality advantage compared with the general Russian population. We consider possible explanations for this advantage using data on 445,000 deaths in Moscow, 1993-95. Log-linear analysis of the distribution of deaths by sex, age, ethnic group, and cause of death reveals a relatively high concentration of endogenous causes and a relatively low concentration of exogenous and behaviourally induced causes among Jews. There is also a significant concentration of deaths from breast cancer among Jewish women. Mortality estimates using the 1994 micro-census population as the denominator reveal an 11-year Russian-Jewish gap in the life expectancy of males at age 20, but only a 2-year life-expectancy gap for women. Only 40 per cent of the Russian-Jewish difference for men, but the entire difference for women, can be eliminated by adjustment for educational differences between the two ethnic groups. Similarities with other Jewish populations and possible explanations are discussed.

The evolving pattern of avoidable mortality in Russia.

BACKGROUND: Life expectancy at birth in Russia is over 12 years less than in western Europe. This study explores the possible role of medical care in explaining this gap by examining the evolving pattern of mortality amenable to timely and effective medical care in Russia compared with Estonia, Latvia, and Lithuania, and the UK. METHODS: Analysis of standardized death rates from causes amenable to health care (treatable) or inter-sectoral health policies (preventable) in all regions and decomposition of differences in life expectancy between Russia and the UK by age, sex, and cause of death for the period 1965-1999/2000. RESULTS: Death rates from treatable causes remained stable between the mid-1960s and mid-1980s in Russia and the Baltic republics while steadily falling in the UK to less than half the rate in Russia. In the 1990s, rates increased in the former Soviet republics, reaching a peak in 1994 but reversing again in Russia in 1998. Deaths from causes amenable to inter-sectoral health interventions were higher in the UK in 1965 than in the Soviet Union but subsequently fell steadily while they increased in the East. Between 1965 and 1999, the male life expectancy gap between Russia and the UK rose from 3.6 to 15.1 years (women: 1.6 and 7.4 years). Treatable causes became an increasingly important contributor to this gap, accounting for almost 3 years by the end of the 1990s in men and 2 years in women. In Russia, elimination of treatable causes of death would have increased life expectancy by 2.9 years in men in 1995/99 compared with 1.2 years in the UK (women: 3.3 and 1.8 years), suggesting that, were the outcomes of health care achieved in the UK to be obtained in Russia, life expectancy for men might improve by about 1.7 years and for women by about 1.5 years. CONCLUSIONS: Our findings suggest that the Soviet health care system has failed to match the achievements of the West over the past three decades, highlighting the need to establish a system that provides effective and equitable care for the Russian population.

Health expectancy in the Russian Federation: a new perspective on the health divide in Europe.

OBJECTIVES: To compare life expectancy and healthy life expectancy in the Russian Federation and in countries of Eastern and Western Europe. METHODS: WHO mortality data and data on self-reported health from the World Values Survey and the Russian Longitudinal Monitoring Survey were used to compare the above three regions. Life expectancy was calculated using Sullivan's method, with years of life lived divided into healthy and unhealthy. The gap in healthy life expectancy between the Russian Federation and Western Europe was examined by decomposing the difference by gender and age. FINDINGS: The probability of remaining alive and healthy declines faster in the Russian Federation than in Western Europe, with the gap between Eastern Europe and the Russian Federation widening at older ages. In the Russian Federation, this rapid decline is due mainly to the high probability of death or of poor health for men and women, respectively. CONCLUSIONS: There is a large toll of premature male mortality in the Russian Federation but there also appears to be a substantial burden of ill-health among women. As in other countries, the responses of men and women to adversity differ, leading to premature death in men but survival in a poor state of health in women. Epidemiological studies including objective measures of health would help policy-makers to estimate more precisely the scale and nature of this problem. Policy-makers must recognize that health expectancy in the Russian Federation is reduced in both men and women.

What targets for international development policies are appropriate for improving health in Russia?

BACKGROUND: The OECD countries and the United Nations have agreed to co-ordinate their work around a series of International Development Targets. The targets for health are based on improvements in infant, child and maternal mortality. Progress towards these goals will be used to assess the effectiveness of development policies. OBJECTIVES: To assess the potential impact of achievement of the International Development Targets on health in Russia, and to identify possible alternatives that may be more relevant to transition countries. DESIGN: The study covered the population of the Russian Federation from 1995-99. The effects of reducing infant, child and maternal mortality on Russian life expectancy at birth were modelled using construction of life tables. Three scenarios were modelled, reducing rates to those of the best performing regions in Russia, those required to achieve the International Development Targets and current UK rates. The results were compared with the effect on life expectancy at birth of policies to reduce adult mortality in different ways. RESULTS: Achieving the International Development Targets for infant, child and maternal mortality (66.7 and 75% reductions) will contribute very little to improving life expectancy in Russia (0.96 years). In contrast, even a 20% reduction in adult mortality would give rise to an increase in male life expectancy at birth of 1.86 years. CONCLUSION: Targets for health improvement in transition countries such as Russia should take account of adult mortality as well as the indicators contained in the International Development Targets.