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