Elsevier

Annals of Epidemiology

Volume 14, Issue 7, August 2004, Pages 453-460
Annals of Epidemiology

Educational differentials in mortality from cardiovascular disease among men and women: The Israel Longitudinal Mortality Study

https://doi.org/10.1016/j.annepidem.2003.10.011Get rights and content

Abstract

Purpose

While socioeconomic inequalities in cardiovascular disease have been observed in most industrialized countries, available information in Israel centers on ethnic variations and the role of education has yet to be investigated. This study examines educational differentials in cardiovascular mortality in Israel for both men and women aged 45 to 69 and 70 to 89 years.

Methods

Data are based on a linkage of records from a 20% sample of the 1983 census with the records of deaths occurring until the end of 1992. The study population includes 152,150 individuals and the number of cardiovascular deaths was 14,651. Educational differentials were assessed for mortality of diseases of the circulatory system, ischemic heart diseases, cerebrovascular diseases, hypertensive diseases, and sudden death.

Results

Substantial mortality differentials were found among individuals aged 45 to 69 years, with larger inequalities among women. The age-adjusted relative risk for mortality of cardiovascular diseases among those with elementary education (⩽8 years) compared with those with high education (⩾13 years) was 1.46 (95% CI: 1.32–1.61) for men and 2.06 (95% CI: 1.76–2.41) for women. Differentials among the elderly were markedly narrower than those for younger adults. Similar trends were observed for mortality of subgroups of causes including cerebrovascular diseases and ischemic heart diseases. Educational differentials were not affected by adjustment for ethnic origin and car ownership.

Conclusions

Those with 8 years of education or less suffer higher risk of cardiovascular mortality compared with adults with 13 or more years of education. Young, less educated women are more vulnerable, and health and social policies oriented towards this group are needed.

Introduction

In the industrialized world socioeconomic mortality differentials have been studied extensively showing that the least advantaged sectors of society suffer the highest mortality 1., 2., 3., 4., 5.. Such a trend was not observed for cardiovascular disease (CVD) mortality among men until the 1950s and 1960s, and forty years ago CVD was regarded as a disease of the affluent classes (6). However, since then the social class gradient in cardiovascular mortality among men in developed countries has reversed with evidence for excess CVD mortality among the lower socioeconomic groups 6., 7., 8., 9., 10., 11., 12.. Since the 1970s a sharp decline in CVD mortality took place in many Western countries 6., 10.. Nevertheless, this beneficial trend has not been felt equally across all segments of society, with a better progression among the high socioeconomic groups 9., 10., 13.. Studies which include women are more scarce 13., 14., 15., and reports regarding gender differences in socioeconomic mortality differentials are somewhat inconsistent 9., 16., 17..

An inverse gradient for the association between socioeconomic position and mortality has been reported for both ischemic heart disease and cerebrovascular disease 10., 13., 18., 19. with some evidence that the gradient is larger for the latter cause 10., 13.. Socioeconomic differences in levels of risk factors for CVD such as blood pressure, cholesterol, smoking, and obesity were generally found to be consistent with mortality differentials 8., 14., 17., 20., 21., 22., 23., 24.. Other pathways suggested for the social gradient in mortality from CVD include differential exposure to work stress (25) and adverse conditions acting before birth and during childhood 26., 27., 28..

Socioeconomic mortality differentials have been demonstrated using several indicators of social position representing occupational, educational, and financial aspects 3., 4.. While the various dimensions of socioeconomic position are interrelated, it has been suggested that they represent somewhat different forces associated with health 29., 30.. Education has been proposed as preferable to other socioeconomic indicators (31), and there is evidence showing that its association with mortality and morbidity is the strongest 2., 30., 31..

Trends observed for CVD mortality in Israel are similar to those of other developed countries, showing a rapid decline in mortality from the early 1970s onwards (33). However, Israeli CVD patterns by gender are somewhat exceptional, with a very low male to female mortality ratio 34., 35.. Israel is also characterized by a unique ethnic composition and the study of health inequalities centered around ethnic differentials 35., 36., 37.. Recently, marked inequalities by a number of socioeconomic indicators have been described for all-cause mortality 38., 39.; however, a comprehensive assessment of socioeconomic differences in CVD mortality in Israel has not been reported previously.

The present study investigates socioeconomic differentials in CVD mortality among Israeli adults. Our objectives are: 1) to estimate educational differentials in CVD mortality in Israel; 2) to enhance understanding of these differentials by focusing on subgroups of causes of death; and 3) to evaluate educational differentials in CVD mortality after adjusting for ethnic origin and a financial-based indicator of socioeconomic position.

Section snippets

Methods

This article uses the Israel Longitudinal Mortality Study (40), which links census records from a 20% systematic sample of households in the 1983 census with records of death occurring in the subsequent 9.5 years, until the end of 1992. Israel has a population register in which a unique ID number identifies every resident, newborn, or immigrant. The linkage was performed by means of the ID number, which appears in both the census records and death notifications, and was performed by the Israel

Results

Twenty four percent of the men died during the 9.5 years of follow-up; 14.3% of those aged 45 to 69 years and 54.2% of 70- to 89-year-olds. Among women 10% of those aged 45 to 69 years and 45.9% of 70- to 89-year-olds died during that period. For both men and women, about 40% of deaths in the younger age group were caused by CVD, increasing to about 50% in the older group (Table 1).

Mortality from CVD increased with decline in the level of education (Table 2). The risk of mortality among men who

Discussion

This study provides the first evaluation based on national longitudinal data, of educational differentials in cardiovascular mortality in a 20% sample of the Israeli Jewish population, with a 10-year mortality follow-up. Substantial differentials by education existed among Israelis during that period with respect to total cardiovascular disease mortality, as well as specific causes including IHD and CRVD mortality, with the differentials being markedly smaller for men aged 70 years and above.

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    This research was supported by grant no. 93-00015/2 from the United States–Israel Binational Science Foundation, Jerusalem.

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