International Journal of Epidemiology 2003;32:1081-1087
© International Epidemiological Association 2003
Population Health |
Estonia 1989–2000: enormous increase in mortality differences by education
1 Stockholm Centre on Health of Societies in Transition, University College of South Stockholm, 14189 Huddinge, Sweden.
2 Institute of Experimental and Clinical Medicine at Tallinn, Estonia.
3 Centre for Health Equity Studies, CHESS, Stockholm University/Karolinska Institute, Stockholm, Sweden.
4 Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
Correspondence: Mall Leinsalu, Stockholm Centre on Health of Societies in Transition, University College of South Stockholm, 14189 Huddinge, Sweden. E-mail: Mall.Leinsalu{at}sh.se
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Abstract |
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 Top Abstract Data and MethodsResultsDiscussionReferences |
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Background Having regained its political autonomy in 1991, Estonia experienced major changes in political, economic, and social realities. We aimed to analyse mortality changes by education from 1989 to 2000 in order to assess the impact of recent changes in Estonia, as well as the delayed effects of pre-transitional developments.
Methods Two census-based analyses were compared. Individual cause-specific death data for those aged 20+ for 1987–1990 (72 003 deaths) and 1999–2000 (35 477 deaths) came from the national mortality database. Population denominators came from the population censuses of 1989 and 2000. Mortality for all causes combined and for selected causes of death were analysed for high, mid, and low educational groups. The absolute differences in mortality were evaluated through life expectancy at age 25 and age-standardized mortality rates. To assess the relative differences between educational levels, mortality rate ratios with 95% CI were calculated using Poisson regression.
Results Educational differences in mortality increased tremendously from 1989 to 2000: over the 10-year period life expectancy improved considerably for graduates, and worsened for those with the lowest education. In 2000, male graduates aged 25 could expect to live 13.1 years longer than corresponding men with the lowest education; among women the difference was 8.6 years. Large differences were observed in all selected causes of death in 1989 and in 2000 and the trends were invariably much more favourable for the higher educated. Educational differences in total mortality increased in all age groups.
Conclusions Social disruption and increasing inequalities in wealth can be considered main recent determinants; however, causal processes, shaped decades before recent reforms, also contribute to this widening gap.
Keywords Cause-specific mortality, educational differences, transition, Estonia
Accepted 3 April 2003
Socioeconomic differences in mortality have been extensively reported in the West.1–3 The last decades have witnessed an increase in relative mortality rate ratios in many countries, although absolute differences are more stable.4–7 Less is known about ex-communist countries. Studies suggest that educational differences in mortality in Eastern Europe at the end of the communist era were at least as big as in the West.8,9 Estonia, the smallest country in the Baltic region, regained its political autonomy in 1991 after 50 years of Soviet occupation. Estonia opted for much more far-reaching and intense free market reforms than other transition economies in Central Europe and the former Soviet Union. Deliberate policies were aimed at stimulating job creation and employment (including international trade opportunities and foreign ownership of firms), above all by low employment protection and reduced social safety nets.10 Its mortality development over the past 40 years has been similar to other ex-communist countries: male life expectancy improved by only about 1 year and female by 4 years from 1959 to 2000. During the first years of political and economic transition, Estonia experienced an unprecedented rise in mortality11 (Figure 1
).
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After 1994, mortality rates returned to the levels found before the 1990s. To assess the impact of recent reforms and the delayed effects of pre-transitional developments we analysed mortality changes by education from 1989 to 2000.
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Data and Methods |
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TopAbstractData and MethodsResultsDiscussionReferences |
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Two census-based cross-sectional analyses were performed. Individual cause-specific death data for those aged 20+ for 1987–1990 (72 003 deaths) and 1999–2000 (35 477 deaths) came from the national mortality database. Population denominators came from the population censuses of 1989 and 2000. Total mortality and selected causes of death were analysed for three educational groups (university, upper secondary, and lower secondary or less education). In 1987–1990 the abridged Soviet version of International Classification of Diseases, Ninth Revision (ICD-9) was used for coding the causes of death; a correspondence table was then used to reclassify the causes of death into ICD-9.12 For 1999–2000 ICD-10 was used. Table 1
presents corresponding categories of ICD-9 and ICD-10 for the selected causes of death.
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Educational differences in total mortality were analysed in four age groups: 20–39, 40–54, 55–69, and 70+. The absolute differences in mortality were evaluated through life expectancy at age 25 and age-standardized mortality rates (European standard population). To assess the relative differences between educational levels, mortality rate ratios with 95% CI were calculated using Poisson regression. Age was adjusted in 5-year intervals in the regression analyses.
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Results |
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TopAbstractData and MethodsResultsDiscussionReferences |
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The proportion of the population with high and middle educational levels rose from 1989 to 2000. This was balanced by a reduction in the proportion of the population with low education (Table 2
).
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The educational distribution remained stable in the youngest age group.
We found a sharp increase in educational differences in mortality from 1989 to 2000 among men and women. Over the 10-year period, life expectancy improved considerably for graduates, and worsened for those with the lowest education. Life expectancy remained stable among women with middle education; for the corresponding group of men it fell (Figure 2). In 2000, male graduates aged 25 could expect to live 13.1 years longer than corresponding men with the lowest education; among women the difference was 8.6 years.
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Educational differences in total mortality increased in all age groups (Table 3
). These increases were largest among younger age groups, but were also to be found among the elderly. Table 4 presents educational differences in mortality by selected causes of death. Large differences were observed in all those causes in 1989 and 2000. Mortality trends were invariably much more favourable for the higher educated. Circulatory diseases had the largest impact on the widening mortality gap.
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Discussion |
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TopAbstractData and MethodsResultsDiscussionReferences |
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The enormous increase in mortality differences by education raises the question of data reliability. In unlinked, census-based, cross-sectional studies, the numerator-denominator bias is of greatest concern. We carefully analysed whether there were differences between census records and death certificates with respect to the coverage of population, the reporting or non-response, or the classification of educational level. However, we were unable to identify any data problems that would seriously affect results.13
The small number of deaths in 1999–2000, especially for some causes of death, makes mortality estimates prone to random fluctuations. Problems with the change from ICD-9 to ICD-10 may have affected trends in cause-specific mortality for Estonia at large, but these biases are unlikely to have affected different educational groups in different ways.
An additional concern was the fact that the lowest educational stratum became much smaller during the 11 years of transition, especially in the 40–69 age group. This was due to two factors. Firstly, the rapid expansion of education in the post war period, which resulted in a smaller proportion of each new birth cohort achieving only lower secondary education or less. Secondly, the sharp rise of mortality in the 40–69 age group, especially among the lowest educated (Table 3
). This excess mortality alone would have resulted in a reduction of the size of the lowest educational stratum of up to 5% between 1989 and 2000. Since the lowest educated group in 2000 was so much smaller than 1989, one could argue that it was also more extreme. Therefore, some of the widening of the educational mortality differences may simply reflect the new distribution of educational categories. However, this is unlikely to contribute much since, firstly, the shrinkage of the lowest educated group is counterbalanced by the growth of the best educated group (which is therefore less extreme) and secondly, since differences between middle and high educated groups also widened.
Educational differences in mortality in 1989 were large compared with those of Western Europe.8 The high mortality from infectious diseases and stomach cancer among the poorly educated is one indicator of adverse living conditions before 1991. Their relatively high mortality from smoking-related or alcohol-related causes in 1989 indicates differences in lifestyle between educational groups.14,15
In Estonia’s rapid political and economic transition, the less educated often lacked the necessary coping skills; they were thus at greater risk of unemployment and were less likely to move from unemployment and inactivity back to employment.10 The new policies favoured graduates, who benefited both in terms of money and health16 and for whom the psychological adjustment was easier.17 Social disruption, poverty, and the increasing gap in wealth are likely contributors to larger educational differences in mortality in 2000. Sharply increased mortality from infectious diseases from 1989 to 2000 among the lowest educated is evidence of poverty-driven causal mechanisms. Income and poverty are linked to many other causes of death, including the most common ones,3,18 although both the strength of association and the causal pathways vary between causes.
Changes in the diet of the population as a whole at the beginning of the 1990s may be one determinant of the overall decline of mortality from circulatory diseases.19 Progress in medical care may also have contributed to the reduction in mortality from circulatory disease in all educational groups, particularly for graduates, who were more successful in getting specialist care.20 The overall improvement in cancer survival rates in the 1990s,21 known to be dependent on access to and quality of medical care, could point to improved medical care in Estonia. The reversing educational gradient for breast cancer mortality is striking and probably best explained by earlier detection, better treatment and survival among graduates, and perhaps also by differential changes in fertility.
Social disruption and poverty works also through behavioural mechanisms. Alcohol has been considered one of the main factors behind the increasing mortality in 1990s Russia.22 Its role is similarly evident in Estonia, with an extremely liberal alcohol policy in the early 1990s. Mortality from alcohol poisoning and liver cirrhosis increased sharply in all educational groups and in both genders. These two alcohol-related causes certainly contributed to the mortality difference by education and to its increase in Estonia.
From 1989 to 2000 the declining mortality of the higher educated and the rising mortality of the lower educated resulted in an enormous mortality gap. The increasing differentiation of wealth and opportunity, partly resulting from recent reforms, can be considered a main, recent underlying factor. However, the situation was partly determined long before the transition period. The fairly high contribution of neoplasms to the widening mortality gap suggests that some underlying factors originated decades before recent reforms. Stomach cancer, determined early in life,23 and lung cancer, with a long latency time,24 are two examples. Cerebrovascular deaths also contribute to the widening gap and, again, this group of diseases, especially haemorrhagic stroke, are believed to be partly determined early in life.23,25 Early life factors linked to education interacting with factors later in life also linked to education (alcohol for example) could result in the widening mortality gap for certain causes of death.
We conclude that there is a particular need to tackle health inequalities in countries in transition. Three such areas could be suggested. Those with a low educational achievement need to be pulled into the new economic developments and allowed to benefit from economic change; the distribution and consumption of alcohol need to be more tightly controlled, and thirdly, a modernized, comprehensive medical care system equally accessible for all would counteract some of the forces now creating a widening of the educational mortality divide.
KEY MESSAGES
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Acknowledgments |
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This study was supported by the Foundation for Baltic and East European Studies (project grant ‘Social and public health developments in Eastern Europe’), and by a grant from the Ministry of Social Affairs of Estonia/the World Bank. We thank three anonymous referees for valuable comments.
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References |
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