Suchergebnisse

This thesis has attempted to assess the importance of various socioeconomic and other factors in mortality at the population level in three different settings: in Europe at the country level, and in the Czech Republic and the Netherlands at the regional level. Each analysis was conducted from a different perspective. The first established causes for the differences and changes in mortality over time that could assist in current European mortality projections. The second was set in a formersocialist country and covered the period from just before the transition to several years after, and provided insights into changing regional mortality differences. The focus of the third analysis was in uncovering reasons for the recent decline in sex differences in mortality. One conclusion that can be drawn from the various types of analysis employed in this thesis is that mortality studies need to consider many different contexts and potential trends. This is even more important in making projections, given the number of assumptions involved. Since all the studies were ecological in nature, it is impossible to control for factors in the way that this is done in studies where personal information is linked to outcome. The methodology and assumptions therefore need a sound justification, the discussion in Chapter 4 with regard to the time lags introduced for the exogenous variables being an example of this. Mortality studies have become interdisciplinary. Mortality, here, was studied by cause of death, because this provides, by definition, an initial explanation for observed differences and changes. However, in looking for additional answers, for example by incorporating direct and indirect determinants of death and disease, one needs to have some understanding of the disease mechanisms. This is because most such factors do not affect mortality immediately, but only after a certain period of time and, further, this time lag may be different for alternative causes of death or even for the same cause of death depending on the level of exposure. For example, large quantities of alcohol consumption may instigate a heart attack (IHD) or a stroke (CRB) within 24 hours, whereas moderate consumption of alcohol is thought to reduce the process of atherosclerosis, and thus protect against IHD. It is therefore important that short and/or long term effects are estimated. In the case when the effect of alcohol consumption is studied at the aggregate level using aggregated data and information on consumption patterns, the effect of the exposure on the outcome should be estimated for a range of theoretically plausible time lags, from which the one with the largest effect should be used in the analysis. In the case of alcohol and IHD, both a short- and long-term lag could be incorporated in the model equation. Throughout the thesis, reference has been made to the life course approach because current mortality differences are the result of many years of differential exposure to both health-damaging and health-promoting factors. The direct factors, such as smoking and alcohol consumption, are often embedded in socioeconomic factors and, as a consequence, political, social and economic changes will invariably impact on future levels of mortality. We have seen the immediate impact on health of the transition in Eastern Europe, but the full effects of 40-50 years of socialism may not disappear for decades to come. One reason is the impact of psychosocial risk factors, rather than the standard risk factors such as smoking, that appear to be of major importance in explaining East- West differences in IHD mortality (Kristenson et al., 1998). It is therefore unlikely, even if all other things were equal, that health patterns in Eastern Europe would quickly catch up the West, even if they were to enter the fourth stage of the epidemiological transition, which is not impossible in the near future given that declines in IHD are already being observed in several central European countries. Previous trends in the "leading" countries may therefore be useful to projection makers in adopting realistic assumptions. This equally applies to trends in other phenomena that appear to follow a set of phases, such as the smoking epidemic. One trend that does not seem to receive sufficient attention in existing mortality projections is the changes in societal norms and values, in particular with regard to their effect on female mortality. Already among most of the younger cohorts in Europe, smoking and moderate to heavy alcohol consumption are no longer an exclusively male habit, and labour force participation rates are also converging. This suggests that future sex differences in life expectancy, within a stable socioeconomic climate, will not be the seven or eight years it once was in most European countries, in particular because the full effect of smoking on mortality has yet to be seen. I would therefore expect future increases in the life expectancy of women to stagnate, particularly in southern Europe because of an even larger delay in the smoking epidemic. Turning to Eastern Europe, the future trends are more difficult to predict because many gains in life expectancy can still be made with regard to non-smoking-related deaths from circulatory system diseases, whose mortality levels are still much higher than in the West.

"Most European countries have experienced labour market reforms at varying times leading to extended working life and a postponement of retirement age. This book provides a gender perspective on the impact of extended working life on the different dimensions of well-being, the factors which can limit extended working life, and the working conditions of older workers. It will be of interest to all scholars and students of social policy, sociology, gender studies and labour studies more broadly"--