title: Variations in the relation between education and cause-specific mortality in 19 European populations: a test of the "fundamental causes" theory of social inequalities in health.
abstract: Link and Phelan have proposed to explain the persistence of health inequalities from the fact that socioeconomic status is a "fundamental cause" which embodies an array of resources that can be used to avoid disease risks no matter what mechanisms are relevant at any given time. To test this theory we compared the magnitude of inequalities in mortality between more and less preventable causes of death in 19 European populations, and assessed whether inequalities in mortality from preventable causes are larger in countries with larger resource inequalities. We collected and harmonized mortality data by educational level on 19 national and regional populations from 16 European countries in the first decade of the 21st century. We calculated age-adjusted Relative Risks of mortality among men and women aged 30-79 for 24 causes of death, which were classified into four groups: amenable to behavior change, amenable to medical intervention, amenable to injury prevention, and non-preventable. Although an overwhelming majority of Relative Risks indicate higher mortality risks among the lower educated, the strength of the education-mortality relation is highly variable between causes of death and populations. Inequalities in mortality are generally larger for causes amenable to behavior change, medical intervention and injury prevention than for non-preventable causes. The contrast between preventable and non-preventable causes is large for causes amenable to behavior change, but absent for causes amenable to injury prevention among women. The contrast between preventable and non-preventable causes is larger in Central & Eastern Europe, where resource inequalities are substantial, than in the Nordic countries and continental Europe, where resource inequalities are relatively small, but they are absent or small in Southern Europe, where resource inequalities are also large. In conclusion, our results provide some further support for the theory of "fundamental causes". However, the absence of larger inequalities for preventable causes in Southern Europe and for injury mortality among women indicate that further empirical and theoretical analysis is necessary to understand when and why the additional resources that a higher socioeconomic status provides, do and do not protect against prevailing health risks.
authors.affiliation: Department of Public Health, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands. Electronic address: j.mackenbach@erasmusmc.nl.
authors.forename: Johan P
authors.initials: JP
authors.lastname: Mackenbach
authors.affiliation: Department of Public Health, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands.
authors.forename: Ivana
authors.initials: I
authors.lastname: Kulhánová
authors.affiliation: Institute of Social and Preventive Medicine, University of Zurich, Switzerland.
authors.forename: Matthias
authors.initials: M
authors.lastname: Bopp
authors.affiliation: Department of Sociology, Vrije Universiteit Brussel, Belgium.
authors.forename: Patrick
authors.initials: P
authors.lastname: Deboosere
authors.affiliation: Department of Public Health, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands; Department of Sociology and Political Science, NTNU, Trondheim, Norway.
authors.forename: Terje A
authors.initials: TA
authors.lastname: Eikemo
authors.affiliation: Department of Public Health, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands.
authors.forename: Rasmus
authors.initials: R
authors.lastname: Hoffmann
authors.affiliation: Department of Public Health, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands.
authors.forename: Margarete C
authors.initials: MC
authors.lastname: Kulik
authors.affiliation: Stockholm Centre on Health of Societies in Transition, Södertörn University, Huddinge, Sweden; Department of Epidemiology and Biostatistics, National Institute for Health Development, Tallinn, Estonia.
authors.forename: Mall
authors.initials: M
authors.lastname: Leinsalu
authors.affiliation: Department of Sociology, University of Helsinki, Finland.
authors.forename: Pekka
authors.initials: P
authors.lastname: Martikainen
authors.affiliation: INSERM, UMR_S 1136, Pierre Louis Institute of Epidemiology and Public Health, Department of Social Epidemiology, Paris, France; Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Pierre Louis Institute of Epidemiology and Public Health, Department of Social Epidemiology, Paris, France.
authors.forename: Gwenn
authors.initials: G
authors.lastname: Menvielle
authors.affiliation: Department of Preventive Medicine and Public Health, Universidad Complutense de Madrid, Spain.
authors.forename: Enrique
authors.initials: E
authors.lastname: Regidor
authors.affiliation: Department of Monitoring and Analyses of Population Health, National Institute of Public Health-National Institute of Hygiene, Warsaw, Poland.
authors.forename: Bogdan
authors.initials: B
authors.lastname: Wojtyniak
authors.affiliation: Center for Health Equity Studies, Stockholm, Sweden.
authors.forename: Olof
authors.initials: O
authors.lastname: Östergren
authors.affiliation: Center for Health Equity Studies, Stockholm, Sweden; Department of Health Sciences, Mid Sweden University, Östersund, Sweden.
authors.forename: Olle
authors.initials: O
authors.lastname: Lundberg
mesh_terms: D000328:Adult; D017677:Age Distribution; D000368:Aged; D002423:Cause of Death; D003431:Cross-Cultural Comparison; D004522:Educational Status; D005060:Europe / Q000453:epidemiology; D005260:Female; D015438:Health Behavior; D054624:Health Status Disparities; D006801:Humans; D008019:Life Style; D008297:Male; D008875:Middle Aged; D009026:Mortality; D017678:Sex Distribution; D064890:Social Determinants of Health; D012959:Socioeconomic Factors
keywords: Causes of death; Education; Europe; Fundamental causes; Inequality; Mortality