1. Bjørn Heine Strand, Senior scientist, PhD Norwegian Institute of Public Health/University of Oslo EuroPRevent Lisboa May 15th, 08:30-08:50. Symposium Session «The infarction is on the other side of the street: geographical inequalities in cardiovascular disease». Session time: 08:30-10.00. Trends in educational inequalities in cause-specific mortality in Norway

2. Outline The Nordic paradox Life expectancy differs across educational levels in Norway What are the drivers for this gap in life expactancy? How imporant is CVD-mortality for this gap? Updated results over 5 decades 1960s - 2010

3. The Nordic paradox Why do socioeconomic health inequalities persist, and even widen in the Nordic countries?

4. Nordic countries Generous welfare state regimes Focus on equality Relatively low income inequality Low prevalence of poverty A good social security system Publicly funded health care

5. Life length: 7 yrs diff in men, 5 in women Source: Steingrímsdóttir et al 2012 84y 77y 87y 82y

6. What is driving the inequalities?

7. Cardiovascular Diseases important CVD: the most important disease group regarding the gap in total mortality between low and high educated (Strand et al BMJ 2010) Changing patterns after year 2000?

8. Strand BH, et al BMC Public Health 2014

9. Methods All deaths age 45-74 in the period 1961-2010 by aducational level (Basic, secondary, tertiary). Split down by 7 causes of death (ICD8-10) (COPD, lung cancer, other cancers, CVD, suicide, external, other). Age adjusted mortality rates and regression based indices: Relative index of Inequality (RII) and Slope Index of Inequality (SII) 708,449 deaths, 62.3 million person years.

10. Shift towards higher education % Men

11. Shift towards higher education % Women

12. Men: Mortality rates (per 100 000 person years) by educational level and period for age 45-74 years. Age adjusted.

13. Women: Mortality rates (per 100 000 person years) by educational level and period for age 45-74 years. Age adjusted.

14. RII and SII SES-Score 0 Hi Mid Low 1 MR MR(1) MR(0) SII=MR(1)-MR(2) RII=MR(1)/MR(2) Eks: MR(1)=1300, MR(0)=800 SII=500, RII=1.63

15. Why increasing mortality inequalities ?

16. *Slope index of inequality (SII), age adjusted. 45-74 yrs in period 1961-2009 in 7 groups of causes of death. Analysis is based on 444,387 deaths and 30.3 mill person years. SII (Per 100 000 py) Strand et al, BMC Pub Health, 2014 Educational inequalities in mortality, men, 45-74 years 508 per 100 000 py (48% of total) 357 per 100 000 py (34% of total)

17. SII (Per 100 000 py) Strand et al, BMC Pub Health, 2014 Educational inequalities in mortality, women, 45-74 years *Slope index of inequality (SII), age adjusted. 45-74 yrs in period 1961-2009 in 7 groups of causes of death. Analysis is based on 264,062 deaths and 32.0 mill person years. 46% of total 27% of total Lung cancer + COPD: 30% of total

18. Summary For the first time in five decades, educational inequalities in total mortality in men (age 45-74 years) have stopped to increase. This levelling off in inequalities in men is mostly because of narrowing inequalities in CVD mortality, which is also seen across Europe. Inequalities in mortality are smaller for women than for men, but are still on the rise, also in the post millennium decade. Rising inequalities among women are due to rising inequalities in lung cancer and COPD mortality. Narrowing inequalities in CVD mortality is also seen in women.

19. Conclusion Educational inwequalities in total mortality seem to be moving from CVD mortality being the single most important driver, to a more heterogenous pattern where deaths from several non-communicable diseases contribute. Inequalities in mortality should be monitored closely in the coming years.

20. Thank you! And thanks to my co-authors: Ólöf Anna Steingrímsdóttir, Else-Karin Grøholt, Inger Ariansen, Sidsel Graff-Iversen and Øyvind Næss. heine@fhi.no