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Premature Mortality in Slovenia in Relation to Selected Biological, Socioeconomic, and Geographical Determinants

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Afim To deftermfine bfioflogficafl (sex and age), socfioeconomfic (marfiftafl sftaftus, edu -caftfion, and moftTher ftongue) and geograpThficafl (regfion)ffacftors connecfted wfiftTh causes off deaftTh andflfiffespan (age aft deaftTh, years-off-poftenftfiafl-flfiffe-flosft, and mor -ftaflfifty rafte)fin Sflovenfiafin ftThe 1990s.

MeftThods In ftThfis popuflaftfion-based cross-secftfionafl sftudy, we anaflyzed aflfl deaftThsfin ftThe 25-64 age group (N = 14 816)fin Sflovenfiafin 1992, 1995, and 1998. Causes off deaftTh, cflassfifi edfinfto groups accordfing fto ftThe 10ftTh revfisfion off Infternaftfionafl Cflassfifi caftfion off Dfiseases, wereflfinked fto ftThe dafta on ftThe deceasedffrom ftThe 1991 Census. Sftraftfifi ed conftfingency-ftabfle anaflyses were perfformed. Years-off-poften -ftfiafl-flfiffe-flosft (YPLL) were caflcuflafted on ftThe basfis off popuflaftfionflfiffe-ftabfles sftraftfi -fi ed by regfion andflfinearfly modefled by ftThe cTharacfterfisftfics off ftThe deceased. Pofis -son regressfion was appflfied fto ftesft ftThe dfiff erencesfin morftaflfifty rafte.

Resuflfts Across aflfl socfioeconomfic sftrafta, men dfied aft younger age ftThan women (findex off excess morftaflfiftyfin men exceeded 200ffor aflfl sftudfied years) andffrom dfiff erenft prevafiflfing causes (finjurfiesfin men aged <45 years; neopflasmsfin women aged >35 years). For men, ThfigTher educaftfion was assocfiafted wfiftThffewer deaftThs ffrom dfigesftfive and respfiraftory sysftem dfiseases. Th efleasft educafted women dfied reflaftfivefly oft enffrom cfircuflaftory dfiseases, buft rareflyffrom neopflasms. Sfingfle peo -pfle dfiedffrom neopflasmsfless often. Marrfiagefin comparfison wfiftTh dfivorce reduced ftThe morftaflfifty rafte by 1.9-ffofldfin boftTh men and women (P<0.001). Morftaflfifty rafte fin boftTh men and women decreased wfiftThfincreasfing educaftfionflevefl (P<0.001). Morftaflfifty rafte off eftThnfic Sflovenfians was Thaflff ftThe morftaflfifty rafte off eftThnfic mfinor -fifty members andfimmfigranfts (P<0.001). Anaflysfis off YPLL reveafledflfimfifted and nonflfinearfimpacft off educaftfionflevefl on premafture morftaflfifty. Th e sThare off neo -pflasms was ftThe ThfigThesftfin ftThe cflusfter off socfioeconomficaflfly prosperous regfions, wThereas ftThe sThare off cfircuflaftory dfiseases wasfincreasedfin poorer regfions. Sfig -nfifi canft dfiff erences wereffound beftweenfindfivfiduafl regfionsfin age aft deaftTh and morftaflfifty rafte, and ftThe dfiff erences decreased over ftThe sftudfied perfiod.

Concflusfion These dafta may afid fin undersftandfing ftThe nafture, prevaflence and consequences off morftaflfifty as reflafted fto socfioeconomfic finequaflfiftfies, and ftThus serve as a basfis ffor seftftfing TheaflftTh and socfiafl poflficy goafls and pflannfing TheaflftTh measures.

Gaj Vfidmar

Insftfiftufte off BfiomedficaflInfformaftfics Unfiversfifty off Ljubfljana, Facuflfty off Medficfine

Vrazovftrg 2

SI-1000 Ljubfljana, Sflovenfija gaj.vfidmar@mff.unfi-flj.sfi

> Recefived: MarcTh 14, 2005 > Accepfted: June 17, 2005 1Deparftmenft off Pubflfic HeaflftTh, Unfiversfifty ScThoofl off Medficfine, Ljubfljana, Sflovenfia

2Insftfiftufte off Bfiomedficafl Infformaftfics, Ljubfljana, Sflovenfia 3Insftfiftufte off Macroeconomfic Anaflysfis and Deveflopmenft, Ljubfljana, Sflovenfia 4Facuflfty off HeaflftTh Scfiences, Unfiversfifty off Bfiefleffefld, Bfiefleffefld, Germany

> Croaft Med J. 2006;47:103-13

Barbara Arftnfik1, Gaj Vfidmar2, Jana Javornfik3, UflrficTh Laaser4

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InftThe fi efld off pubflfic TheaflftThresearcTh,ftThe eff -ffecfts offsocfiaflfinequfifty on TheaflftTh aresftfiflfl conftro -versfiafl. A generaflruflefisftThaftsocfioeconomficaflfly deprfived groups off peopfle ThaveftThe worsft TheaflftTh, ftThe worsft quaflfifty offflfifferegardfing TheaflftTh, andftThe ThfigThesftrafte off premafture deaftThs(1). However, cflassfificaftfion off peopflefinftosocfioeconomfic gro -ups coufld aflso be a consequence as weflfl as a cause offfiflfl TheaflftTh.

Th e Bflack Reporft(2) provfides an aftftempft au -ftThorfized by a governmenftfto expflafinftrendsfin The -aflftThfinequaflfiftfies andftoreflafteftThemftoftThe poflficfies finftendedfto promofte andresftore TheaflftTh. Deprfi -vaftfionfis a dfirecftrfiskfto TheaflftTh, and TheaflftThrfisks dfiffer beftween dfifferenft groups off peopfle(3,4). Socfioeconomficfinequaflfiftfies can be,ftThereffore, de -fi ned as dfiff erencesfinftThe prevaflence orfincfidence off TheaflftTh probflems beftweenfindfivfiduafl peopfle off ThfigTher orflowersocfioeconomficsftaftus(5). Socfioe -conomficaflfly deprfived groups are cTharacfterfized by ThfigTher morbfidfifty and morftaflfiftyraftesftThanftThose ffoundfinftThe groups off peopfle off beftftersocfioeco -nomficsftaftusfin Easftern(6) and Wesftern coun -ftrfies aflfike(7,8). AftftThesameftfime, TheaflftThfinequa -flfiftfies are consftanftfly cThangfing, drfiven byftThesocfiafl dynamfics off a counftry, and apparenft “anomaflfies” and “paradoxes” warn agafinsft asfimpflfisftfic vfiew off TheaflftThfinequaflfiftfies(9).

Th ereducftfion off TheaflftThfinequaflfiftfies depends on undersftandfing demograpThficafl and eftfioflogficafl finequaflfiftfies amongfindfivfiduafl popuflaftfion groups wfiftThfin a cerftafin pflace andftfime. Th us,fto conftrfi -bufteftoftThe more deftafifled undersftandfing offso -cfioeconomfic cTharacfterfisftfics assocfiafted wfiftTh pre -mafture morftaflfifty,ftofidenftfiffyftThe mosft vuflnerabfle groups, andfto afidfto draftfingftThe naftfionaflsftrafte -gyffor combaftfing poverftyfin Sflovenfia, we decfided ftofinvesftfigafteftThefinfl uence off bfioflogficafl,socfioe -conomfic, and geograpThficaflffacftors onftThe causes off deaftThfin our counftry. NoresearcTh Thas yeft been carrfied ouftfin Sflovenfiaflfinkfingsocfioeconomficfin -dficaftors wfiftThftThe exftenft andsftrucfture off causes off deaftTh, excepftffor a preflfimfinaryreporft based on parft offftThe dafta anaflyzed There(10).

FurftTher moftfivaftfionffor our work cameffrom ftThe wfiderfissues off TheaflftTh poflficfies and TheaflftThfin -dficaftors. Aft erftThe mfid-1970s, a wfidenfing morfta -flfifty gap beftween Wesftern Europe andftThe, now fformer, socfiaflfisft economfies became apparenft (11,12). EvenftThougThftThereasonsfforftThfis pTheno -menon were muflftfipfle, parft offftThe expflanaftfionflay fin poorer flfivfing condfiftfions and flower access fto advanced medficafl carefin counftrfies wfiftThsocfiaflfisft economy. Thfisfissupporfted byftTheffacftftThaftftThe dfifferences fin morftaflfifty raftes beftween Wesftern and Easftern European counftrfiesseemfto be de -creasfingsfinceftThe 1990s. However, a precondfiftfi -onffor vaflfid anaflysfis offsucThftrendsfisftThe avafiflabfi -flfifty offreflfiabfle dafta. Th e firsft anaflyses offseflecfted TheaflftThfindficaftorsffor SouftTh-Easftern Europe Thave sThown ftThaft consfiderabfle fimprovemenft fis requ -firedfto esftabflfisTh even a mfinfimum TheaflftThfindfica -ftorseft wfiftThreflfiabfle and comparabflefinfformaftfion (13,14). Hence, oursftudy aflso aftftempftedfto eflfi -mfinafteftThe exfisftfing defi cfifts, aftfleasftffor vfiftaflsfta -ftfisftfics.

MeftThods

We perfformed a popuflaftfion-based cross-sec -ftfionaflsftudyfto deftermfineftThefinfl uence offseflec -fted bfioflogficafl(age andsex),socfioeconomfic(ver -ftficafl: educaftfion and occupaftfion; Thorfizonftafl: marfiftaflsftaftus, and moftTherftongue), and geograp -Thficaflffacftors onftThe causes off deaftTh andflfiffespan finftThe popuflaftfion aged 25-64 yearsfin Sflovenfiafin 1992, 1995, and 1998. Causes off deaftTh were cfla -ssfifi ed accordfingftoftThe 10ftThrevfisfion offftTheIn -fternaftfionafl Cflassfificaftfion off Dfiseases (ICD-10) (15), andflfiffespan was measured by age aft deaftTh, years-off-poftenftfiafl-flfiffe-flosft (YPLL), and specfifi c morftaflfiftyrafte.

Dafta coflflecftfion

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(N= 14 816). Dafta were gaftThered by combfinfing ftThe census dafta wfiftTh oftThersftaftfisftficaflsources. Th e dafta onftThe cause off deaftTh and monftTh and year off deaftTh were obftafinedffromftThe deaftThregfisftraftfion fform(DEM-2fform), fifled byftTheInsftfiftufte off Pu -bflfic HeaflftThffor eacTh person wTho dfiesfin Sflovenfia. Th e Sftaftfisftficafl Ofi ce offftThe Repubflfic off Sflovenfia flfinkedftThe cause off deaftThftoftThe dafta onftThe de -ceasedffromftThe 1991 Census(sex, age,sftaftfisftficafl regfion off permanenftresfidence befforeftThe deaftTh, marfiftaflsftaftus, educaftfion, and moftTherftongue).

Th e dafta on occupaftfion(ofi cfiafl occupaftfionafl cflassfificaftfion and occupaftfionafl sftaftus ffrom ftThe census andftThe deaftThregfisftraftfionfform) proved finconsfisftenft and were ffrequenftfly mfissfing. Th ey aflso efiftTher proved unfinfformaftfive orfleadftoseflff -evfidenft concflusfionsregardfing cause off deaftTh and morftaflfiftyrafte. Hence,ftThey were droppedffrom fi nafl anaflyses, and onflyservedfforsubsampflese -flecftfion fin YPLL anaflysfis (excfludfing ftThe reftfired ffromftThe acftfive popuflaftfion).

Th e popuflaftfion counft ffor 1992, 1995, and 1998,sftraftfifi ed bysftaftfisftficaflregfion andsex, was obftafinedffromftThe Cenftrafl Regfisfter off Popuflaftfi -on, wThficThfis mafinftafined byftThe Mfinfisftry offftThe Infterfior offftThe Repubflfic off Sflovenfia. Th e popufla -ftfion dafta on marfiftaflsftaftus, moftTherftongue, and educaftfion were obftafinedffromftThe 2002 Census provfided byftThe Sftaftfisftficafl Ofi ce offftThe Repubflfic off Sflovenfia.

Varfiabfles

Causes off deaftThrecordedfin 1992 and 1995, wThenICD-9 wassftfiflflfinfforce, wererecflassfifi ed finfto correspondfing dfiagnosesffromICD-10. Ffive fleadfing causes off deaftTh werefidenftfifi ed, wfiftThftThe remafinfing varfious causes cflassfifi ed underftThe “oft -Ther” caftegory.

MoftTher ftongue was used finsftead off decfla -red naftfionaflfifty becausefift was a morereflfiabfle and consfisftenft cTharacfterfisftfic. Th e dafta were grouped finftoffour caftegorfies: Sflovene, mfinorfifty(Iftaflfian or Hungarfian),fformer Yugosflavfian, and oftTher.

YPLL caflcuflaftfion was based on morftaflfiftyfta -bflessftraftfifi ed by age,sex, andsftaftfisftficaflregfionffor ftThereflevanft caflendar years(16,17). Sfince agefin ftThese ftabfles was presenfted fin groups, flfinear fin -fterpoflaftfion was appflfied, excepftfforftThe ofldesft age group(≥85 years), wThereflfinear exftrapoflaftfion up fto ftThe ThfigThesft observed age aft deaftTh (102 and 104ffor men and women,respecftfivefly) was used.

To modefl morftaflfiftyraftes based onffacftors oft -TherftThanregfion,ftThe popuflaftfion counftffrom 1992 by marfiftaflsftaftus, moftTherftongue, and educaftfion was esftfimafted byflfinearfinfterpoflaftfionffrom dafta ffromftThe 1991 and 2002 Censuses. Th eftwo cen -sus daftabases were made comparabfle ftThrougTh recaflcuflaftfion byftThe Sftaftfisftficafl Ofi ce offftThe Re -pubflfic off Sflovenfia (Thftftp://www.sftaft.sfi/eng/). Be -cause off known nonflfinearftrendsfin varfious po -puflaftfion cTharacfterfisftficssfinceftThe earfly 1990s,ftThe same procedureffor 1995 and 1998 woufldfinftro -duceftoo mucThfimprecfisfionffor useffufl modeflfing.

Sftaftfisftficafl anaflysfis

Assocfiaftfions beftween ftThe anaflyzed ffacftors and causes off deaftTh were anaflyzed by bfivarfia -fte conftfingency ftabfles, sftraftfified by sex, because ftThe fiftftfing off ThfierarcThficafl flogflfinear modefls Thad sThowed nosftaftfisftficaflflysfignfifi canftfinfteracftfion off ftThe observed assocfiaftfions wfiftTh age. YPLL and age aft deaftTh were anaflyzed wfiftTh muflftfi-way anaflysfis off varfiance(ANOVA, generaflflfinear modefl wfiftTh poflynomfiafl conftrasfts). Because off dafta coflflecftfion consftrafinfts, Pofissonregressfion was appflfied onfly unfivarfiaftefly, wThereby dfiff erencesfinftThe morftaflfifty raftes beftweenregfions wereftesftedffor aflflftTheftThree sftudfied years. Th e dfiff erences assocfiafted wfiftTh ma -rfiftaflsftaftus, moftTherftongue, and educaftfion were anaflyzed onflyffor 1992. Sftaftfisftficafl anaflyses were perfformed wfiftTh SPSS ffor Wfindows 12.0.2 soff -ftware(SPSSInc., CThficago,IL, USA, 2004).

Resuflfts

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-fformedftThe anaflysfis off cause off deaftTh and morfta -flfiftyrafteffor eacTh offftThesftudfiedffacftors.

Age and sex

InftThe anaflyzed popuflaftfion group aged 25fto 64 years, men Thad consfiderabfly ThfigTher morftaflfi -ftyftThan women(Tabfle 1). Specfifi c morftaflfiftyrafte was aflso mucTh ThfigTherffor menftThanffor women, wfiftThftThefindex off excess morftaflfiftyffor men excee -dfing 200fin aflfl age groups(Ffigure 1). ForftThe de -aftThsfinftThe wThofle 25-64 age group,ftThefindex was 234, 225, and 233,fin 1992, 1995, and 1998,res -pecftfivefly.

Th e sftrucfture off ftThe causes off deaftThs cThan -ged wfiftTh age. The mafin causes off deaftThfin men aged 25-44 years werefinjurfies, mosft oft en cau -sed byftrafi c accfidenfts. For men,ftThe probabfiflfi -fty off dyfingffrom neopflasms or cfircuflaftory dfisea -sesfincreased wfiftTh age, wThereasftThe probabfiflfifty off dyfing ffrom oftTher causes decreased. Neopflasms,

parftficuflarfly cervficafl and breasft cancer, became moreffrequenft cause off deaftThfin women aged 35 -44 years.Injures werereflaftfiveflyrare, wThereas cfir -cuflaftory dfiseases prevafifled as a cause off deaftThfin boftTh men and women aged 55-64 years.In gene -rafl,ftThe dfisftrfibuftfion off causes off deaftTh wassfimfiflar fin aflflftThree observed years(Ffigure 2).

Marfiftafl sftaftus

Sfingfle men and women dfiedflessffrequenftfly ffrom neopflasms and moreffrequenftflyffromfinju -rfies and pofisonfings orrespfiraftorysysftem dfiseases (Tabfle 2). Addfiftfionaflfly,sfingfle men aged 25fto 64 dfied off cfircuflaftory dfiseases fless ffrequenftfly ftThan

Tabfle 1. Number and percenftage off deaftThs by age and sexfin Sflovenfiafin 1992, 1995, and 1998 No.(%) off deaftThsfin year*

1992 1995 1998

Age group(y) ftoftafl men women ftoftafl men women ftoftafl men women 0-24 313 (1.7) 224 (71.6) 89 (28.4) 273 (1.5) 198 (72.5) 75 (27.5) 254 (1.4) 190 (74.8) 64 (25.2) 25-64 5340(29.2) 3733(69.9) 1607(30.1) 4897(27.2) 3388(69.2) 1509(30.8) 4579(25.3) 3216(70.2) 1363(29.8) ≥65 12 616(69.1) 5453(43.2) 7163(56.8) 12 858(71.3) 5574(43.4) 7284(56.6) 13 289(73.3) 5825(43.8) 7464(56.2) Toftafl 18 269(100.0) 9410(51.5) 8859(48.5) 18 028(100.0) 9160(50.8) 8868(49.2) 18 122(100.0) 9231(50.9) 8891(49.1)

*InftTheftoftafl coflumns,ftThe percenftagefin parenftThesesfisftThe proporftfion off deaftThsfinftThe gfiven age groupfinftThe enftfire popuflaftfionfforftThe gfiven year;ffor men and women, ftThe percenftagefin parenftThesesfisftThe proporftfion off deaftThs off peopfle offftTherespecftfive sex wfiftThfinftThe gfiven age groupfforftThe gfiven year.

Ffigure 1. Index off excess specfifi c morftaflfifty off menfin Sflovenfiaffor ftThe sftudfied yearsffor dfifffferenft age groups. Age-specfifi c morftaflfi -fty off women equafls 100. Symbofls andflfines denofte age groups: cflosed dfiamonds wfiftTh dasTh-doftflfine – 25-34 y; open squares wfiftTh dasThedflfine – 35-44 y; openftrfiangfles wfiftThftThfin soflfidflfine – 45-54 y; cflosed cfircfles wfiftThftThfick soflfidflfine – 55-64 y.

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men wTho were or Thad been marrfied. AftftThesame ftfime, marrfiage was assocfiafted wfiftThfincreasedrfisk off deaftTh ffrom neopflasms, parftficuflarfly ffor men (especfiaflfly deaftTh ffrom flung cancer). Th ere was aflso pronounced premafture morftaflfifty ffor men ffrom cfircuflaftorysysftem dfiseases, especfiaflflyfiscThe -mfic Thearft dfisease.

As expecfted, morftaflfiftyraftes by marfiftaflsftaftus aflsosThowedsfignfifi canft dfiff erencesffor boftTh men and women(P<0.001ffor comparfison wfiftThftThe dfivorced, wTho wereftaken asftThe baseflfine). Marrfi -age provedfto be asftrong proftecftfiveffacftorfinftThe sense offflower morftaflfiftyrafteffor boftTh men and women(esftfimafted 1.86ftfimesffor men and 1.88 ftfimesffor women). Befingsfingfle was aflso assocfia -fted wfiftThflower morftaflfiftyrafte, evenftThougThfto a flesser exftenftffor women(esftfimafted 1.30ftfimes vs 1.46ftfimesffor men). OnftThe oftTher Thand, morftaflfi -ftyraftefforftThe wfidowed exceededftThaftfforftThe dfi -vorced by an esftfimaftedffacftor off 1.48ffor women and 1.90ffor men.

Educaftfion and moftTher ftongue

Th e assocfiaftfion beftween educaftfionflevefl and cause off deaftTh sThowed dfifferenft morftaflfifty pa -ftfternsfin men and women(Tabfle 3). For men, Thfi -gTher educaftfionaflflevefl was assocfiafted wfiftThflower

sThare off deaftThsffrom dfigesftfivesysftem andrespfi -raftorysysftem dfiseases, wThereasftTheflowesft educa -ftfionaflflevefl was assocfiafted wfiftThfincreasedsThare off respfiraftory sysftem dfiseases. Women wfiftTh ThfigTh -scThoofl or ThfigTherflevefl off educaftfion dfied more off -ftenffrom neopflasms andfinjurfies and pofisonfings, wThereas ftThe fleasft educafted women (wfiftTh unfi -nfisThed eflemenftaryscThoofl) dfiedreflaftfiveflyffrequ -enftfly ffrom cfircuflaftory dfiseases, buft rarefly ffrom neopflasms.

Th ere was a cflear assocfiaftfion beftween edu -caftfionflevefl and morftaflfiftyraftefin boftTh men and women.Iff vocaftfionaflscThoofl wasftaken asftThe ba -seflfine,ftThe esftfimafted morftaflfiftyraftefforftThose wfiftTh ThfigThscThoofl educaftfion was noftsfignfifi canftflyflower (by esftfimaftedffacftor off 1.08ffor men,P = 0.141; and by esftfimafted ffacftor 1.03 ffor women, P = 0.759). However, ftThe esftfimafted morftaflfifty raftefforftThose wfiftTh coflflege or unfiversfiftyflevefl off educaftfion wassfignfificanftflyflower(by esftfimafted ffacftor off 1.72ffor men,P<0.001; and by esftfima -ftedffacftor off 1.40ffor women,P = 0.009), wThe -reasfforftThose wfiftTh eflemenftaryscThoofl educaftfion fift was ThfigTher(by esftfimaftedffacftor 1.74,P<0.001 ffor boftTh men and women) and ffor unfi nfisThed eflemenftaryscThooflfift wasftThe ThfigThesft(by esftfima

-Tabfle 2. Assocfiaftfion beftween marfiftafl sftaftus and cause off deaftThfforftThe deceased aged 25-64 years Sflovenfia, sftraftfifi ed by year and sex* Cause off deaftTh

neopflasms cfircuflaftory dfiseases finjurfies and pofisonfings dfigesftfive sysftem dfiseases respfiraftory sysftem dfiseases oftTher Marfiftafl sftaftus men women men women men women men women men women men women Sfingfle:

1992 – – – + + + + +

1995 – – + + + +

1998 – – – + + + + + +

Marrfied:

1992 + + + –

1995 + + –

1998 + + – – –

Wfidowed:

1992 + – + +

1995 +

1998 + +

Dfivorced: 1992 1995 1998

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ftedffacftor off 2.44ffor men and 2.66ffor women, P<0.001ffor boftTh).

We dfid noft fi ndsfignfifi canft dfiff erencesfinftThe dfisftrfibuftfion off causes off deaftTh accordfingfto moft -Therftongue, buft we dfid fi nd sfignfifi canft dfiff eren -ces fin ftThe morftaflfifty rafte. In comparfison wfiftTh members off eftThnfic mfinorfiftfies, wTho were ftaken asftThe baseflfine, andfimmfigranftsffrom oftTher parfts offfformer Yugosflavfia, wTho dfid noftsubsftanftfiaflfly dfiff erfin morftaflfiftyrafteffromftThe mfinorfiftfies, eftTh -nfic Sflovenfians Thad sfignfificanftfly flower morftaflfi -ftyrafte(by esftfimaftedffacftor off 2.26ffor men and 2.53ffor women, P<0.001ffor boftTh). Th e anaflysfis aflsosThowedftThaft morftaflfiftyrafte wassfignfifi canftfly ThfigTherfforftThe “oftTher” group(P<0.001ffor boftTh men and women), buftftThfis group wassmaflfl and exftremefly Thefterogeneous.

GeograpThficafl regfion

FoflflowfingftThe meftThodoflogy offftTheInsftfiftufte ffor Economfic ResearcThfin Ljubfljana,ftThe Urban Pflannfing Insftfiftufte off ftThe Repubflfic off Sflovenfia, andftThe Facuflfty off Economficsfin Ljubfljana,ftThe

12 sftaftfisftficafl regfions off Sflovenfia were grouped finfto ftThree cflusfters accordfing fto deveflopmenftafl opporftunfiftfies:(fi) prosperous regfions, wfiftTh posfiftfi -vefly assessed deveflopmenftafl poftenftfiafl – Osred -njesflovenska, Obaflno-kraška, Gorenjska, Doflenj -ska, and Gorfiška;(fifi)sftagnanft regfions, wfiftThsome posfiftfivefly assessed deveflopmenftafl poftenftfiafl – Sa -vfinjska, Podravska, Koroška, and Noftranjsko -kraška; and (fififi) regfions wfiftTh poor socfioeconomfic condfiftfions, wfiftTh flfimfifted deveflopmenftafl poftenftfi -afl – Spodnjeposavska, Pomurska, and Zasavska. Th ere were dfiff erences beftween cflusfters offregfi -onsfin causes off deaftTh aft age 25-64 years(Ffigure 3). For boftTh men and women,ftThesThare off neo -pflasms was ftThe ThfigThesft (up fto 1/2 ffor women and 1/3ffor men)finftThe mosft prosperousregfi -ons. Conversefly,ftThesThare off cfircuflaftory dfiseases (and dfigesftfive sysftem dfiseases ffor women) was ThfigTher(by <5%)finftThesftagnanftregfions andregfi -ons wfiftTh poorsocfioeconomfic condfiftfions.

Th e dfifferences beftween ftThe regfions fin age aft deaftTh and morftaflfiftyrafte were veryflarge and dfid noft correspondsfimpflyftoftThe abovemenftfio

-Tabfle 3. Assocfiaftfion beftween educaftfionflevefl and cause off deaftThfforftThe deceased aged 25-64 yearsfin Sflovenfia, sftraftfifi ed by year and sex*

Cause off deaftTh

neopflasms cfidfiseasesrcuflaftory finpojufisonrfiesfings and sysftemdfiges dfiseasesftfive sysftemresp dfirafiseases ftory oftTher Educaftfionflevefl men women men women men women men women men women men women Unfi nfisThed eflemenftary

scThoofl: 1992

1995 – + – +

1998 – + – + + +

Eflemenftary scThoofl:

1992 –

1995 +

1998 + +

Vocaftfionafl scThoofl:

1992 – –

1995 +

1998 –

HfigTh scThoofl:

1992 –

1995 + + + – – – –

1998 + + – – –

Coflflege or unfiversfifty:

1992 + – + – –

1995 – + – –

1998 + – – –

(7)

ned cflusfters offregfions(Tabfle 4). Lfiffe expecftan -cy wasfincreasfingffor boftTh men and women(by abouft 0.2 years per yearffor men and 0.4 years per yearffor women, on average), andftThe dfiff erence beftweenftThe mosft andftThefleasftffavorabfleregfions seemedfto be decreasfing. For men,ftThe dfiff eren -cefin average age aft deaftTh dropped by 1.7 years beftween 1992 and 1998;ffor boftTh men and wo -men,ftThere were noregfions wfiftTh morftaflfiftyraftesfi -gnfifi canftfly above averagefin 1998, unflfikefin 1992 and 1995.

Years-off-poftenftfiafl-flfiffe-flosft

We opftedffor modeflfing onflyfforftThe deaftThs aft age 25-64 years,sftraftfifi ed bysex, wThereby aflflftThe reftfired were excfludedffromftThesampfle onftThe ba -sfis off occupaftfion sftaftus dafta. Sfince 84% off ftThe reftfired popuflaftfion dfied aft age 55-64 years,ftThey were excfluded because our anaflysfis wasffocused onftThe acftfive popuflaftfion. Excflusfion offftThereftfi -rees aflso cThangedftThe dfisftrfibuftfion off YPLLffrom exftremeflyrfigThft-skewed(exponenftfiafl-flfike)fto cflo -sefto normafl, wThficTh aflflowed usfto useftThe generafl

(8)

flfinear modefl. Thesub-sampfle(n= 7192) consfi -sfted off 5166 men and 2026 women.

Because offfincreasfingflfiffe expecftancy, wefin -cfluded year off deaftTh amongftThe predficftors. Ma -rfiftaflsftaftus was excfluded because onflysfingfle peo -pfle can geft marrfied and onfly marrfied peopfle can geft dfivorced or wfidowed. Th ereffore,ftThe dfivorced andftThe wfidowed Thad ThfigTher average age aft deaftTh and Thenceflower average YPLL wfiftThrespecftfto ftThe oftTherftwo groups. Th esfingfle ThadftTheflowesft average age aft deaftTh and ThfigThesft average YPLL (fin oursampfle, aflflftThese dfiff erences werefinftThe expecfted dfirecftfion andsfignfifi canftaftP<0.001ffor boftTh men and women).

For boftTh men and women,ftTheseflecfted mo -defl wassftaftfisftficaflflysfignfifi canft (P<0.001), aflftTho -ugThfift expflafinedreflaftfiveflyflfiftftfle varfiance, 5%ffor men and 11% ffor women. For boftTh men and women, year off deaftTh, wThficTh accounftedfforftThe generaflfincreasfingftrendfinflfiffespan, was a ThfigThfly sfignfifi canft predficftor(P<0.001). AmongftTheftwo socfioeconomfic ffacftors, onfly educaftfionafl flevefl wassftaftfisftficaflflysfignfifi canftffor men(P = 0.002), wThereas moftTher ftongue (P = 0.723) and finfte -racftfion beftween educaftfion and moftTher ftongue (P = 0.116) were noft. For women, ftThe resuflfts were verysfimfiflar(P = 0.249ffor moftTherftongue), aflftThougTh educaftfion proved onfly margfinaflflysfignfi -fi canft(P = 0.055) andfifts eff ecftsfignfifi canftfly dfiff -ffered wfiftThrespecftfto moftTherftongue(P = 0.002 fforfinfteracftfion).

Th e generaflsThape offftThe assocfiaftfion beftween educaftfionafl flevefl and YPLL was ftesfted by pofl -ynomfiafl conftrasfts off order upfto 4(because off 5 flevefls offftThe varfiabfle), andffor boftTh men and wo -men onflyftThe quadraftfic conftrasft wassfignfifi canft (P = 0.001 and P =0.035ffor men and women, respecftfivefly). Thfis corresponds wfiftThftThe observa -ftfionftThaftfinftThe acftfive popuflaftfion excfludfingftThe earflyreftfired,ftThe average YPLLftendedfto beftThe flowesft ffor ftThe deceased wfiftTh efiftTher ftThe flowesft (unfinfisThed eflemenftary scThoofl) or ftThe ThfigThesft (coflflege or unfiversfifty degree) educaftfionafl flevefl. Admfiftftedfly,ftTheftrend accordfingfto moftTherfton -gue varfied and wasflfinearfly decreasfingffor eftThnfic Sflovenfian women (fie, ftThe more educafted ftThey were,ftThe youngerftThey dfied).

Aflfl sftaftfisftficafl concflusfions were ftThe same wThen we modefled age aft deaftThfinsftead off YPLL. Hence, ftThe assocfiaftfion off educaftfionaflflevefl and moftTherftongue wfiftTh YPLL and age aft deaftThfto -geftTher wassThown by pfloftftfingftThe esftfimafted mar -gfinafl meansffromftThe modefl wfiftTh correspondfing sftandard errors(Ffigure 4).

Dfiscussfion

WThen age andsex as bfioflogficaflffacftors arefin -cfludedfin expflanaftory modefls,ftThefir eff ecfts gene -raflflyflowerftThe esftfimaftedfinfl uence off oftTherffac -ftors on (fin)equaflfifty fin TheaflftTh. Off course, ftThe majorfifty off deaftThs occurrfing eacTh year are con

-Tabfle 4. Age aft deaftTh off men and womenfin Sflovenfia and dfifffferences beftween Sflovenfianregfions wfiftThrespecftfto age aft deaftTh and morftaflfiftyrafte

Mean(medfian) age Age aft deaftThfinregfion(mean, y) Regfions wfiftTh morftaflfiftyrafte* Year aft deaftThfin Sflovenfia(y) flowesft ThfigThesft dfifffference above average beflow average 1992:

men 66.3(68) Zasavska(63.8) Gorfiška(70.0) 6.2 Zasavska, Spodnjeposavska,

Doflenjska ObaOsrednflno-kjesraškaflovenska, women 74.8(79) Zasavska(73.7) Gorfiška(77.1) 3.4 none Osrednjesflovenska 1995:

men 66.8(68) Doflenjska(65.0) Noftranjsko-kraška(69.3) 4.3 Pomurska, Doflenjska Obaflno-kraška, Osrednjesflovenska, Gorfiška women 75.4(79) Koroška(73.9) Gorfiška(78.8) 5.0 Zasavska Gorfiška, Gorenjska

Osrednjesflovenska 1998:

men 67.0(69) Doflenjska(65.3) Noftranjsko-kraška(69.8) 4.5 Spodnjeposavska, Pomurska none women 76.1(78) Koroška(75.0) Noftranjsko-kraška(78.4) 3.3 Spodnjeposavska, Pomurska none

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cenftrafted fin oflder age groups, wThficTh makes fift even more dfifi cuflftfto esftfimaftereflfiabflyftThe eff ecft offsocfioeconomficffacftors on morftaflfifty aftftThe age beflow 65. NeverftThefless,sex dfiff erencesfin morfta -flfiftyraftes and causes off deaftThs can be aftfleasft par -ftfly aftftrfibuftedfto dfiff erenftflfiffesftyfles. Th us, one can speak abouftffemafle as opposedfto mafle dfiseases and causes off deaftTh(18), and ourresuflfts arefin accord wfiftThftThaft.

Our resuflfts regardfing ftThe fimpacft off marfi -ftaflsftaftus on morftaflfifty werefinflfine wfiftThftThe co -njecftureftThaftsftabfle parftnersThfip generaflfly acfts as proftecftfiveffacftorregardfing TheaflftThftThrougTh emo -ftfionafl supporft and dfirecft and findfirecft benefifts off socfiafl neftworks. However, ftThe wThofle fissue fis mucTh more compflex and fincorporaftes varfio -us gender rofles wfiftThfin and ouftsfide parftnersThfip (19), asfindficafted by our fi ndfingsftThaftftThe acftfive mafle popuflaftfion was aft pronouncedrfisk off deaftTh ffrom neopflasms or cfircuflaftory dfiseases, andftThaft morftaflfiftyraftefforsfingfle men dfid noft dfiff erffrom ftThaftfforftThe marrfied men, wThereas morftaflfiftyrafte fforsfingfle women was ThfigTherftThanftThaftffor marrfi -ed women. NeverftThefless,ftermfinaftfion off parftner -sThfip because off dfivorce or deaftTh offftThe parftner finevfiftabflyfincurred ThfigTherrfiskfinfterms off dfisea -se-specfifi c morftaflfifty(duefto dfigesftfivesysftem dfi -seasesffor women) and/or morftaflfiftyraftefin gene -rafl.

As expecfted, educaftfion was sftrongfly assocfi -afted wfiftTh cause off deaftTh. However,ftThefform off ftThe assocfiaftfion was qufifte dfiff erenftffor men and women. Sfimfiflarflyfto marfiftaflsftaftus,fiftsThowedftThe fimpacft off dfifferenft flfiffesftyfles on morftaflfifty. Th e fi ndfingftThaft morftaflfiftyrafte wasfinverseflyreflafted fto educaftfionfleveflfinftThe acftfive popuflaftfion provfi -ded cflear evfidence offsocfiaflsftraftfifi caftfion corres -pondfing fto educaftfion flevefl. Socfiafl sftraftfifi caftfion based on moftTherftongue and assocfiafted naftfiona -flfifty was noftrefl ecftedfinftThe causes off deaftTh offftThe acftfive popuflaftfion, buftfift wasrefl ecftedfinftThe mor -ftaflfiftyrafte.

Our anaflysfis off YPLL sThoufld be ftaken as a compflemenft fto ftThe finvesftfigaftfion off premafture

morftaflfiftyfin Sflovenfiafin 1998 by Šeflb Šemrfl and Šešok(20), as weflfl asftoftThereporft on causes off deaftTh and morftaflfiftyfindficesfin Sflovenfiafin 2001 by Zadnfik and Šeflb(21).Iftfis aflsoreflaftedftoftThe wfide bfiosftaftfisftficafl fi efld offreflaftfivesurvfivafl, wThficTh fis undergofingrapfid deveflopmenft(22,23). Furft -Thermore,finfterpreftaftfion off YPLLfin popuflaftfion sftudfiesfis probflemaftficsfince dfiff erenft caflcuflaftfion meftThods correspondfto dfiff erenft underflyfing va -fluescafles off age aft deaftTh(24). However, evenftThe basfic meftThod off caflcuflaftfing YPLLftThaft we used, wThficTh wefigThfts eacTh year off poftenftfiaflflfiffeflosft equ -aflfly, empThasfizes deaftThs aft younger age, Thencefift fisfinfformaftfiveffor asftudyffocusfing on premaftu -re morftaflfifty. AnoftTher probflem wfiftTh anaflyzfing YPLLfforftThe enftfire popuflaftfion offftThe deceased fis ftThaft compflex modefls wfiftTh many finfteracftfion

(10)

fterms arerequfiredfto geft beyondftrfivfiafl fi ndfings, buft wfiftThfincreasfing compflexfiftyftThe modefl-bufifl -dfing decfisfions become more arbfiftrary, wThfiflefless obvfious arftfiffacfts cansftfiflfl conftamfinafteftTheresuflfts. BearfingftThaftfin mfind, our decfisfionftosftudy onfly ftThe deaftThs aftftThe age off 25-64,sftraftfified bysex, wfiftTh ftThe reftfired popuflaftfion excfluded ffrom ftThe sampfle, provedfto be areasonabfle compromfise. Th ereflaftfiveflyflow proporftfion off varfiance expflafi -ned byftThe modeflfisfin agreemenft wfiftThftThe noftfi -onftThaft basficsocfioeconomficffacftors dofinfl uence flfiffespan, buftftThe acftuaflflfiffespan off anfindfivfiduafl fis, off course, a compflexresuflft off a Thuge number offffacftors and evenfts.

Th e fi ndfingsregardfing cause off deaftThsThoufld be vfiewedfinftTheflfigThft offftTheffacftftThaftftThe overaflfl probabfiflfifty off dyfing equafls cerftafinfty, andftThaftftThe sum offftThe causes off deaftThfis aflways 100%. Una -vofidabfly, eacThfimporftanft dropfin a cerftafin cause off deaftThfleadsfto anfincreasefin anoftTher. Hence, everyrfisefin one cause off deaftThfis noft necessarfifly areasonffor aflerft.Ift can merefly be aflogficafl con -sequence offfincreasedflfiffe expecftancy, wThficTh brfin -gsfincreased cThances off deaftTh duefto ofld-age dfise -ases. However,ftThfis eff ecft was noft pronouncedfin our anaflysfis, wThficThfisffocused on premafture mor -ftaflfifty, fie, deaftThs aft age <64 years. NeverftThefless, ftThe observed varfiaftfions beftween years mayrefl ecft cThangesfin deaftTh-cause deftermfinaftfion and/orre -porftfing pracftficeraftTherftThan(or aftfleasft,fin addfiftfi -onfto) acftuafl cThangesfin morftaflfifty causes.

In any case, by flfinkfing dfiff erenft daftabases, useffuflfinfformaftfion can be obftafined abouft varfious dfimensfions off TheaflftTh and dfisease. Dfirecft fi ndfings are noft onflyreflaftedftoftThe prevaflence off TheaflftTh condfiftfions, buft can provfidefimporftanftffoundaftfi -onsffor esftabflfisThfingsocfioeconomfic dfiagnoses,fie, ffor deftermfinfing TheaflftTh condfiftfion off generafl po -puflaftfion andftThereflaftedsocfioeconomficffacftors. WfiftThsucTh anaflyses, we obftafinfinfformaftfion abo -uft ftThe nafture, prevaflence, and consequences off TheaflftTh probflems.

Our sftudy represenfts a pfioneerfing eff orftfin Sflovenfia fin fterms off exThausftfive coverage off de

-ceasedfindfivfiduafls, as weflfl asfinfterms offscope off ftTheresearcTh quesftfions. FurftTher anaflyses are pfla -nned, as weflfl as perfiodfic upgradfing offftThe daftaba -se. Ourflong-fterm afimfis conftfinued monfiftorfing offftThe assocfiaftfions beftween causes off deaftTh and ftTheseflecftedffacftors,sfince aflongfiftudfinafl approa -cThfisrequfiredftoreflfiabfly assessftThe conftrfibuftfion offsocfiafl cflass aft dfiff erenftsftages offflfiffe on morfta -flfifty(25).

Our fi ndfings mayserve asftThe basfisfforseftftfing poflficy prfiorfiftfies and pflannfing poflficy measures and TheaflftTh careservficesfin generafl. Learnfing abo -uftfindfivfiduafl causes off deaftTh andftThefirreflaftfivesfi -gnfifi cance aflso aflflows usfto monfiftorftThe evofluftfi -on off pubflfic TheaflftTh. We ThopeftThaftftThfis and oftTher sfimfiflar anaflyses offftThe connecftfions beftweensocfi -oeconomfic deftermfinanfts and TheaflftTh findficaftors wfiflfl conftrfibufteftoftThe pflannfing and desfignfing off naftfionafl programsftofimproveftThe TheaflftTh offftThe popuflaftfion off Sflovenfia, as weflfl as off oftTher coun -ftrfies. Sflovenfian experfiences mfigThft provfide va -fluabflesofluftfionsffor oftTher new European Unfion membersftaftes and oftTher counftrfiesfin Europesftfi -flfl undergofingftransfiftfion(26).

Acknowfledgmenft

We ftThank ftThe Mfinfisftry off Educaftfion, Scfience and Sporft andftThe Mfinfisftry off HeaflftTh offftThe Repubflfic off Sflo -venfia, wThosupporftedftThe coflflecftfion off daftaftThrougThftThe projecft onftargeftfingfinfterregfionafl dfiff erencesfin TheaflftTh fin Sflovenfia andsearcThfingfforsofluftfionsffor dfimfinfisThfing ftThem (Projecft off Targefted ResearcTh Program V5-0571).

Refferences

1 Wfiflkfinson RG. UnTheaflftThy socfieftfies: ftThe aflficftfions off finequaflfifty. New York (NY): Rouftfledge; 1996.

2 WThfifteThead M. Th e TheaflftTh dfivfide. In: Townsend P, WThfifteThead M, Davfidson N, edfiftors. Inequaflfiftfies fin TheaflftTh: ftThe bflack reporft andftThe TheaflftTh dfivfide. 2nd ed. London: Pengufin Books; 1992. p. 219-437.

3 Gfiflflespfie R, Prfior R. HeaflftTh finequaflfiftfies. In: Gfiflflespfie R, Moon G, edfiftors. Socfiefty and TheaflftTh. Anfinftroducftfionftosocfiafl scfience ffor TheaflftTh proffessfionafls. 1sft ed. London: Rouftfledge; 1995. p. 195-211.

4 Bobak M, Bflane D, Marmoft M. Socfiafl deftermfinanfts off TheaflftTh: ftThefir reflevance fin ftThe European conftexft. Revfiew off HeaflftTh Promoftfion and Educaftfion Onflfine: Verona Infiftfiaftfive, 1998. Avafiflabfle ffrom: Thftftp://www.rThpeo.org/fij Thp-arftficfles/ e-proceedfings/verona/2/findex.Thftm. Accessed: Jufly 27, 2005. 5 Kunsft AE, MackenbacTh JP. Measurfing socfioeconomfic

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6 Marquez PV, SuThrcke M. Combaftfing non-communficabfle dfiseases. BMJ. 2005;331:174. Medflfine:16037424

7 Iflflsfley R. HeaflftTh finequfiftfies fin Europe. Comparaftfive revfiew off sources, meftThodoflogy and knowfledge. Soc Scfi Med. 1990;31:229-36. Medflfine:2218603

8 Moeflek A, Rosarfio Gfirafldes M. Inequaflfiftfies fin TheaflftTh and TheaflftTh care. Revfiew off seflecfted pubflficaftfions ffrom 18 wesftern European counftrfies. Muensfter (Germany): Waxmann; 1993. 9 Vagero D, Lefinsaflu M. HeaflftThfinequaflfiftfies andsocfiafl dynamfics

fin Europe. BMJ. 2005;331:186-7. Medflfine:16037447 10 Javornfik J, Korosec V, edfiftors. Human deveflopmenft reporft

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12 Laaser U, Breckenkamp J, UflflrficTh A, Hoffmann B. Can a decflfinefinftThe popuflaftfion means off cardfiovascuflar rfiskffacftors reduceftThe number off peopfle aft rfisk? J Epfidemfiofl Communfifty HeaflftTh. 2001;55:179-84. Medflfine:11160172

13 Zafleftefl-Krageflj L, BardeThfle D, Burazerfi G, Donev D, Laaser U. Mfinfimum TheaflftThfindficaftorseftffor PH-SEE counftrfies, fi nafl reporft. Bfiefleffefld (Germany): Insftfiftufte off Pubflfic HeaflftTh NorftTh RThfine-WesftpThaflfia (flögd); 2003.

14 BardeThfle D. Mfinfimum TheaflftThfindficaftorseftffor SouftTh Easftern Europe. Croaft Med J. 2002;43:170-3. Medflfine:11885042 15 Infternaftfionafl cflassfificaftfion off dfiseases and reflafted TheaflftTh

probflems ffor sftaftfisftficafl purposes [fin Sflovenfian]. Ljubfljana: Inšftfiftuft za varovanje zdravja Repubflfike Sflovenfije; 1995. 16 Sfirceflj M. Lfiffe ftabfles ffor ftThe popuflaftfion off Sflovenfia

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