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Inequalities in life and death: Income and mortality in an ageing population
Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.ORCID iD: 0000-0002-0582-5058
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Income serves as an indicator of success relative to others, and provides individuals with resources that strengthen their capability to face challenges and benefit from opportunities. Out of all social determinants of health, income is one of the strongest predictors of health outcomes. The positive association between income and health in the working-age population is well established; those with higher income tend to have better health. Less is known about the association between income and health among older persons. Several studies have observed that in old age, health inequalities decrease and the relationship between income and health weakens. However, at what point in the ageing process the association starts to weaken, and to what extent, is debated.

The ageing process highlights the need for several theoretical considerations in studies on income and health. Societies are stratified by age, as manifested through transitions in and out of education, work, and retirement. Moreover, the individual experience of the ageing process involves biological processes of decline. Many health problems, and particularly death, are uncommon events during most of adulthood. In old age, however, health decline becomes a normative experience, and in Sweden, more than 90 percent of all deaths occur among people aged 65 or older. The characteristics and magnitude of age-related changes in the association between income and mortality constitute one of the prime concerns in this thesis. I have used two contending perspectives to understand the empirical results: the cumulative (dis)advantage theory and the age-as-leveler hypothesis.

In this thesis, I have investigated the association between income and mortality across ages, with a focus on later life. More specifically, I studied the shape and magnitude of the income-mortality association across the life course. Furthermore, I tested two potential mechanisms that may shape this association in old age: health decline and mortality selection. Overall, this thesis shows to what extent and in what ways the association between income and mortality is maintained in old age

This thesis includes four empirical studies. Study I, II, and IV are based on data from Swedish national registers (n = 801,017 – 5,011,414). Study III used survey data (LNU and SWEOLD) linked with data from administrative registries (n = 2619). The results from Study I showed that the income-mortality association was curvilinear with diminishing returns of income in both mid-life and late-life. Study II showed that relative mortality inequalities in income decreased with age and absolute mortality inequalities in income increased with age up to age 85-90, after which the mortality inequalities decreased. The results from Study III showed that health decline partly explained the weakened income-mortality association among the oldest old. Finally, Study IV showed that selective mortality had a substantial impact on poverty rates in old age; poverty rates were consistently and substantially lower for those who survived than those who died. Furthermore, selective mortality had the largest influence on the surviving population when mortality rates were at their highest.

 

Place, publisher, year, edition, pages
Stockholm: Department of Public Health Sciences, Stockholm University , 2019. , p. 63
Series
Stockholm Studies in Public Health Sciences, ISSN 2003-0061 ; 1
Keywords [en]
income, health, mortality, ageing, inequality, age-as-leveler, cumulative disadvantage
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public Health Sciences
Identifiers
URN: urn:nbn:se:su:diva-167822ISBN: 978-91-7797-698-1 (print)ISBN: 978-91-7797-699-8 (electronic)OAI: oai:DiVA.org:su-167822DiVA, id: diva2:1302480
Public defence
2019-05-27, De Geersalen, Geovetenskapens hus, Svante Arrhenius väg 14, Stockholm, 10:00 (English)
Opponent
Supervisors
Note

At the time of the doctoral defense, the following papers were unpublished and had a status as follows: Paper 3: Manuscript. Paper 4: Manuscript.

Available from: 2019-05-02 Created: 2019-04-04 Last updated: 2019-04-23Bibliographically approved
List of papers
1. The shape of the association between income and mortality in old age: A longitudinal Swedish national register study
Open this publication in new window or tab >>The shape of the association between income and mortality in old age: A longitudinal Swedish national register study
2016 (English)In: SSM - Population Health, ISSN 2352-8273, Vol. 2, p. 750-756Article in journal (Refereed) Published
Abstract [en]

This study used data on the total population to examine the longitudinal association between midlife income and mortality and late-life income and mortality in an aging Swedish cohort. We specifically examined the shape of the associations between income and mortality with focus on where in the income distribution that higher incomes began to provide diminishing returns. The study is based on a total Swedish population cohort between the ages of 50 and 60 years in 1990 (n=801,017) followed in registers for up to 19 years. We measured equivalent disposable household income in 1990 and 2005 and mortality between 2006 and 2009. Cox proportional hazard models with penalized splines (P-spline) enabled us to examine for non-linearity in the relationship between income and mortality. The results showed a clear non-linear association. The shape of the association between midlife (ages 50-60) income and mortality was curvilinear; returns diminished as income increased. The shape of the association between late-life (ages 65-75) income and mortality was also curvilinear; returns diminished as income increased. The association between late-life income and mortality remained after controlling for midlife income. In summary, the results indicated that a non-linear association between income and mortality is maintained into old age, in which higher incomes give diminishing returns.

Keywords
Income, Health inequality, Mortality, Old age, Late-life, Non-linear, Diminishing returns, Sweden
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public Health Sciences
Identifiers
urn:nbn:se:su:diva-167818 (URN)10.1016/j.ssmph.2016.10.005 (DOI)29349186 (PubMedID)
Available from: 2019-04-04 Created: 2019-04-04 Last updated: 2019-04-05Bibliographically approved
2. Divergence and Convergence: How Do Income Inequalities in Mortality Change over the Life Course?
Open this publication in new window or tab >>Divergence and Convergence: How Do Income Inequalities in Mortality Change over the Life Course?
2019 (English)In: Gerontology, ISSN 0304-324X, E-ISSN 1423-0003, Vol. 65, no 3, p. 313-322Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Do inequalities in health by income increase or decrease with age? The empirical evidence is not conclusive and competing theories arrive at different conclusions.

OBJECTIVE: This study examined inequality in mortality by income over the adult life course with longitudinal data on people aged 30-99 between the years 1990 and 2009. Each person was followed for 19 years.

METHODS: We used Swedish total population data with 5,011,414 individual observations. We calculated the probability of having died for ages between 31 and 99. This approach to calculating death risk incorporates selective mortality during the follow-up period into the measure. Age and year standardized income positions were calculated for all individuals. Inequality was assessed by comparing the top 10% income group and the bottom 10% income group. Relative inequality was measured by risk ratios (RR) and absolute inequality by percentage point differences.

RESULTS: The results showed that the highest relative income inequality in mortality was at age 56 for men (RR: 4.7) and at age 40 for women (RR: 4.1) with differing patterns across the younger age categories between the sexes. The highest absolute income inequality in mortality was found at age 78 for men (19% difference) and at age 89 for women (14% difference) with similar patterns for both sexes. Both measures of inequality decreased after the peak, with small or no inequalities above age 95. Income inequality in mortality remained in advanced age, with larger absolute inequalities in older ages and larger relative inequalities in younger ages.

CONCLUSION: The results for absolute and relative measures of inequality differed substantially; this highlights the importance of discussing and making an active choice of inequality measure. To explain and understand the patterns of inequality in mortality over the adult life course, we conclude that the "age-as-leveler" and "cumulative disadvantage" theories are best applied to an absolute measure of inequality.

Keywords
Absolute inequality, Aging, Income, Mortality, Old age, Relative inequality
National Category
Public Health, Global Health, Social Medicine and Epidemiology Gerontology, specialising in Medical and Health Sciences
Research subject
Public Health Sciences
Identifiers
urn:nbn:se:su:diva-167817 (URN)10.1159/000494082 (DOI)000467677700013 ()30636252 (PubMedID)
Available from: 2019-04-04 Created: 2019-04-04 Last updated: 2019-05-27Bibliographically approved
3. What levels the association between income and mortality in later life: age or health decline?
Open this publication in new window or tab >>What levels the association between income and mortality in later life: age or health decline?
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Objectives

Researchers frequently use the “age-as-leveler” hypothesis to explain decreasing inequality and a weakened relationship between socioeconomic position and health in old age. This study examined whether health status can explain the age pattern in the association between income and mortality as predicted by the age-as-leveler hypothesis.

Method

This study used longitudinal (1991–2002) data from the SWEOLD and LNU surveys. The analytical sample consisted of 2619 people aged 54 to 92 in 2003. Mortality (2003-2014) and income (1991-2000) was collected from Swedish national registers. Poisson regression was used to estimate associations between mortality, income, age, and health status. Average marginal effects were used to visualize interaction effects between income and age.

Results

The association between income and mortality weakened in those 84 and older. However, health status explained a large part of the effect that age had on the association between income and mortality. Analyses done after stratifying the sample by health status showed that the association between income and mortality was strong in people who reported good health and weak or non-existent in those who reported poor health.

Discussion

Age leveled the income-mortality association; however, health status, not age, explained most of the leveling.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public Health Sciences
Identifiers
urn:nbn:se:su:diva-167820 (URN)
Available from: 2019-04-04 Created: 2019-04-04 Last updated: 2019-04-05Bibliographically approved
4. Poverty after 63: the impact of selective mortality
Open this publication in new window or tab >>Poverty after 63: the impact of selective mortality
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: The amount and share of older people in developed countries are growing dramatically and poverty among them is relatively high. If life expectancy continues to increase and a larger segment of the population reaches old age, we may expect to see increased poverty rates among the old.

Objective: The objective of this study was to examine poverty rates in six cohorts aged 63-101 in Sweden during 1990 to 2006, as well as the impact of selective mortality on old age poverty rates during the study period.

Methods: We used Swedish total population data with 1 293 434 individual observations. We calculated poverty rates for six cohorts of women and men aged 63 to 86 at baseline, and followed the cohorts for 15 years. The impact of selective mortality on poverty rates was assessed by comparing poverty in the complete cohort with a sample of the cohort that survived for the duration of the follow-up period.

Results: Poverty rates increased with age for men and women in all six cohorts. Women experienced substantially higher poverty rates than did men. Those who survived during the 15-year follow-up period had 8-32 percent lower poverty rate at baseline compared to the complete cohort poverty rate. Men experienced larger poverty differences between the complete cohort sample and the survivor sample in the younger cohorts than did women. Women experienced larger poverty differences between the complete sample and the survivor sample in the oldest cohort than did men.

Conclusion: Selective mortality influences poverty rates greatly. In a scenario where everyone lives longer and other things is held constant, the results from this study suggest that poverty rates among the old could be substantially higher.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public Health Sciences
Identifiers
urn:nbn:se:su:diva-167821 (URN)
Available from: 2019-04-04 Created: 2019-04-04 Last updated: 2019-04-05Bibliographically approved

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