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Estonia 1989–2000: enormous increase in mortality differences by education

Estonia 1989–2000: enormous increase in mortality differences by education Abstract Background Having regained its political autonomy in 1991, Estonia experienced major changes in political, economic, and social realities. We aimed to analyse mortality changes by education from 1989 to 2000 in order to assess the impact of recent changes in Estonia, as well as the delayed effects of pre-transitional developments. Methods Two census-based analyses were compared. Individual cause-specific death data for those aged 20+ for 1987–1990 (72 003 deaths) and 1999–2000 (35 477 deaths) came from the national mortality database. Population denominators came from the population censuses of 1989 and 2000. Mortality for all causes combined and for selected causes of death were analysed for high, mid, and low educational groups. The absolute differences in mortality were evaluated through life expectancy at age 25 and age-standardized mortality rates. To assess the relative differences between educational levels, mortality rate ratios with 95% CI were calculated using Poisson regression. Results Educational differences in mortality increased tremendously from 1989 to 2000: over the 10-year period life expectancy improved considerably for graduates, and worsened for those with the lowest education. In 2000, male graduates aged 25 could expect to live 13.1 years longer than corresponding men with the lowest education; among women the difference was 8.6 years. Large differences were observed in all selected causes of death in 1989 and in 2000 and the trends were invariably much more favourable for the higher educated. Educational differences in total mortality increased in all age groups. Conclusions Social disruption and increasing inequalities in wealth can be considered main recent determinants; however, causal processes, shaped decades before recent reforms, also contribute to this widening gap. Cause-specific mortality, educational differences, transition, Estonia Socioeconomic differences in mortality have been extensively reported in the West.1–3 The last decades have witnessed an increase in relative mortality rate ratios in many countries, although absolute differences are more stable.4–7 Less is known about ex-communist countries. Studies suggest that educational differences in mortality in Eastern Europe at the end of the communist era were at least as big as in the West.8,9 Estonia, the smallest country in the Baltic region, regained its political autonomy in 1991 after 50 years of Soviet occupation. Estonia opted for much more far-reaching and intense free market reforms than other transition economies in Central Europe and the former Soviet Union. Deliberate policies were aimed at stimulating job creation and employment (including international trade opportunities and foreign ownership of firms), above all by low employment protection and reduced social safety nets.10 Its mortality development over the past 40 years has been similar to other ex-communist countries: male life expectancy improved by only about 1 year and female by 4 years from 1959 to 2000. During the first years of political and economic transition, Estonia experienced an unprecedented rise in mortality11 (Figure 1). After 1994, mortality rates returned to the levels found before the 1990s. To assess the impact of recent reforms and the delayed effects of pre-transitional developments we analysed mortality changes by education from 1989 to 2000. Data and Methods Two census-based cross-sectional analyses were performed. Individual cause-specific death data for those aged 20+ for 1987–1990 (72 003 deaths) and 1999–2000 (35 477 deaths) came from the national mortality database. Population denominators came from the population censuses of 1989 and 2000. Total mortality and selected causes of death were analysed for three educational groups (university, upper secondary, and lower secondary or less education). In 1987–1990 the abridged Soviet version of International Classification of Diseases, Ninth Revision (ICD-9) was used for coding the causes of death; a correspondence table was then used to reclassify the causes of death into ICD-9.12 For 1999–2000 ICD-10 was used. Table 1 presents corresponding categories of ICD-9 and ICD-10 for the selected causes of death. Educational differences in total mortality were analysed in four age groups: 20–39, 40–54, 55–69, and 70+. The absolute differences in mortality were evaluated through life expectancy at age 25 and age-standardized mortality rates (European standard population). To assess the relative differences between educational levels, mortality rate ratios with 95% CI were calculated using Poisson regression. Age was adjusted in 5-year intervals in the regression analyses. Results The proportion of the population with high and middle educational levels rose from 1989 to 2000. This was balanced by a reduction in the proportion of the population with low education (Table 2). The educational distribution remained stable in the youngest age group. We found a sharp increase in educational differences in mortality from 1989 to 2000 among men and women. Over the 10-year period, life expectancy improved considerably for graduates, and worsened for those with the lowest education. Life expectancy remained stable among women with middle education; for the corresponding group of men it fell (Figure 2). In 2000, male graduates aged 25 could expect to live 13.1 years longer than corresponding men with the lowest education; among women the difference was 8.6 years. Educational differences in total mortality increased in all age groups (Table 3). These increases were largest among younger age groups, but were also to be found among the elderly. Table 4 presents educational differences in mortality by selected causes of death. Large differences were observed in all those causes in 1989 and 2000. Mortality trends were invariably much more favourable for the higher educated. Circulatory diseases had the largest impact on the widening mortality gap. Discussion The enormous increase in mortality differences by education raises the question of data reliability. In unlinked, census-based, cross-sectional studies, the numerator-denominator bias is of greatest concern. We carefully analysed whether there were differences between census records and death certificates with respect to the coverage of population, the reporting or non-response, or the classification of educational level. However, we were unable to identify any data problems that would seriously affect results.13 The small number of deaths in 1999–2000, especially for some causes of death, makes mortality estimates prone to random fluctuations. Problems with the change from ICD-9 to ICD-10 may have affected trends in cause-specific mortality for Estonia at large, but these biases are unlikely to have affected different educational groups in different ways. An additional concern was the fact that the lowest educational stratum became much smaller during the 11 years of transition, especially in the 40–69 age group. This was due to two factors. Firstly, the rapid expansion of education in the post war period, which resulted in a smaller proportion of each new birth cohort achieving only lower secondary education or less. Secondly, the sharp rise of mortality in the 40–69 age group, especially among the lowest educated (Table 3). This excess mortality alone would have resulted in a reduction of the size of the lowest educational stratum of up to 5% between 1989 and 2000. Since the lowest educated group in 2000 was so much smaller than 1989, one could argue that it was also more extreme. Therefore, some of the widening of the educational mortality differences may simply reflect the new distribution of educational categories. However, this is unlikely to contribute much since, firstly, the shrinkage of the lowest educated group is counterbalanced by the growth of the best educated group (which is therefore less extreme) and secondly, since differences between middle and high educated groups also widened. Educational differences in mortality in 1989 were large compared with those of Western Europe.8 The high mortality from infectious diseases and stomach cancer among the poorly educated is one indicator of adverse living conditions before 1991. Their relatively high mortality from smoking-related or alcohol-related causes in 1989 indicates differences in lifestyle between educational groups.14,15 In Estonia’s rapid political and economic transition, the less educated often lacked the necessary coping skills; they were thus at greater risk of unemployment and were less likely to move from unemployment and inactivity back to employment.10 The new policies favoured graduates, who benefited both in terms of money and health16 and for whom the psychological adjustment was easier.17 Social disruption, poverty, and the increasing gap in wealth are likely contributors to larger educational differences in mortality in 2000. Sharply increased mortality from infectious diseases from 1989 to 2000 among the lowest educated is evidence of poverty-driven causal mechanisms. Income and poverty are linked to many other causes of death, including the most common ones,3,18 although both the strength of association and the causal pathways vary between causes. Changes in the diet of the population as a whole at the beginning of the 1990s may be one determinant of the overall decline of mortality from circulatory diseases.19 Progress in medical care may also have contributed to the reduction in mortality from circulatory disease in all educational groups, particularly for graduates, who were more successful in getting specialist care.20 The overall improvement in cancer survival rates in the 1990s,21 known to be dependent on access to and quality of medical care, could point to improved medical care in Estonia. The reversing educational gradient for breast cancer mortality is striking and probably best explained by earlier detection, better treatment and survival among graduates, and perhaps also by differential changes in fertility. Social disruption and poverty works also through behavioural mechanisms. Alcohol has been considered one of the main factors behind the increasing mortality in 1990s Russia.22 Its role is similarly evident in Estonia, with an extremely liberal alcohol policy in the early 1990s. Mortality from alcohol poisoning and liver cirrhosis increased sharply in all educational groups and in both genders. These two alcohol-related causes certainly contributed to the mortality difference by education and to its increase in Estonia. From 1989 to 2000 the declining mortality of the higher educated and the rising mortality of the lower educated resulted in an enormous mortality gap. The increasing differentiation of wealth and opportunity, partly resulting from recent reforms, can be considered a main, recent underlying factor. However, the situation was partly determined long before the transition period. The fairly high contribution of neoplasms to the widening mortality gap suggests that some underlying factors originated decades before recent reforms. Stomach cancer, determined early in life,23 and lung cancer, with a long latency time,24 are two examples. Cerebrovascular deaths also contribute to the widening gap and, again, this group of diseases, especially haemorrhagic stroke, are believed to be partly determined early in life.23,25 Early life factors linked to education interacting with factors later in life also linked to education (alcohol for example) could result in the widening mortality gap for certain causes of death. We conclude that there is a particular need to tackle health inequalities in countries in transition. Three such areas could be suggested. Those with a low educational achievement need to be pulled into the new economic developments and allowed to benefit from economic change; the distribution and consumption of alcohol need to be more tightly controlled, and thirdly, a modernized, comprehensive medical care system equally accessible for all would counteract some of the forces now creating a widening of the educational mortality divide. KEY MESSAGES Educational differences in mortality increased tremendously in Estonia from 1989 to 2000. From 1989 to 2000 mortality decreased considerably for those with university education and increased for those with the lowest education. Increasing inequalities were observed for all age groups and for most causes of death. The available evidence suggests that social disruption and increasing inequalities in wealth can be considered main recent determinants; however causal processes, shaped decades before recent reforms, also contribute to this widening gap. Table 1 Correspondence of selected causes of death in 1987–1990 (ICD-9) and in 1999–2000 (ICD-10) . 1987–1990 . 1999–2000 . Cause of death . ICD-9 . ICD-10 . Infectious diseases 001–139 A00–B99 Stomach cancer 151 C16 Lung cancer 162 C33–C34 Breast cancer 174–175 C50 Ischaemic heart disease 410–414 I20–I25 Cerebrovascular disease 430–438 I60–I69 Chronic respiratory disease 490–494; 496 J40–J47 Alcoholic liver cirrhosis 571.0–571.3 K70 Transport accidents E800–E848 V01–V99 Alcohol poisoning E860 X45 Suicide E950–E959 X60–X84 Homicide E960–E978 X85–Y09, Y35, Y36 . 1987–1990 . 1999–2000 . Cause of death . ICD-9 . ICD-10 . Infectious diseases 001–139 A00–B99 Stomach cancer 151 C16 Lung cancer 162 C33–C34 Breast cancer 174–175 C50 Ischaemic heart disease 410–414 I20–I25 Cerebrovascular disease 430–438 I60–I69 Chronic respiratory disease 490–494; 496 J40–J47 Alcoholic liver cirrhosis 571.0–571.3 K70 Transport accidents E800–E848 V01–V99 Alcohol poisoning E860 X45 Suicide E950–E959 X60–X84 Homicide E960–E978 X85–Y09, Y35, Y36 Open in new tab Table 1 Correspondence of selected causes of death in 1987–1990 (ICD-9) and in 1999–2000 (ICD-10) . 1987–1990 . 1999–2000 . Cause of death . ICD-9 . ICD-10 . Infectious diseases 001–139 A00–B99 Stomach cancer 151 C16 Lung cancer 162 C33–C34 Breast cancer 174–175 C50 Ischaemic heart disease 410–414 I20–I25 Cerebrovascular disease 430–438 I60–I69 Chronic respiratory disease 490–494; 496 J40–J47 Alcoholic liver cirrhosis 571.0–571.3 K70 Transport accidents E800–E848 V01–V99 Alcohol poisoning E860 X45 Suicide E950–E959 X60–X84 Homicide E960–E978 X85–Y09, Y35, Y36 . 1987–1990 . 1999–2000 . Cause of death . ICD-9 . ICD-10 . Infectious diseases 001–139 A00–B99 Stomach cancer 151 C16 Lung cancer 162 C33–C34 Breast cancer 174–175 C50 Ischaemic heart disease 410–414 I20–I25 Cerebrovascular disease 430–438 I60–I69 Chronic respiratory disease 490–494; 496 J40–J47 Alcoholic liver cirrhosis 571.0–571.3 K70 Transport accidents E800–E848 V01–V99 Alcohol poisoning E860 X45 Suicide E950–E959 X60–X84 Homicide E960–E978 X85–Y09, Y35, Y36 Open in new tab Table 2 Educational distribution of Estonian population in 1989 and 2000 . Men . Women . . 1989 . 2000 . . 2000 . . N . (%) . N . (%) . N . (%) . N . (%) . All ages 20+     University 65 329 13.2 65 938 15.0 76 957 12.6 90 875 16.4     Upper secondary 241 965 48.9 243 624 55.4 297 062 48.7 312 500 56.5     Lower secondary or less 187 925 37.9 130 138 29.6 235 987 38.7 149 307 27.0 20–39     University 31 269 13.6 22 043 12.2 39 369 17.1 32 442 17.6     Upper secondary 157 036 68.4 125 340 69.2 167 292 72.9 135 362 73.2     Lower secondary or less 41 134 17.9 33 634 18.6 22 903 10.0 17 046 9.2 40–54     University 21 428 15.7 23 843 18.7 24 727 16.2 32 526 22.2     Upper secondary 54 066 39.5 74 827 58.6 76 705 50.3 96 007 65.4     Lower secondary or less 61 305 44.8 29 049 22.7 50 912 33.4 18 213 12.4 55–69     University 10 501 11.1 15 331 16.6 11 115 7.8 19 839 15.4     Upper secondary 24 292 25.7 33 236 36.0 39 534 27.9 57 059 44.4     Lower secondary or less 59 805 63.2 43 782 47.4 91 292 64.3 51 608 40.2 70+     University 2131 6.2 4721 12.2 1746 2.0 6068 6.6     Upper secondary 6571 19.1 10 221 26.5 13 531 15.7 24 072 26.0     Lower secondary or less 25 681 74.7 23 673 61.3 70 880 82.3 62 440 67.4 . Men . Women . . 1989 . 2000 . . 2000 . . N . (%) . N . (%) . N . (%) . N . (%) . All ages 20+     University 65 329 13.2 65 938 15.0 76 957 12.6 90 875 16.4     Upper secondary 241 965 48.9 243 624 55.4 297 062 48.7 312 500 56.5     Lower secondary or less 187 925 37.9 130 138 29.6 235 987 38.7 149 307 27.0 20–39     University 31 269 13.6 22 043 12.2 39 369 17.1 32 442 17.6     Upper secondary 157 036 68.4 125 340 69.2 167 292 72.9 135 362 73.2     Lower secondary or less 41 134 17.9 33 634 18.6 22 903 10.0 17 046 9.2 40–54     University 21 428 15.7 23 843 18.7 24 727 16.2 32 526 22.2     Upper secondary 54 066 39.5 74 827 58.6 76 705 50.3 96 007 65.4     Lower secondary or less 61 305 44.8 29 049 22.7 50 912 33.4 18 213 12.4 55–69     University 10 501 11.1 15 331 16.6 11 115 7.8 19 839 15.4     Upper secondary 24 292 25.7 33 236 36.0 39 534 27.9 57 059 44.4     Lower secondary or less 59 805 63.2 43 782 47.4 91 292 64.3 51 608 40.2 70+     University 2131 6.2 4721 12.2 1746 2.0 6068 6.6     Upper secondary 6571 19.1 10 221 26.5 13 531 15.7 24 072 26.0     Lower secondary or less 25 681 74.7 23 673 61.3 70 880 82.3 62 440 67.4 Open in new tab Table 2 Educational distribution of Estonian population in 1989 and 2000 . Men . Women . . 1989 . 2000 . . 2000 . . N . (%) . N . (%) . N . (%) . N . (%) . All ages 20+     University 65 329 13.2 65 938 15.0 76 957 12.6 90 875 16.4     Upper secondary 241 965 48.9 243 624 55.4 297 062 48.7 312 500 56.5     Lower secondary or less 187 925 37.9 130 138 29.6 235 987 38.7 149 307 27.0 20–39     University 31 269 13.6 22 043 12.2 39 369 17.1 32 442 17.6     Upper secondary 157 036 68.4 125 340 69.2 167 292 72.9 135 362 73.2     Lower secondary or less 41 134 17.9 33 634 18.6 22 903 10.0 17 046 9.2 40–54     University 21 428 15.7 23 843 18.7 24 727 16.2 32 526 22.2     Upper secondary 54 066 39.5 74 827 58.6 76 705 50.3 96 007 65.4     Lower secondary or less 61 305 44.8 29 049 22.7 50 912 33.4 18 213 12.4 55–69     University 10 501 11.1 15 331 16.6 11 115 7.8 19 839 15.4     Upper secondary 24 292 25.7 33 236 36.0 39 534 27.9 57 059 44.4     Lower secondary or less 59 805 63.2 43 782 47.4 91 292 64.3 51 608 40.2 70+     University 2131 6.2 4721 12.2 1746 2.0 6068 6.6     Upper secondary 6571 19.1 10 221 26.5 13 531 15.7 24 072 26.0     Lower secondary or less 25 681 74.7 23 673 61.3 70 880 82.3 62 440 67.4 . Men . Women . . 1989 . 2000 . . 2000 . . N . (%) . N . (%) . N . (%) . N . (%) . All ages 20+     University 65 329 13.2 65 938 15.0 76 957 12.6 90 875 16.4     Upper secondary 241 965 48.9 243 624 55.4 297 062 48.7 312 500 56.5     Lower secondary or less 187 925 37.9 130 138 29.6 235 987 38.7 149 307 27.0 20–39     University 31 269 13.6 22 043 12.2 39 369 17.1 32 442 17.6     Upper secondary 157 036 68.4 125 340 69.2 167 292 72.9 135 362 73.2     Lower secondary or less 41 134 17.9 33 634 18.6 22 903 10.0 17 046 9.2 40–54     University 21 428 15.7 23 843 18.7 24 727 16.2 32 526 22.2     Upper secondary 54 066 39.5 74 827 58.6 76 705 50.3 96 007 65.4     Lower secondary or less 61 305 44.8 29 049 22.7 50 912 33.4 18 213 12.4 55–69     University 10 501 11.1 15 331 16.6 11 115 7.8 19 839 15.4     Upper secondary 24 292 25.7 33 236 36.0 39 534 27.9 57 059 44.4     Lower secondary or less 59 805 63.2 43 782 47.4 91 292 64.3 51 608 40.2 70+     University 2131 6.2 4721 12.2 1746 2.0 6068 6.6     Upper secondary 6571 19.1 10 221 26.5 13 531 15.7 24 072 26.0     Lower secondary or less 25 681 74.7 23 673 61.3 70 880 82.3 62 440 67.4 Open in new tab Table 3 Age-standardizeda mortality rates per 100 000 and mortality rate ratios for different age groups by educational level in Estonia 1989–2000 . Men . Women . . Mortality rates . Mortality rate ratios (95% CI) . Mortality rates . Mortality rate ratios (95% CI) . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . a European standard population. All ages 20+     University 1565.2 1194.9 −370.3 1.00 1.00 962.4 631.3 −331.1 1.00 1.00     Upper secondary 1802.8 2094.2 +291.4 1.34 (1.27, 1.40) 1.91 (1.80, 2.03) 997.5 984.6 −12.9 1.14 (1.07, 1.21) 1.72 (1.60, 1.85)     Lower secondary or less 2331.3 2725.1 +393.8 1.73 (1.65, 1.81) 2.38 (2.25, 2.53) 1274.2 1428.0 +153.8 1.37 (1.29, 1.45) 2.23 (2.07, 2.39) 20–39     University 155.5 111.8 −43.7 1.00 1.00 52.5 64.5 +12.0 1.00 1.00     Upper secondary 242.9 331.7 +88.8 1.69 (1.45, 1.97) 3.69 (2.74, 4.99) 79.0 84.3 +5.3 1.50 (1.20, 1.89) 1.48 (1.07, 2.06)     Lower secondary or less 591.2 672.0 +80.8 4.13 (3.54, 4.82) 7.26 (5.31, 9.91) 224.3 317.5 +93.3 4.12 (3.21, 5.28) 5.13 (3.52, 7.48) 40–54     University 439.0 439.4 +0.4 1.00 1.00 237.7 191.0 −46.7 1.00 1.00     Upper secondary 831.3 1190.3 +359.0 1.89 (1.69, 2.12) 2.71 (2.34, 3.13) 309.8 408.9 +99.1 1.32 (1.14, 1.52) 2.19 (1.80, 2.66)     Lower secondary or less 1277.0 1995.4 +718.4 2.91 (2.61, 3.24) 4.50 (3.88, 5.22) 435.9 815.3 +379.4 1.81 (1.56, 2.09) 4.10 (3.31, 5.08) 55–69     University 2089.8 1717.2 −372.5 1.00 1.00 1003.8 680.1 −323.6 1.00 1.00     Upper secondary 2768.3 3196.4 +428.1 1.35 (1.24, 1.46) 1.86 (1.69, 2.05) 1200.0 1159.9 −40.2 1.22 (1.09, 1.36) 1.69 (1.48, 1.92)     Lower secondary or less 3276.3 3889.0 +612.6 1.60 (1.48, 1.72) 2.26 (2.06, 2.48) 1389.1 1539.2 +150.0 1.41 (1.27, 1.56) 2.20 (1.94, 2.50) 70+     University 10 168.0 7482.6 −2685.4 1.00 1.00 6958.2 5051.8 −1906.4 1.00 1.00     Upper secondary 10 008.5 10 292.4 +283.9 0.97 (0.90, 1.05) 1.50 (1.37, 1.65) 6748.9 6585.4 −163.4 0.96 (0.88, 1.03) 1.42 (1.28, 1.58)     Lower secondary or less 11 117.6 10 893.9 −223.7 1.09 (1.02, 1.17) 1.60 (1.47, 1.75) 7979.6 7252.0 −727.6 1.13 (1.03, 1.23) 1.57 (1.42, 1.73) . Men . Women . . Mortality rates . Mortality rate ratios (95% CI) . Mortality rates . Mortality rate ratios (95% CI) . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . a European standard population. All ages 20+     University 1565.2 1194.9 −370.3 1.00 1.00 962.4 631.3 −331.1 1.00 1.00     Upper secondary 1802.8 2094.2 +291.4 1.34 (1.27, 1.40) 1.91 (1.80, 2.03) 997.5 984.6 −12.9 1.14 (1.07, 1.21) 1.72 (1.60, 1.85)     Lower secondary or less 2331.3 2725.1 +393.8 1.73 (1.65, 1.81) 2.38 (2.25, 2.53) 1274.2 1428.0 +153.8 1.37 (1.29, 1.45) 2.23 (2.07, 2.39) 20–39     University 155.5 111.8 −43.7 1.00 1.00 52.5 64.5 +12.0 1.00 1.00     Upper secondary 242.9 331.7 +88.8 1.69 (1.45, 1.97) 3.69 (2.74, 4.99) 79.0 84.3 +5.3 1.50 (1.20, 1.89) 1.48 (1.07, 2.06)     Lower secondary or less 591.2 672.0 +80.8 4.13 (3.54, 4.82) 7.26 (5.31, 9.91) 224.3 317.5 +93.3 4.12 (3.21, 5.28) 5.13 (3.52, 7.48) 40–54     University 439.0 439.4 +0.4 1.00 1.00 237.7 191.0 −46.7 1.00 1.00     Upper secondary 831.3 1190.3 +359.0 1.89 (1.69, 2.12) 2.71 (2.34, 3.13) 309.8 408.9 +99.1 1.32 (1.14, 1.52) 2.19 (1.80, 2.66)     Lower secondary or less 1277.0 1995.4 +718.4 2.91 (2.61, 3.24) 4.50 (3.88, 5.22) 435.9 815.3 +379.4 1.81 (1.56, 2.09) 4.10 (3.31, 5.08) 55–69     University 2089.8 1717.2 −372.5 1.00 1.00 1003.8 680.1 −323.6 1.00 1.00     Upper secondary 2768.3 3196.4 +428.1 1.35 (1.24, 1.46) 1.86 (1.69, 2.05) 1200.0 1159.9 −40.2 1.22 (1.09, 1.36) 1.69 (1.48, 1.92)     Lower secondary or less 3276.3 3889.0 +612.6 1.60 (1.48, 1.72) 2.26 (2.06, 2.48) 1389.1 1539.2 +150.0 1.41 (1.27, 1.56) 2.20 (1.94, 2.50) 70+     University 10 168.0 7482.6 −2685.4 1.00 1.00 6958.2 5051.8 −1906.4 1.00 1.00     Upper secondary 10 008.5 10 292.4 +283.9 0.97 (0.90, 1.05) 1.50 (1.37, 1.65) 6748.9 6585.4 −163.4 0.96 (0.88, 1.03) 1.42 (1.28, 1.58)     Lower secondary or less 11 117.6 10 893.9 −223.7 1.09 (1.02, 1.17) 1.60 (1.47, 1.75) 7979.6 7252.0 −727.6 1.13 (1.03, 1.23) 1.57 (1.42, 1.73) Open in new tab Table 3 Age-standardizeda mortality rates per 100 000 and mortality rate ratios for different age groups by educational level in Estonia 1989–2000 . Men . Women . . Mortality rates . Mortality rate ratios (95% CI) . Mortality rates . Mortality rate ratios (95% CI) . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . a European standard population. All ages 20+     University 1565.2 1194.9 −370.3 1.00 1.00 962.4 631.3 −331.1 1.00 1.00     Upper secondary 1802.8 2094.2 +291.4 1.34 (1.27, 1.40) 1.91 (1.80, 2.03) 997.5 984.6 −12.9 1.14 (1.07, 1.21) 1.72 (1.60, 1.85)     Lower secondary or less 2331.3 2725.1 +393.8 1.73 (1.65, 1.81) 2.38 (2.25, 2.53) 1274.2 1428.0 +153.8 1.37 (1.29, 1.45) 2.23 (2.07, 2.39) 20–39     University 155.5 111.8 −43.7 1.00 1.00 52.5 64.5 +12.0 1.00 1.00     Upper secondary 242.9 331.7 +88.8 1.69 (1.45, 1.97) 3.69 (2.74, 4.99) 79.0 84.3 +5.3 1.50 (1.20, 1.89) 1.48 (1.07, 2.06)     Lower secondary or less 591.2 672.0 +80.8 4.13 (3.54, 4.82) 7.26 (5.31, 9.91) 224.3 317.5 +93.3 4.12 (3.21, 5.28) 5.13 (3.52, 7.48) 40–54     University 439.0 439.4 +0.4 1.00 1.00 237.7 191.0 −46.7 1.00 1.00     Upper secondary 831.3 1190.3 +359.0 1.89 (1.69, 2.12) 2.71 (2.34, 3.13) 309.8 408.9 +99.1 1.32 (1.14, 1.52) 2.19 (1.80, 2.66)     Lower secondary or less 1277.0 1995.4 +718.4 2.91 (2.61, 3.24) 4.50 (3.88, 5.22) 435.9 815.3 +379.4 1.81 (1.56, 2.09) 4.10 (3.31, 5.08) 55–69     University 2089.8 1717.2 −372.5 1.00 1.00 1003.8 680.1 −323.6 1.00 1.00     Upper secondary 2768.3 3196.4 +428.1 1.35 (1.24, 1.46) 1.86 (1.69, 2.05) 1200.0 1159.9 −40.2 1.22 (1.09, 1.36) 1.69 (1.48, 1.92)     Lower secondary or less 3276.3 3889.0 +612.6 1.60 (1.48, 1.72) 2.26 (2.06, 2.48) 1389.1 1539.2 +150.0 1.41 (1.27, 1.56) 2.20 (1.94, 2.50) 70+     University 10 168.0 7482.6 −2685.4 1.00 1.00 6958.2 5051.8 −1906.4 1.00 1.00     Upper secondary 10 008.5 10 292.4 +283.9 0.97 (0.90, 1.05) 1.50 (1.37, 1.65) 6748.9 6585.4 −163.4 0.96 (0.88, 1.03) 1.42 (1.28, 1.58)     Lower secondary or less 11 117.6 10 893.9 −223.7 1.09 (1.02, 1.17) 1.60 (1.47, 1.75) 7979.6 7252.0 −727.6 1.13 (1.03, 1.23) 1.57 (1.42, 1.73) . Men . Women . . Mortality rates . Mortality rate ratios (95% CI) . Mortality rates . Mortality rate ratios (95% CI) . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . a European standard population. All ages 20+     University 1565.2 1194.9 −370.3 1.00 1.00 962.4 631.3 −331.1 1.00 1.00     Upper secondary 1802.8 2094.2 +291.4 1.34 (1.27, 1.40) 1.91 (1.80, 2.03) 997.5 984.6 −12.9 1.14 (1.07, 1.21) 1.72 (1.60, 1.85)     Lower secondary or less 2331.3 2725.1 +393.8 1.73 (1.65, 1.81) 2.38 (2.25, 2.53) 1274.2 1428.0 +153.8 1.37 (1.29, 1.45) 2.23 (2.07, 2.39) 20–39     University 155.5 111.8 −43.7 1.00 1.00 52.5 64.5 +12.0 1.00 1.00     Upper secondary 242.9 331.7 +88.8 1.69 (1.45, 1.97) 3.69 (2.74, 4.99) 79.0 84.3 +5.3 1.50 (1.20, 1.89) 1.48 (1.07, 2.06)     Lower secondary or less 591.2 672.0 +80.8 4.13 (3.54, 4.82) 7.26 (5.31, 9.91) 224.3 317.5 +93.3 4.12 (3.21, 5.28) 5.13 (3.52, 7.48) 40–54     University 439.0 439.4 +0.4 1.00 1.00 237.7 191.0 −46.7 1.00 1.00     Upper secondary 831.3 1190.3 +359.0 1.89 (1.69, 2.12) 2.71 (2.34, 3.13) 309.8 408.9 +99.1 1.32 (1.14, 1.52) 2.19 (1.80, 2.66)     Lower secondary or less 1277.0 1995.4 +718.4 2.91 (2.61, 3.24) 4.50 (3.88, 5.22) 435.9 815.3 +379.4 1.81 (1.56, 2.09) 4.10 (3.31, 5.08) 55–69     University 2089.8 1717.2 −372.5 1.00 1.00 1003.8 680.1 −323.6 1.00 1.00     Upper secondary 2768.3 3196.4 +428.1 1.35 (1.24, 1.46) 1.86 (1.69, 2.05) 1200.0 1159.9 −40.2 1.22 (1.09, 1.36) 1.69 (1.48, 1.92)     Lower secondary or less 3276.3 3889.0 +612.6 1.60 (1.48, 1.72) 2.26 (2.06, 2.48) 1389.1 1539.2 +150.0 1.41 (1.27, 1.56) 2.20 (1.94, 2.50) 70+     University 10 168.0 7482.6 −2685.4 1.00 1.00 6958.2 5051.8 −1906.4 1.00 1.00     Upper secondary 10 008.5 10 292.4 +283.9 0.97 (0.90, 1.05) 1.50 (1.37, 1.65) 6748.9 6585.4 −163.4 0.96 (0.88, 1.03) 1.42 (1.28, 1.58)     Lower secondary or less 11 117.6 10 893.9 −223.7 1.09 (1.02, 1.17) 1.60 (1.47, 1.75) 7979.6 7252.0 −727.6 1.13 (1.03, 1.23) 1.57 (1.42, 1.73) Open in new tab Table 4 Age-standardizeda mortality rates per 100 000 and mortality rate ratios for selected causes of death by educational level in Estonia 1989–2000 in age group 20+ . Men . Women . . Mortality rates . Mortality rate ratios (95% CI) . Mortality rates . Mortality rate ratios (95% CI) . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . a European standard population. Infectious diseases     University 7.9 7.4 −0.5 1.00 1.00 5.3 2.2 −3.1 1.00 1.00     Upper secondary 9.4 16.6 +7.2 1.26 (0.69, 2.32) 3.33 (1.53, 7.22) 4.7 6.1 +1.4 1.29 (0.60, 2.75) 2.61 (0.93, 7.36)     Lower secondary or less 24.0 50.5 +26.5 4.12 (2.34, 7.26) 7.88 (3.67, 16.92) 5.9 22.3 +16.4 1.40 (0.65, 3.02) 4.98 (1.74, 14.29) Stomach cancer     University 46.0 26.8 −19.2 1.00 1.00 21.2 13.9 −7.3 1.00 1.00     Upper secondary 61.0 53.7 −7.2 1.27 (0.98, 1.65) 2.07 (1.40, 3.04) 28.4 23.0 −5.4 1.27 (0.90, 1.79) 1.55 (1.00, 2.40)     Lower secondary or less 66.6 53.1 −13.5 1.55 (1.21, 1.98) 2.12 (1.45, 3.10) 30.7 27.2 −3.5 1.37 (0.97, 1.92) 1.68 (1.09, 2.61) Lung cancer     University 64.3 49.6 −14.7 1.00 1.00 14.4 12.4 −2.0 1.00 1.00     Upper secondary 117.1 126.2 +9.1 1.79 (1.45, 2.22) 2.41 (1.83, 3.17) 20.1 18.3 −1.8 1.42 (0.90, 2.23) 1.55 (0.94, 2.57)     Lower secondary or less 152.2 162.5 +10.3 2.74 (2.24, 3.36) 3.34 (2.56, 4.36) 15.5 19.5 +4.0 1.10 (0.70, 1.72) 1.27 (0.76, 2.11) Breast cancer     University – – – – – 44.0 24.6 −19.4 1.00 1.00     Upper secondary – – – – – 33.4 46.3 +12.9 0.71 (0.56, 0.89) 1.72 (1.26, 2.35)     Lower secondary or less – – – – – 27.3 42.3 +15.1 0.55 (0.44, 0.70) 1.33 (0.95, 1.84) Ischaemic heart disease     University 669.3 371.7 −297.6 1.00 1.00 360.1 200.7 −159.4 1.00 1.00     Upper secondary 660.8 618.4 −42.4 1.07 (0.99, 1.16) 1.84 (1.65, 2.06) 348.0 299.1 −48.9 1.05 (0.93, 1.18) 1.67 (1.45, 1.93)     Lower secondary or less 862.9 781.9 −81.0 1.39 (1.30, 1.50) 2.25 (2.02, 2.50) 504.3 445.5 −58.8 1.50 (1.34, 1.68) 2.36 (2.06, 2.70) Cerebrovascular disease     University 257.6 161.1 −96.5 1.00 1.00 219.2 114.9 −104.3 1.00 1.00     Upper secondary 285.8 282.1 −3.7 1.20 (1.05, 1.36) 1.88 (1.59, 2.23) 230.4 188.7 −41.7 1.17 (1.01, 1.36) 1.80 (1.51, 2.16)     Lower secondary or less 340.4 315.2 −25.2 1.45 (1.28, 1.63) 2.07 (1.76, 2.44) 290.7 244.7 −46.0 1.45 (1.26, 1.67) 2.22 (1.86, 2.64) Chronic respiratory disease     University 18.3 15.8 −2.5 1.00 1.00 6.5 5.1 −1.4 1.00 1.00     Upper secondary 24.4 34.7 +10.3 1.46 (0.93, 2.31) 2.33 (1.36, 3.98) 10.7 6.6 −4.1 2.01 (1.01, 4.01) 1.28 (0.59, 2.76)     Lower secondary or less 48.7 48.1 −0.6 3.28 (2.16, 5.00) 3.32 (2.00, 5.54) 15.5 11.2 −4.3 2.87 (1.46, 5.66) 2.18 (1.04, 4.56) Alcoholic liver cirrhosis     University 1.2 11.3 +10.1 1.00 1.00 0.4 1.6 +1.2 1.00 1.00     Upper secondary 2.6 17.5 +14.9 1.26 (0.42, 3.77) 1.39 (0.82, 2.37) 0.6 5.5 +4.9 1.57 (0.19, 13.07) 3.21 (0.98, 10.47)     Lower secondary or less 3.4 24.7 +21.3 2.15 (0.75, 6.22) 1.66 (0.97, 2.84) 0.5 16.8 +16.3 1.57 (0.17, 14.29) 5.54 (1.64, 18.71) Transport accidents     University 25.3 18.4 −7.0 1.00 1.00 15.8 6.9 −8.8 1.00 1.00     Upper secondary 41.6 38.3 −3.3 1.68 (1.29, 2.18) 2.18 (1.40, 3.40) 12.5 8.4 −4.1 1.18 (0.80, 1.73) 1.34 (0.70, 2.57)     Lower secondary or less 65.9 62.4 −3.5 2.64 (2.03, 3.44) 3.44 (2.20, 5.40) 17.1 20.4 +3.4 1.42 (0.94, 2.13) 2.42 (1.20, 4.86) Alcohol poisoning     University 8.2 11.5 +3.3 1.00 1.00 0.3 2.8 +2.5 1.00 1.00     Upper secondary 15.9 41.6 +25.7 1.69 (1.07, 2.65) 3.14 (1.94, 5.10) 2.9 9.2 +6.3 7.81 (1.07, 57.24) 2.73 (1.18, 6.34)     Lower secondary or less 36.2 62.1 +25.9 4.54 (2.93, 7.04) 3.71 (2.26, 6.07) 8.9 26.7 +17.8 32.43 (4.45, 236.48) 4.91 (2.05, 11.73) Suicide     University 25.6 33.4 +7.8 1.00 1.00 11.5 8.8 −2.7 1.00 1.00     Upper secondary 42.7 71.5 +28.8 1.58 (1.21, 2.06) 1.99 (1.47, 2.69) 16.2 11.6 −4.6 1.13 (0.79, 1.60) 1.34 (0.78, 2.30)     Lower secondary or less 89.7 95.0 +5.2 3.45 (2.67, 4.47) 2.40 (1.76, 3.28) 20.5 20.0 −0.5 1.28 (0.89, 1.85) 2.20 (1.25, 3.85) Homicide     University 6.2 15.7 +9.5 1.00 1.00 1.6 3.5 +1.9 1.00 1.00     Upper secondary 13.2 32.3 +19.1 2.90 (1.61, 5.24) 2.13 (1.35, 3.36) 3.7 5.9 +2.2 2.80 (1.01, 7.79) 2.05 (0.81, 5.22)     Lower secondary or less 25.1 38.6 +13.5 5.71 (3.16, 10.30) 2.21 (1.37, 3.56) 9.0 23.1 +14.1 5.40 (1.90, 15.37) 5.46 (2.09, 14.25) . Men . Women . . Mortality rates . Mortality rate ratios (95% CI) . Mortality rates . Mortality rate ratios (95% CI) . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . a European standard population. Infectious diseases     University 7.9 7.4 −0.5 1.00 1.00 5.3 2.2 −3.1 1.00 1.00     Upper secondary 9.4 16.6 +7.2 1.26 (0.69, 2.32) 3.33 (1.53, 7.22) 4.7 6.1 +1.4 1.29 (0.60, 2.75) 2.61 (0.93, 7.36)     Lower secondary or less 24.0 50.5 +26.5 4.12 (2.34, 7.26) 7.88 (3.67, 16.92) 5.9 22.3 +16.4 1.40 (0.65, 3.02) 4.98 (1.74, 14.29) Stomach cancer     University 46.0 26.8 −19.2 1.00 1.00 21.2 13.9 −7.3 1.00 1.00     Upper secondary 61.0 53.7 −7.2 1.27 (0.98, 1.65) 2.07 (1.40, 3.04) 28.4 23.0 −5.4 1.27 (0.90, 1.79) 1.55 (1.00, 2.40)     Lower secondary or less 66.6 53.1 −13.5 1.55 (1.21, 1.98) 2.12 (1.45, 3.10) 30.7 27.2 −3.5 1.37 (0.97, 1.92) 1.68 (1.09, 2.61) Lung cancer     University 64.3 49.6 −14.7 1.00 1.00 14.4 12.4 −2.0 1.00 1.00     Upper secondary 117.1 126.2 +9.1 1.79 (1.45, 2.22) 2.41 (1.83, 3.17) 20.1 18.3 −1.8 1.42 (0.90, 2.23) 1.55 (0.94, 2.57)     Lower secondary or less 152.2 162.5 +10.3 2.74 (2.24, 3.36) 3.34 (2.56, 4.36) 15.5 19.5 +4.0 1.10 (0.70, 1.72) 1.27 (0.76, 2.11) Breast cancer     University – – – – – 44.0 24.6 −19.4 1.00 1.00     Upper secondary – – – – – 33.4 46.3 +12.9 0.71 (0.56, 0.89) 1.72 (1.26, 2.35)     Lower secondary or less – – – – – 27.3 42.3 +15.1 0.55 (0.44, 0.70) 1.33 (0.95, 1.84) Ischaemic heart disease     University 669.3 371.7 −297.6 1.00 1.00 360.1 200.7 −159.4 1.00 1.00     Upper secondary 660.8 618.4 −42.4 1.07 (0.99, 1.16) 1.84 (1.65, 2.06) 348.0 299.1 −48.9 1.05 (0.93, 1.18) 1.67 (1.45, 1.93)     Lower secondary or less 862.9 781.9 −81.0 1.39 (1.30, 1.50) 2.25 (2.02, 2.50) 504.3 445.5 −58.8 1.50 (1.34, 1.68) 2.36 (2.06, 2.70) Cerebrovascular disease     University 257.6 161.1 −96.5 1.00 1.00 219.2 114.9 −104.3 1.00 1.00     Upper secondary 285.8 282.1 −3.7 1.20 (1.05, 1.36) 1.88 (1.59, 2.23) 230.4 188.7 −41.7 1.17 (1.01, 1.36) 1.80 (1.51, 2.16)     Lower secondary or less 340.4 315.2 −25.2 1.45 (1.28, 1.63) 2.07 (1.76, 2.44) 290.7 244.7 −46.0 1.45 (1.26, 1.67) 2.22 (1.86, 2.64) Chronic respiratory disease     University 18.3 15.8 −2.5 1.00 1.00 6.5 5.1 −1.4 1.00 1.00     Upper secondary 24.4 34.7 +10.3 1.46 (0.93, 2.31) 2.33 (1.36, 3.98) 10.7 6.6 −4.1 2.01 (1.01, 4.01) 1.28 (0.59, 2.76)     Lower secondary or less 48.7 48.1 −0.6 3.28 (2.16, 5.00) 3.32 (2.00, 5.54) 15.5 11.2 −4.3 2.87 (1.46, 5.66) 2.18 (1.04, 4.56) Alcoholic liver cirrhosis     University 1.2 11.3 +10.1 1.00 1.00 0.4 1.6 +1.2 1.00 1.00     Upper secondary 2.6 17.5 +14.9 1.26 (0.42, 3.77) 1.39 (0.82, 2.37) 0.6 5.5 +4.9 1.57 (0.19, 13.07) 3.21 (0.98, 10.47)     Lower secondary or less 3.4 24.7 +21.3 2.15 (0.75, 6.22) 1.66 (0.97, 2.84) 0.5 16.8 +16.3 1.57 (0.17, 14.29) 5.54 (1.64, 18.71) Transport accidents     University 25.3 18.4 −7.0 1.00 1.00 15.8 6.9 −8.8 1.00 1.00     Upper secondary 41.6 38.3 −3.3 1.68 (1.29, 2.18) 2.18 (1.40, 3.40) 12.5 8.4 −4.1 1.18 (0.80, 1.73) 1.34 (0.70, 2.57)     Lower secondary or less 65.9 62.4 −3.5 2.64 (2.03, 3.44) 3.44 (2.20, 5.40) 17.1 20.4 +3.4 1.42 (0.94, 2.13) 2.42 (1.20, 4.86) Alcohol poisoning     University 8.2 11.5 +3.3 1.00 1.00 0.3 2.8 +2.5 1.00 1.00     Upper secondary 15.9 41.6 +25.7 1.69 (1.07, 2.65) 3.14 (1.94, 5.10) 2.9 9.2 +6.3 7.81 (1.07, 57.24) 2.73 (1.18, 6.34)     Lower secondary or less 36.2 62.1 +25.9 4.54 (2.93, 7.04) 3.71 (2.26, 6.07) 8.9 26.7 +17.8 32.43 (4.45, 236.48) 4.91 (2.05, 11.73) Suicide     University 25.6 33.4 +7.8 1.00 1.00 11.5 8.8 −2.7 1.00 1.00     Upper secondary 42.7 71.5 +28.8 1.58 (1.21, 2.06) 1.99 (1.47, 2.69) 16.2 11.6 −4.6 1.13 (0.79, 1.60) 1.34 (0.78, 2.30)     Lower secondary or less 89.7 95.0 +5.2 3.45 (2.67, 4.47) 2.40 (1.76, 3.28) 20.5 20.0 −0.5 1.28 (0.89, 1.85) 2.20 (1.25, 3.85) Homicide     University 6.2 15.7 +9.5 1.00 1.00 1.6 3.5 +1.9 1.00 1.00     Upper secondary 13.2 32.3 +19.1 2.90 (1.61, 5.24) 2.13 (1.35, 3.36) 3.7 5.9 +2.2 2.80 (1.01, 7.79) 2.05 (0.81, 5.22)     Lower secondary or less 25.1 38.6 +13.5 5.71 (3.16, 10.30) 2.21 (1.37, 3.56) 9.0 23.1 +14.1 5.40 (1.90, 15.37) 5.46 (2.09, 14.25) Open in new tab Table 4 Age-standardizeda mortality rates per 100 000 and mortality rate ratios for selected causes of death by educational level in Estonia 1989–2000 in age group 20+ . Men . Women . . Mortality rates . Mortality rate ratios (95% CI) . Mortality rates . Mortality rate ratios (95% CI) . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . a European standard population. Infectious diseases     University 7.9 7.4 −0.5 1.00 1.00 5.3 2.2 −3.1 1.00 1.00     Upper secondary 9.4 16.6 +7.2 1.26 (0.69, 2.32) 3.33 (1.53, 7.22) 4.7 6.1 +1.4 1.29 (0.60, 2.75) 2.61 (0.93, 7.36)     Lower secondary or less 24.0 50.5 +26.5 4.12 (2.34, 7.26) 7.88 (3.67, 16.92) 5.9 22.3 +16.4 1.40 (0.65, 3.02) 4.98 (1.74, 14.29) Stomach cancer     University 46.0 26.8 −19.2 1.00 1.00 21.2 13.9 −7.3 1.00 1.00     Upper secondary 61.0 53.7 −7.2 1.27 (0.98, 1.65) 2.07 (1.40, 3.04) 28.4 23.0 −5.4 1.27 (0.90, 1.79) 1.55 (1.00, 2.40)     Lower secondary or less 66.6 53.1 −13.5 1.55 (1.21, 1.98) 2.12 (1.45, 3.10) 30.7 27.2 −3.5 1.37 (0.97, 1.92) 1.68 (1.09, 2.61) Lung cancer     University 64.3 49.6 −14.7 1.00 1.00 14.4 12.4 −2.0 1.00 1.00     Upper secondary 117.1 126.2 +9.1 1.79 (1.45, 2.22) 2.41 (1.83, 3.17) 20.1 18.3 −1.8 1.42 (0.90, 2.23) 1.55 (0.94, 2.57)     Lower secondary or less 152.2 162.5 +10.3 2.74 (2.24, 3.36) 3.34 (2.56, 4.36) 15.5 19.5 +4.0 1.10 (0.70, 1.72) 1.27 (0.76, 2.11) Breast cancer     University – – – – – 44.0 24.6 −19.4 1.00 1.00     Upper secondary – – – – – 33.4 46.3 +12.9 0.71 (0.56, 0.89) 1.72 (1.26, 2.35)     Lower secondary or less – – – – – 27.3 42.3 +15.1 0.55 (0.44, 0.70) 1.33 (0.95, 1.84) Ischaemic heart disease     University 669.3 371.7 −297.6 1.00 1.00 360.1 200.7 −159.4 1.00 1.00     Upper secondary 660.8 618.4 −42.4 1.07 (0.99, 1.16) 1.84 (1.65, 2.06) 348.0 299.1 −48.9 1.05 (0.93, 1.18) 1.67 (1.45, 1.93)     Lower secondary or less 862.9 781.9 −81.0 1.39 (1.30, 1.50) 2.25 (2.02, 2.50) 504.3 445.5 −58.8 1.50 (1.34, 1.68) 2.36 (2.06, 2.70) Cerebrovascular disease     University 257.6 161.1 −96.5 1.00 1.00 219.2 114.9 −104.3 1.00 1.00     Upper secondary 285.8 282.1 −3.7 1.20 (1.05, 1.36) 1.88 (1.59, 2.23) 230.4 188.7 −41.7 1.17 (1.01, 1.36) 1.80 (1.51, 2.16)     Lower secondary or less 340.4 315.2 −25.2 1.45 (1.28, 1.63) 2.07 (1.76, 2.44) 290.7 244.7 −46.0 1.45 (1.26, 1.67) 2.22 (1.86, 2.64) Chronic respiratory disease     University 18.3 15.8 −2.5 1.00 1.00 6.5 5.1 −1.4 1.00 1.00     Upper secondary 24.4 34.7 +10.3 1.46 (0.93, 2.31) 2.33 (1.36, 3.98) 10.7 6.6 −4.1 2.01 (1.01, 4.01) 1.28 (0.59, 2.76)     Lower secondary or less 48.7 48.1 −0.6 3.28 (2.16, 5.00) 3.32 (2.00, 5.54) 15.5 11.2 −4.3 2.87 (1.46, 5.66) 2.18 (1.04, 4.56) Alcoholic liver cirrhosis     University 1.2 11.3 +10.1 1.00 1.00 0.4 1.6 +1.2 1.00 1.00     Upper secondary 2.6 17.5 +14.9 1.26 (0.42, 3.77) 1.39 (0.82, 2.37) 0.6 5.5 +4.9 1.57 (0.19, 13.07) 3.21 (0.98, 10.47)     Lower secondary or less 3.4 24.7 +21.3 2.15 (0.75, 6.22) 1.66 (0.97, 2.84) 0.5 16.8 +16.3 1.57 (0.17, 14.29) 5.54 (1.64, 18.71) Transport accidents     University 25.3 18.4 −7.0 1.00 1.00 15.8 6.9 −8.8 1.00 1.00     Upper secondary 41.6 38.3 −3.3 1.68 (1.29, 2.18) 2.18 (1.40, 3.40) 12.5 8.4 −4.1 1.18 (0.80, 1.73) 1.34 (0.70, 2.57)     Lower secondary or less 65.9 62.4 −3.5 2.64 (2.03, 3.44) 3.44 (2.20, 5.40) 17.1 20.4 +3.4 1.42 (0.94, 2.13) 2.42 (1.20, 4.86) Alcohol poisoning     University 8.2 11.5 +3.3 1.00 1.00 0.3 2.8 +2.5 1.00 1.00     Upper secondary 15.9 41.6 +25.7 1.69 (1.07, 2.65) 3.14 (1.94, 5.10) 2.9 9.2 +6.3 7.81 (1.07, 57.24) 2.73 (1.18, 6.34)     Lower secondary or less 36.2 62.1 +25.9 4.54 (2.93, 7.04) 3.71 (2.26, 6.07) 8.9 26.7 +17.8 32.43 (4.45, 236.48) 4.91 (2.05, 11.73) Suicide     University 25.6 33.4 +7.8 1.00 1.00 11.5 8.8 −2.7 1.00 1.00     Upper secondary 42.7 71.5 +28.8 1.58 (1.21, 2.06) 1.99 (1.47, 2.69) 16.2 11.6 −4.6 1.13 (0.79, 1.60) 1.34 (0.78, 2.30)     Lower secondary or less 89.7 95.0 +5.2 3.45 (2.67, 4.47) 2.40 (1.76, 3.28) 20.5 20.0 −0.5 1.28 (0.89, 1.85) 2.20 (1.25, 3.85) Homicide     University 6.2 15.7 +9.5 1.00 1.00 1.6 3.5 +1.9 1.00 1.00     Upper secondary 13.2 32.3 +19.1 2.90 (1.61, 5.24) 2.13 (1.35, 3.36) 3.7 5.9 +2.2 2.80 (1.01, 7.79) 2.05 (0.81, 5.22)     Lower secondary or less 25.1 38.6 +13.5 5.71 (3.16, 10.30) 2.21 (1.37, 3.56) 9.0 23.1 +14.1 5.40 (1.90, 15.37) 5.46 (2.09, 14.25) . Men . Women . . Mortality rates . Mortality rate ratios (95% CI) . Mortality rates . Mortality rate ratios (95% CI) . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . a European standard population. Infectious diseases     University 7.9 7.4 −0.5 1.00 1.00 5.3 2.2 −3.1 1.00 1.00     Upper secondary 9.4 16.6 +7.2 1.26 (0.69, 2.32) 3.33 (1.53, 7.22) 4.7 6.1 +1.4 1.29 (0.60, 2.75) 2.61 (0.93, 7.36)     Lower secondary or less 24.0 50.5 +26.5 4.12 (2.34, 7.26) 7.88 (3.67, 16.92) 5.9 22.3 +16.4 1.40 (0.65, 3.02) 4.98 (1.74, 14.29) Stomach cancer     University 46.0 26.8 −19.2 1.00 1.00 21.2 13.9 −7.3 1.00 1.00     Upper secondary 61.0 53.7 −7.2 1.27 (0.98, 1.65) 2.07 (1.40, 3.04) 28.4 23.0 −5.4 1.27 (0.90, 1.79) 1.55 (1.00, 2.40)     Lower secondary or less 66.6 53.1 −13.5 1.55 (1.21, 1.98) 2.12 (1.45, 3.10) 30.7 27.2 −3.5 1.37 (0.97, 1.92) 1.68 (1.09, 2.61) Lung cancer     University 64.3 49.6 −14.7 1.00 1.00 14.4 12.4 −2.0 1.00 1.00     Upper secondary 117.1 126.2 +9.1 1.79 (1.45, 2.22) 2.41 (1.83, 3.17) 20.1 18.3 −1.8 1.42 (0.90, 2.23) 1.55 (0.94, 2.57)     Lower secondary or less 152.2 162.5 +10.3 2.74 (2.24, 3.36) 3.34 (2.56, 4.36) 15.5 19.5 +4.0 1.10 (0.70, 1.72) 1.27 (0.76, 2.11) Breast cancer     University – – – – – 44.0 24.6 −19.4 1.00 1.00     Upper secondary – – – – – 33.4 46.3 +12.9 0.71 (0.56, 0.89) 1.72 (1.26, 2.35)     Lower secondary or less – – – – – 27.3 42.3 +15.1 0.55 (0.44, 0.70) 1.33 (0.95, 1.84) Ischaemic heart disease     University 669.3 371.7 −297.6 1.00 1.00 360.1 200.7 −159.4 1.00 1.00     Upper secondary 660.8 618.4 −42.4 1.07 (0.99, 1.16) 1.84 (1.65, 2.06) 348.0 299.1 −48.9 1.05 (0.93, 1.18) 1.67 (1.45, 1.93)     Lower secondary or less 862.9 781.9 −81.0 1.39 (1.30, 1.50) 2.25 (2.02, 2.50) 504.3 445.5 −58.8 1.50 (1.34, 1.68) 2.36 (2.06, 2.70) Cerebrovascular disease     University 257.6 161.1 −96.5 1.00 1.00 219.2 114.9 −104.3 1.00 1.00     Upper secondary 285.8 282.1 −3.7 1.20 (1.05, 1.36) 1.88 (1.59, 2.23) 230.4 188.7 −41.7 1.17 (1.01, 1.36) 1.80 (1.51, 2.16)     Lower secondary or less 340.4 315.2 −25.2 1.45 (1.28, 1.63) 2.07 (1.76, 2.44) 290.7 244.7 −46.0 1.45 (1.26, 1.67) 2.22 (1.86, 2.64) Chronic respiratory disease     University 18.3 15.8 −2.5 1.00 1.00 6.5 5.1 −1.4 1.00 1.00     Upper secondary 24.4 34.7 +10.3 1.46 (0.93, 2.31) 2.33 (1.36, 3.98) 10.7 6.6 −4.1 2.01 (1.01, 4.01) 1.28 (0.59, 2.76)     Lower secondary or less 48.7 48.1 −0.6 3.28 (2.16, 5.00) 3.32 (2.00, 5.54) 15.5 11.2 −4.3 2.87 (1.46, 5.66) 2.18 (1.04, 4.56) Alcoholic liver cirrhosis     University 1.2 11.3 +10.1 1.00 1.00 0.4 1.6 +1.2 1.00 1.00     Upper secondary 2.6 17.5 +14.9 1.26 (0.42, 3.77) 1.39 (0.82, 2.37) 0.6 5.5 +4.9 1.57 (0.19, 13.07) 3.21 (0.98, 10.47)     Lower secondary or less 3.4 24.7 +21.3 2.15 (0.75, 6.22) 1.66 (0.97, 2.84) 0.5 16.8 +16.3 1.57 (0.17, 14.29) 5.54 (1.64, 18.71) Transport accidents     University 25.3 18.4 −7.0 1.00 1.00 15.8 6.9 −8.8 1.00 1.00     Upper secondary 41.6 38.3 −3.3 1.68 (1.29, 2.18) 2.18 (1.40, 3.40) 12.5 8.4 −4.1 1.18 (0.80, 1.73) 1.34 (0.70, 2.57)     Lower secondary or less 65.9 62.4 −3.5 2.64 (2.03, 3.44) 3.44 (2.20, 5.40) 17.1 20.4 +3.4 1.42 (0.94, 2.13) 2.42 (1.20, 4.86) Alcohol poisoning     University 8.2 11.5 +3.3 1.00 1.00 0.3 2.8 +2.5 1.00 1.00     Upper secondary 15.9 41.6 +25.7 1.69 (1.07, 2.65) 3.14 (1.94, 5.10) 2.9 9.2 +6.3 7.81 (1.07, 57.24) 2.73 (1.18, 6.34)     Lower secondary or less 36.2 62.1 +25.9 4.54 (2.93, 7.04) 3.71 (2.26, 6.07) 8.9 26.7 +17.8 32.43 (4.45, 236.48) 4.91 (2.05, 11.73) Suicide     University 25.6 33.4 +7.8 1.00 1.00 11.5 8.8 −2.7 1.00 1.00     Upper secondary 42.7 71.5 +28.8 1.58 (1.21, 2.06) 1.99 (1.47, 2.69) 16.2 11.6 −4.6 1.13 (0.79, 1.60) 1.34 (0.78, 2.30)     Lower secondary or less 89.7 95.0 +5.2 3.45 (2.67, 4.47) 2.40 (1.76, 3.28) 20.5 20.0 −0.5 1.28 (0.89, 1.85) 2.20 (1.25, 3.85) Homicide     University 6.2 15.7 +9.5 1.00 1.00 1.6 3.5 +1.9 1.00 1.00     Upper secondary 13.2 32.3 +19.1 2.90 (1.61, 5.24) 2.13 (1.35, 3.36) 3.7 5.9 +2.2 2.80 (1.01, 7.79) 2.05 (0.81, 5.22)     Lower secondary or less 25.1 38.6 +13.5 5.71 (3.16, 10.30) 2.21 (1.37, 3.56) 9.0 23.1 +14.1 5.40 (1.90, 15.37) 5.46 (2.09, 14.25) Open in new tab Figure 1 Open in new tabDownload slide Average life expectancy at birth in Estonia 1989–2000 Source: Statistical Office of Estonia, 2001.11 Figure 1 Open in new tabDownload slide Average life expectancy at birth in Estonia 1989–2000 Source: Statistical Office of Estonia, 2001.11 Figure 2 Open in new tabDownload slide Average life expectancy at age 25 by educational level in Estonia 1989–2000 Figure 2 Open in new tabDownload slide Average life expectancy at age 25 by educational level in Estonia 1989–2000 This study was supported by the Foundation for Baltic and East European Studies (project grant ‘Social and public health developments in Eastern Europe’), and by a grant from the Ministry of Social Affairs of Estonia/the World Bank. We thank three anonymous referees for valuable comments. References 1 Mackenbach JP, Kunst AE, Cavelaars AEJM, Groenhof F, Geurts JJM, The EU Working Group on Socioeconomic Inequalities in Health. Socioeconomic inequalities in morbidity and mortality in Western Europe. Lancet 1997 ; 349 : 1655 –59. 2 Sorlie P, Backlund R, Keller J. US mortality by economic, demographic, and social characteristics: the National Longitudinal Mortality Study. Am J Public Health 1995 ; 85 : 949 –56. 3 Martikainen P, Mäkelä P, Koskinen S, Valkonen T. Income differences in mortality: a register-based follow-up study of three million men and women. Int J Epidemiol 2001 ; 30 : 1397 –405. 4 Marmot MG, McDowall ME. Mortality decline and widening social inequalities. Lancet 1986 ; 2 : 274 –76. 5 Pappas G, Queen S, Hadden W, Fisher G. The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. 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Population 2000. Tallinn: Statistical Office of Estonia, 2001 . 12 State Committee of Statistics of the USSR. The short list of causes of death for 1981, Based on the Ninth Revision of the International Classification of Diseases, Injuries and Causes of Death from 1975. Moscow, 1980 (in Russian). 13 Kunst AE, Leinsalu M, Habicht J, Kasmel A, Niglas K. Social Inequalities in Health in Estonia. Technical Document. Tallinn: Ministry of Social Affairs, 2002 . (http://www.sm.ee/gopro30/Web/gpweb.nsf/pages/index.html). 14 Carlson P. Risk behaviours and self-rated health in Russia 1998. J Epidemiol Community Health 2001 ; 55 : 806 –17. 15 McKee M, Bobak M, Rose R et al. Patterns of smoking in Russia. Tobacco Control 1998 ; 7 : 22 –26. 16 Leinsalu M. Social variation in self-rated health in Estonia: a cross-sectional study. Soc Sci Med 2002 ; 55 : 847 –61. 17 Bobak M, Pikhart H, Hertzman C, Rose R, Marmot M. Socioeconomic factors, perceived control and self-reported health in Russia. A cross-sectional survey. Soc Sci Med 1998 ; 47 : 269 –79. 18 Davey Smith G, Neaton JD, Wentworth D, Stamler R, Stamler J. Socioeconomic differentials in mortality risk among men screened for the Multiple Risk Factor Intervention Trial: Part I, results for 300,685 White men. Am J Public Health 1996 ; 86 : 486 –96. 19 Volozh O, Solodkaya E, Abina J et al. Some biological cardiovascular risk factors and diet in samples of the male population of Tallinn, Estonia in 1984/1985 and 1992/1993. Eur J Public Health 2002 ; 12 : 16 –21. 20 Kunst AE, Leinsalu M, Kasmel A, Habicht J. Social Inequalities in Health in Estonia. Main Report. Tallinn: Ministry of Social Affairs, 2002 . (http://www.sm.ee/gopro30/Web/gpweb.nsf/pages/index.html). 21 Aareleid T, Brenner H. Trends in cancer patient survival in Estonia before and after the transition from a Soviet republic to an open-market economy. Int J Cancer 2002 ; 102 : 45 –50. 22 Leon DA, Chenet L, Shkolnikov VM et al. Huge variation in Russian mortality rates 1984–94: artefact, alcohol, or what? Lancet 1997 ; 350 : 383 –88. 23 Leon DA, Davey Smith G. Infant mortality, stomach cancer, stroke, and coronary heart disease: ecological analysis. BMJ 2000 ; 320 : 1705 –06. 24 Peto R, Lopez A, Boreham J. Mortality from tobacco in developed countries: indirect estimation from national vital statistics. Lancet 1992 ; 339 : 1268 –78. 25 Hyppönen E, Leon DA, Kenward MG, Lithell H. Prenatal growth and risk of occlusive and haemorrhagic stroke in Swedish men and women born 1915–29: historical cohort study. BMJ 2001 ; 323 : 1033 –34. © International Epidemiological Association 2003 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Epidemiology Oxford University Press

Estonia 1989–2000: enormous increase in mortality differences by education

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References (21)

Publisher
Oxford University Press
Copyright
© International Epidemiological Association 2003
ISSN
0300-5771
eISSN
1464-3685
DOI
10.1093/ije/dyg192
Publisher site
See Article on Publisher Site

Abstract

Abstract Background Having regained its political autonomy in 1991, Estonia experienced major changes in political, economic, and social realities. We aimed to analyse mortality changes by education from 1989 to 2000 in order to assess the impact of recent changes in Estonia, as well as the delayed effects of pre-transitional developments. Methods Two census-based analyses were compared. Individual cause-specific death data for those aged 20+ for 1987–1990 (72 003 deaths) and 1999–2000 (35 477 deaths) came from the national mortality database. Population denominators came from the population censuses of 1989 and 2000. Mortality for all causes combined and for selected causes of death were analysed for high, mid, and low educational groups. The absolute differences in mortality were evaluated through life expectancy at age 25 and age-standardized mortality rates. To assess the relative differences between educational levels, mortality rate ratios with 95% CI were calculated using Poisson regression. Results Educational differences in mortality increased tremendously from 1989 to 2000: over the 10-year period life expectancy improved considerably for graduates, and worsened for those with the lowest education. In 2000, male graduates aged 25 could expect to live 13.1 years longer than corresponding men with the lowest education; among women the difference was 8.6 years. Large differences were observed in all selected causes of death in 1989 and in 2000 and the trends were invariably much more favourable for the higher educated. Educational differences in total mortality increased in all age groups. Conclusions Social disruption and increasing inequalities in wealth can be considered main recent determinants; however, causal processes, shaped decades before recent reforms, also contribute to this widening gap. Cause-specific mortality, educational differences, transition, Estonia Socioeconomic differences in mortality have been extensively reported in the West.1–3 The last decades have witnessed an increase in relative mortality rate ratios in many countries, although absolute differences are more stable.4–7 Less is known about ex-communist countries. Studies suggest that educational differences in mortality in Eastern Europe at the end of the communist era were at least as big as in the West.8,9 Estonia, the smallest country in the Baltic region, regained its political autonomy in 1991 after 50 years of Soviet occupation. Estonia opted for much more far-reaching and intense free market reforms than other transition economies in Central Europe and the former Soviet Union. Deliberate policies were aimed at stimulating job creation and employment (including international trade opportunities and foreign ownership of firms), above all by low employment protection and reduced social safety nets.10 Its mortality development over the past 40 years has been similar to other ex-communist countries: male life expectancy improved by only about 1 year and female by 4 years from 1959 to 2000. During the first years of political and economic transition, Estonia experienced an unprecedented rise in mortality11 (Figure 1). After 1994, mortality rates returned to the levels found before the 1990s. To assess the impact of recent reforms and the delayed effects of pre-transitional developments we analysed mortality changes by education from 1989 to 2000. Data and Methods Two census-based cross-sectional analyses were performed. Individual cause-specific death data for those aged 20+ for 1987–1990 (72 003 deaths) and 1999–2000 (35 477 deaths) came from the national mortality database. Population denominators came from the population censuses of 1989 and 2000. Total mortality and selected causes of death were analysed for three educational groups (university, upper secondary, and lower secondary or less education). In 1987–1990 the abridged Soviet version of International Classification of Diseases, Ninth Revision (ICD-9) was used for coding the causes of death; a correspondence table was then used to reclassify the causes of death into ICD-9.12 For 1999–2000 ICD-10 was used. Table 1 presents corresponding categories of ICD-9 and ICD-10 for the selected causes of death. Educational differences in total mortality were analysed in four age groups: 20–39, 40–54, 55–69, and 70+. The absolute differences in mortality were evaluated through life expectancy at age 25 and age-standardized mortality rates (European standard population). To assess the relative differences between educational levels, mortality rate ratios with 95% CI were calculated using Poisson regression. Age was adjusted in 5-year intervals in the regression analyses. Results The proportion of the population with high and middle educational levels rose from 1989 to 2000. This was balanced by a reduction in the proportion of the population with low education (Table 2). The educational distribution remained stable in the youngest age group. We found a sharp increase in educational differences in mortality from 1989 to 2000 among men and women. Over the 10-year period, life expectancy improved considerably for graduates, and worsened for those with the lowest education. Life expectancy remained stable among women with middle education; for the corresponding group of men it fell (Figure 2). In 2000, male graduates aged 25 could expect to live 13.1 years longer than corresponding men with the lowest education; among women the difference was 8.6 years. Educational differences in total mortality increased in all age groups (Table 3). These increases were largest among younger age groups, but were also to be found among the elderly. Table 4 presents educational differences in mortality by selected causes of death. Large differences were observed in all those causes in 1989 and 2000. Mortality trends were invariably much more favourable for the higher educated. Circulatory diseases had the largest impact on the widening mortality gap. Discussion The enormous increase in mortality differences by education raises the question of data reliability. In unlinked, census-based, cross-sectional studies, the numerator-denominator bias is of greatest concern. We carefully analysed whether there were differences between census records and death certificates with respect to the coverage of population, the reporting or non-response, or the classification of educational level. However, we were unable to identify any data problems that would seriously affect results.13 The small number of deaths in 1999–2000, especially for some causes of death, makes mortality estimates prone to random fluctuations. Problems with the change from ICD-9 to ICD-10 may have affected trends in cause-specific mortality for Estonia at large, but these biases are unlikely to have affected different educational groups in different ways. An additional concern was the fact that the lowest educational stratum became much smaller during the 11 years of transition, especially in the 40–69 age group. This was due to two factors. Firstly, the rapid expansion of education in the post war period, which resulted in a smaller proportion of each new birth cohort achieving only lower secondary education or less. Secondly, the sharp rise of mortality in the 40–69 age group, especially among the lowest educated (Table 3). This excess mortality alone would have resulted in a reduction of the size of the lowest educational stratum of up to 5% between 1989 and 2000. Since the lowest educated group in 2000 was so much smaller than 1989, one could argue that it was also more extreme. Therefore, some of the widening of the educational mortality differences may simply reflect the new distribution of educational categories. However, this is unlikely to contribute much since, firstly, the shrinkage of the lowest educated group is counterbalanced by the growth of the best educated group (which is therefore less extreme) and secondly, since differences between middle and high educated groups also widened. Educational differences in mortality in 1989 were large compared with those of Western Europe.8 The high mortality from infectious diseases and stomach cancer among the poorly educated is one indicator of adverse living conditions before 1991. Their relatively high mortality from smoking-related or alcohol-related causes in 1989 indicates differences in lifestyle between educational groups.14,15 In Estonia’s rapid political and economic transition, the less educated often lacked the necessary coping skills; they were thus at greater risk of unemployment and were less likely to move from unemployment and inactivity back to employment.10 The new policies favoured graduates, who benefited both in terms of money and health16 and for whom the psychological adjustment was easier.17 Social disruption, poverty, and the increasing gap in wealth are likely contributors to larger educational differences in mortality in 2000. Sharply increased mortality from infectious diseases from 1989 to 2000 among the lowest educated is evidence of poverty-driven causal mechanisms. Income and poverty are linked to many other causes of death, including the most common ones,3,18 although both the strength of association and the causal pathways vary between causes. Changes in the diet of the population as a whole at the beginning of the 1990s may be one determinant of the overall decline of mortality from circulatory diseases.19 Progress in medical care may also have contributed to the reduction in mortality from circulatory disease in all educational groups, particularly for graduates, who were more successful in getting specialist care.20 The overall improvement in cancer survival rates in the 1990s,21 known to be dependent on access to and quality of medical care, could point to improved medical care in Estonia. The reversing educational gradient for breast cancer mortality is striking and probably best explained by earlier detection, better treatment and survival among graduates, and perhaps also by differential changes in fertility. Social disruption and poverty works also through behavioural mechanisms. Alcohol has been considered one of the main factors behind the increasing mortality in 1990s Russia.22 Its role is similarly evident in Estonia, with an extremely liberal alcohol policy in the early 1990s. Mortality from alcohol poisoning and liver cirrhosis increased sharply in all educational groups and in both genders. These two alcohol-related causes certainly contributed to the mortality difference by education and to its increase in Estonia. From 1989 to 2000 the declining mortality of the higher educated and the rising mortality of the lower educated resulted in an enormous mortality gap. The increasing differentiation of wealth and opportunity, partly resulting from recent reforms, can be considered a main, recent underlying factor. However, the situation was partly determined long before the transition period. The fairly high contribution of neoplasms to the widening mortality gap suggests that some underlying factors originated decades before recent reforms. Stomach cancer, determined early in life,23 and lung cancer, with a long latency time,24 are two examples. Cerebrovascular deaths also contribute to the widening gap and, again, this group of diseases, especially haemorrhagic stroke, are believed to be partly determined early in life.23,25 Early life factors linked to education interacting with factors later in life also linked to education (alcohol for example) could result in the widening mortality gap for certain causes of death. We conclude that there is a particular need to tackle health inequalities in countries in transition. Three such areas could be suggested. Those with a low educational achievement need to be pulled into the new economic developments and allowed to benefit from economic change; the distribution and consumption of alcohol need to be more tightly controlled, and thirdly, a modernized, comprehensive medical care system equally accessible for all would counteract some of the forces now creating a widening of the educational mortality divide. KEY MESSAGES Educational differences in mortality increased tremendously in Estonia from 1989 to 2000. From 1989 to 2000 mortality decreased considerably for those with university education and increased for those with the lowest education. Increasing inequalities were observed for all age groups and for most causes of death. The available evidence suggests that social disruption and increasing inequalities in wealth can be considered main recent determinants; however causal processes, shaped decades before recent reforms, also contribute to this widening gap. Table 1 Correspondence of selected causes of death in 1987–1990 (ICD-9) and in 1999–2000 (ICD-10) . 1987–1990 . 1999–2000 . Cause of death . ICD-9 . ICD-10 . Infectious diseases 001–139 A00–B99 Stomach cancer 151 C16 Lung cancer 162 C33–C34 Breast cancer 174–175 C50 Ischaemic heart disease 410–414 I20–I25 Cerebrovascular disease 430–438 I60–I69 Chronic respiratory disease 490–494; 496 J40–J47 Alcoholic liver cirrhosis 571.0–571.3 K70 Transport accidents E800–E848 V01–V99 Alcohol poisoning E860 X45 Suicide E950–E959 X60–X84 Homicide E960–E978 X85–Y09, Y35, Y36 . 1987–1990 . 1999–2000 . Cause of death . ICD-9 . ICD-10 . Infectious diseases 001–139 A00–B99 Stomach cancer 151 C16 Lung cancer 162 C33–C34 Breast cancer 174–175 C50 Ischaemic heart disease 410–414 I20–I25 Cerebrovascular disease 430–438 I60–I69 Chronic respiratory disease 490–494; 496 J40–J47 Alcoholic liver cirrhosis 571.0–571.3 K70 Transport accidents E800–E848 V01–V99 Alcohol poisoning E860 X45 Suicide E950–E959 X60–X84 Homicide E960–E978 X85–Y09, Y35, Y36 Open in new tab Table 1 Correspondence of selected causes of death in 1987–1990 (ICD-9) and in 1999–2000 (ICD-10) . 1987–1990 . 1999–2000 . Cause of death . ICD-9 . ICD-10 . Infectious diseases 001–139 A00–B99 Stomach cancer 151 C16 Lung cancer 162 C33–C34 Breast cancer 174–175 C50 Ischaemic heart disease 410–414 I20–I25 Cerebrovascular disease 430–438 I60–I69 Chronic respiratory disease 490–494; 496 J40–J47 Alcoholic liver cirrhosis 571.0–571.3 K70 Transport accidents E800–E848 V01–V99 Alcohol poisoning E860 X45 Suicide E950–E959 X60–X84 Homicide E960–E978 X85–Y09, Y35, Y36 . 1987–1990 . 1999–2000 . Cause of death . ICD-9 . ICD-10 . Infectious diseases 001–139 A00–B99 Stomach cancer 151 C16 Lung cancer 162 C33–C34 Breast cancer 174–175 C50 Ischaemic heart disease 410–414 I20–I25 Cerebrovascular disease 430–438 I60–I69 Chronic respiratory disease 490–494; 496 J40–J47 Alcoholic liver cirrhosis 571.0–571.3 K70 Transport accidents E800–E848 V01–V99 Alcohol poisoning E860 X45 Suicide E950–E959 X60–X84 Homicide E960–E978 X85–Y09, Y35, Y36 Open in new tab Table 2 Educational distribution of Estonian population in 1989 and 2000 . Men . Women . . 1989 . 2000 . . 2000 . . N . (%) . N . (%) . N . (%) . N . (%) . All ages 20+     University 65 329 13.2 65 938 15.0 76 957 12.6 90 875 16.4     Upper secondary 241 965 48.9 243 624 55.4 297 062 48.7 312 500 56.5     Lower secondary or less 187 925 37.9 130 138 29.6 235 987 38.7 149 307 27.0 20–39     University 31 269 13.6 22 043 12.2 39 369 17.1 32 442 17.6     Upper secondary 157 036 68.4 125 340 69.2 167 292 72.9 135 362 73.2     Lower secondary or less 41 134 17.9 33 634 18.6 22 903 10.0 17 046 9.2 40–54     University 21 428 15.7 23 843 18.7 24 727 16.2 32 526 22.2     Upper secondary 54 066 39.5 74 827 58.6 76 705 50.3 96 007 65.4     Lower secondary or less 61 305 44.8 29 049 22.7 50 912 33.4 18 213 12.4 55–69     University 10 501 11.1 15 331 16.6 11 115 7.8 19 839 15.4     Upper secondary 24 292 25.7 33 236 36.0 39 534 27.9 57 059 44.4     Lower secondary or less 59 805 63.2 43 782 47.4 91 292 64.3 51 608 40.2 70+     University 2131 6.2 4721 12.2 1746 2.0 6068 6.6     Upper secondary 6571 19.1 10 221 26.5 13 531 15.7 24 072 26.0     Lower secondary or less 25 681 74.7 23 673 61.3 70 880 82.3 62 440 67.4 . Men . Women . . 1989 . 2000 . . 2000 . . N . (%) . N . (%) . N . (%) . N . (%) . All ages 20+     University 65 329 13.2 65 938 15.0 76 957 12.6 90 875 16.4     Upper secondary 241 965 48.9 243 624 55.4 297 062 48.7 312 500 56.5     Lower secondary or less 187 925 37.9 130 138 29.6 235 987 38.7 149 307 27.0 20–39     University 31 269 13.6 22 043 12.2 39 369 17.1 32 442 17.6     Upper secondary 157 036 68.4 125 340 69.2 167 292 72.9 135 362 73.2     Lower secondary or less 41 134 17.9 33 634 18.6 22 903 10.0 17 046 9.2 40–54     University 21 428 15.7 23 843 18.7 24 727 16.2 32 526 22.2     Upper secondary 54 066 39.5 74 827 58.6 76 705 50.3 96 007 65.4     Lower secondary or less 61 305 44.8 29 049 22.7 50 912 33.4 18 213 12.4 55–69     University 10 501 11.1 15 331 16.6 11 115 7.8 19 839 15.4     Upper secondary 24 292 25.7 33 236 36.0 39 534 27.9 57 059 44.4     Lower secondary or less 59 805 63.2 43 782 47.4 91 292 64.3 51 608 40.2 70+     University 2131 6.2 4721 12.2 1746 2.0 6068 6.6     Upper secondary 6571 19.1 10 221 26.5 13 531 15.7 24 072 26.0     Lower secondary or less 25 681 74.7 23 673 61.3 70 880 82.3 62 440 67.4 Open in new tab Table 2 Educational distribution of Estonian population in 1989 and 2000 . Men . Women . . 1989 . 2000 . . 2000 . . N . (%) . N . (%) . N . (%) . N . (%) . All ages 20+     University 65 329 13.2 65 938 15.0 76 957 12.6 90 875 16.4     Upper secondary 241 965 48.9 243 624 55.4 297 062 48.7 312 500 56.5     Lower secondary or less 187 925 37.9 130 138 29.6 235 987 38.7 149 307 27.0 20–39     University 31 269 13.6 22 043 12.2 39 369 17.1 32 442 17.6     Upper secondary 157 036 68.4 125 340 69.2 167 292 72.9 135 362 73.2     Lower secondary or less 41 134 17.9 33 634 18.6 22 903 10.0 17 046 9.2 40–54     University 21 428 15.7 23 843 18.7 24 727 16.2 32 526 22.2     Upper secondary 54 066 39.5 74 827 58.6 76 705 50.3 96 007 65.4     Lower secondary or less 61 305 44.8 29 049 22.7 50 912 33.4 18 213 12.4 55–69     University 10 501 11.1 15 331 16.6 11 115 7.8 19 839 15.4     Upper secondary 24 292 25.7 33 236 36.0 39 534 27.9 57 059 44.4     Lower secondary or less 59 805 63.2 43 782 47.4 91 292 64.3 51 608 40.2 70+     University 2131 6.2 4721 12.2 1746 2.0 6068 6.6     Upper secondary 6571 19.1 10 221 26.5 13 531 15.7 24 072 26.0     Lower secondary or less 25 681 74.7 23 673 61.3 70 880 82.3 62 440 67.4 . Men . Women . . 1989 . 2000 . . 2000 . . N . (%) . N . (%) . N . (%) . N . (%) . All ages 20+     University 65 329 13.2 65 938 15.0 76 957 12.6 90 875 16.4     Upper secondary 241 965 48.9 243 624 55.4 297 062 48.7 312 500 56.5     Lower secondary or less 187 925 37.9 130 138 29.6 235 987 38.7 149 307 27.0 20–39     University 31 269 13.6 22 043 12.2 39 369 17.1 32 442 17.6     Upper secondary 157 036 68.4 125 340 69.2 167 292 72.9 135 362 73.2     Lower secondary or less 41 134 17.9 33 634 18.6 22 903 10.0 17 046 9.2 40–54     University 21 428 15.7 23 843 18.7 24 727 16.2 32 526 22.2     Upper secondary 54 066 39.5 74 827 58.6 76 705 50.3 96 007 65.4     Lower secondary or less 61 305 44.8 29 049 22.7 50 912 33.4 18 213 12.4 55–69     University 10 501 11.1 15 331 16.6 11 115 7.8 19 839 15.4     Upper secondary 24 292 25.7 33 236 36.0 39 534 27.9 57 059 44.4     Lower secondary or less 59 805 63.2 43 782 47.4 91 292 64.3 51 608 40.2 70+     University 2131 6.2 4721 12.2 1746 2.0 6068 6.6     Upper secondary 6571 19.1 10 221 26.5 13 531 15.7 24 072 26.0     Lower secondary or less 25 681 74.7 23 673 61.3 70 880 82.3 62 440 67.4 Open in new tab Table 3 Age-standardizeda mortality rates per 100 000 and mortality rate ratios for different age groups by educational level in Estonia 1989–2000 . Men . Women . . Mortality rates . Mortality rate ratios (95% CI) . Mortality rates . Mortality rate ratios (95% CI) . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . a European standard population. All ages 20+     University 1565.2 1194.9 −370.3 1.00 1.00 962.4 631.3 −331.1 1.00 1.00     Upper secondary 1802.8 2094.2 +291.4 1.34 (1.27, 1.40) 1.91 (1.80, 2.03) 997.5 984.6 −12.9 1.14 (1.07, 1.21) 1.72 (1.60, 1.85)     Lower secondary or less 2331.3 2725.1 +393.8 1.73 (1.65, 1.81) 2.38 (2.25, 2.53) 1274.2 1428.0 +153.8 1.37 (1.29, 1.45) 2.23 (2.07, 2.39) 20–39     University 155.5 111.8 −43.7 1.00 1.00 52.5 64.5 +12.0 1.00 1.00     Upper secondary 242.9 331.7 +88.8 1.69 (1.45, 1.97) 3.69 (2.74, 4.99) 79.0 84.3 +5.3 1.50 (1.20, 1.89) 1.48 (1.07, 2.06)     Lower secondary or less 591.2 672.0 +80.8 4.13 (3.54, 4.82) 7.26 (5.31, 9.91) 224.3 317.5 +93.3 4.12 (3.21, 5.28) 5.13 (3.52, 7.48) 40–54     University 439.0 439.4 +0.4 1.00 1.00 237.7 191.0 −46.7 1.00 1.00     Upper secondary 831.3 1190.3 +359.0 1.89 (1.69, 2.12) 2.71 (2.34, 3.13) 309.8 408.9 +99.1 1.32 (1.14, 1.52) 2.19 (1.80, 2.66)     Lower secondary or less 1277.0 1995.4 +718.4 2.91 (2.61, 3.24) 4.50 (3.88, 5.22) 435.9 815.3 +379.4 1.81 (1.56, 2.09) 4.10 (3.31, 5.08) 55–69     University 2089.8 1717.2 −372.5 1.00 1.00 1003.8 680.1 −323.6 1.00 1.00     Upper secondary 2768.3 3196.4 +428.1 1.35 (1.24, 1.46) 1.86 (1.69, 2.05) 1200.0 1159.9 −40.2 1.22 (1.09, 1.36) 1.69 (1.48, 1.92)     Lower secondary or less 3276.3 3889.0 +612.6 1.60 (1.48, 1.72) 2.26 (2.06, 2.48) 1389.1 1539.2 +150.0 1.41 (1.27, 1.56) 2.20 (1.94, 2.50) 70+     University 10 168.0 7482.6 −2685.4 1.00 1.00 6958.2 5051.8 −1906.4 1.00 1.00     Upper secondary 10 008.5 10 292.4 +283.9 0.97 (0.90, 1.05) 1.50 (1.37, 1.65) 6748.9 6585.4 −163.4 0.96 (0.88, 1.03) 1.42 (1.28, 1.58)     Lower secondary or less 11 117.6 10 893.9 −223.7 1.09 (1.02, 1.17) 1.60 (1.47, 1.75) 7979.6 7252.0 −727.6 1.13 (1.03, 1.23) 1.57 (1.42, 1.73) . Men . Women . . Mortality rates . Mortality rate ratios (95% CI) . Mortality rates . Mortality rate ratios (95% CI) . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . a European standard population. All ages 20+     University 1565.2 1194.9 −370.3 1.00 1.00 962.4 631.3 −331.1 1.00 1.00     Upper secondary 1802.8 2094.2 +291.4 1.34 (1.27, 1.40) 1.91 (1.80, 2.03) 997.5 984.6 −12.9 1.14 (1.07, 1.21) 1.72 (1.60, 1.85)     Lower secondary or less 2331.3 2725.1 +393.8 1.73 (1.65, 1.81) 2.38 (2.25, 2.53) 1274.2 1428.0 +153.8 1.37 (1.29, 1.45) 2.23 (2.07, 2.39) 20–39     University 155.5 111.8 −43.7 1.00 1.00 52.5 64.5 +12.0 1.00 1.00     Upper secondary 242.9 331.7 +88.8 1.69 (1.45, 1.97) 3.69 (2.74, 4.99) 79.0 84.3 +5.3 1.50 (1.20, 1.89) 1.48 (1.07, 2.06)     Lower secondary or less 591.2 672.0 +80.8 4.13 (3.54, 4.82) 7.26 (5.31, 9.91) 224.3 317.5 +93.3 4.12 (3.21, 5.28) 5.13 (3.52, 7.48) 40–54     University 439.0 439.4 +0.4 1.00 1.00 237.7 191.0 −46.7 1.00 1.00     Upper secondary 831.3 1190.3 +359.0 1.89 (1.69, 2.12) 2.71 (2.34, 3.13) 309.8 408.9 +99.1 1.32 (1.14, 1.52) 2.19 (1.80, 2.66)     Lower secondary or less 1277.0 1995.4 +718.4 2.91 (2.61, 3.24) 4.50 (3.88, 5.22) 435.9 815.3 +379.4 1.81 (1.56, 2.09) 4.10 (3.31, 5.08) 55–69     University 2089.8 1717.2 −372.5 1.00 1.00 1003.8 680.1 −323.6 1.00 1.00     Upper secondary 2768.3 3196.4 +428.1 1.35 (1.24, 1.46) 1.86 (1.69, 2.05) 1200.0 1159.9 −40.2 1.22 (1.09, 1.36) 1.69 (1.48, 1.92)     Lower secondary or less 3276.3 3889.0 +612.6 1.60 (1.48, 1.72) 2.26 (2.06, 2.48) 1389.1 1539.2 +150.0 1.41 (1.27, 1.56) 2.20 (1.94, 2.50) 70+     University 10 168.0 7482.6 −2685.4 1.00 1.00 6958.2 5051.8 −1906.4 1.00 1.00     Upper secondary 10 008.5 10 292.4 +283.9 0.97 (0.90, 1.05) 1.50 (1.37, 1.65) 6748.9 6585.4 −163.4 0.96 (0.88, 1.03) 1.42 (1.28, 1.58)     Lower secondary or less 11 117.6 10 893.9 −223.7 1.09 (1.02, 1.17) 1.60 (1.47, 1.75) 7979.6 7252.0 −727.6 1.13 (1.03, 1.23) 1.57 (1.42, 1.73) Open in new tab Table 3 Age-standardizeda mortality rates per 100 000 and mortality rate ratios for different age groups by educational level in Estonia 1989–2000 . Men . Women . . Mortality rates . Mortality rate ratios (95% CI) . Mortality rates . Mortality rate ratios (95% CI) . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . a European standard population. All ages 20+     University 1565.2 1194.9 −370.3 1.00 1.00 962.4 631.3 −331.1 1.00 1.00     Upper secondary 1802.8 2094.2 +291.4 1.34 (1.27, 1.40) 1.91 (1.80, 2.03) 997.5 984.6 −12.9 1.14 (1.07, 1.21) 1.72 (1.60, 1.85)     Lower secondary or less 2331.3 2725.1 +393.8 1.73 (1.65, 1.81) 2.38 (2.25, 2.53) 1274.2 1428.0 +153.8 1.37 (1.29, 1.45) 2.23 (2.07, 2.39) 20–39     University 155.5 111.8 −43.7 1.00 1.00 52.5 64.5 +12.0 1.00 1.00     Upper secondary 242.9 331.7 +88.8 1.69 (1.45, 1.97) 3.69 (2.74, 4.99) 79.0 84.3 +5.3 1.50 (1.20, 1.89) 1.48 (1.07, 2.06)     Lower secondary or less 591.2 672.0 +80.8 4.13 (3.54, 4.82) 7.26 (5.31, 9.91) 224.3 317.5 +93.3 4.12 (3.21, 5.28) 5.13 (3.52, 7.48) 40–54     University 439.0 439.4 +0.4 1.00 1.00 237.7 191.0 −46.7 1.00 1.00     Upper secondary 831.3 1190.3 +359.0 1.89 (1.69, 2.12) 2.71 (2.34, 3.13) 309.8 408.9 +99.1 1.32 (1.14, 1.52) 2.19 (1.80, 2.66)     Lower secondary or less 1277.0 1995.4 +718.4 2.91 (2.61, 3.24) 4.50 (3.88, 5.22) 435.9 815.3 +379.4 1.81 (1.56, 2.09) 4.10 (3.31, 5.08) 55–69     University 2089.8 1717.2 −372.5 1.00 1.00 1003.8 680.1 −323.6 1.00 1.00     Upper secondary 2768.3 3196.4 +428.1 1.35 (1.24, 1.46) 1.86 (1.69, 2.05) 1200.0 1159.9 −40.2 1.22 (1.09, 1.36) 1.69 (1.48, 1.92)     Lower secondary or less 3276.3 3889.0 +612.6 1.60 (1.48, 1.72) 2.26 (2.06, 2.48) 1389.1 1539.2 +150.0 1.41 (1.27, 1.56) 2.20 (1.94, 2.50) 70+     University 10 168.0 7482.6 −2685.4 1.00 1.00 6958.2 5051.8 −1906.4 1.00 1.00     Upper secondary 10 008.5 10 292.4 +283.9 0.97 (0.90, 1.05) 1.50 (1.37, 1.65) 6748.9 6585.4 −163.4 0.96 (0.88, 1.03) 1.42 (1.28, 1.58)     Lower secondary or less 11 117.6 10 893.9 −223.7 1.09 (1.02, 1.17) 1.60 (1.47, 1.75) 7979.6 7252.0 −727.6 1.13 (1.03, 1.23) 1.57 (1.42, 1.73) . Men . Women . . Mortality rates . Mortality rate ratios (95% CI) . Mortality rates . Mortality rate ratios (95% CI) . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . a European standard population. All ages 20+     University 1565.2 1194.9 −370.3 1.00 1.00 962.4 631.3 −331.1 1.00 1.00     Upper secondary 1802.8 2094.2 +291.4 1.34 (1.27, 1.40) 1.91 (1.80, 2.03) 997.5 984.6 −12.9 1.14 (1.07, 1.21) 1.72 (1.60, 1.85)     Lower secondary or less 2331.3 2725.1 +393.8 1.73 (1.65, 1.81) 2.38 (2.25, 2.53) 1274.2 1428.0 +153.8 1.37 (1.29, 1.45) 2.23 (2.07, 2.39) 20–39     University 155.5 111.8 −43.7 1.00 1.00 52.5 64.5 +12.0 1.00 1.00     Upper secondary 242.9 331.7 +88.8 1.69 (1.45, 1.97) 3.69 (2.74, 4.99) 79.0 84.3 +5.3 1.50 (1.20, 1.89) 1.48 (1.07, 2.06)     Lower secondary or less 591.2 672.0 +80.8 4.13 (3.54, 4.82) 7.26 (5.31, 9.91) 224.3 317.5 +93.3 4.12 (3.21, 5.28) 5.13 (3.52, 7.48) 40–54     University 439.0 439.4 +0.4 1.00 1.00 237.7 191.0 −46.7 1.00 1.00     Upper secondary 831.3 1190.3 +359.0 1.89 (1.69, 2.12) 2.71 (2.34, 3.13) 309.8 408.9 +99.1 1.32 (1.14, 1.52) 2.19 (1.80, 2.66)     Lower secondary or less 1277.0 1995.4 +718.4 2.91 (2.61, 3.24) 4.50 (3.88, 5.22) 435.9 815.3 +379.4 1.81 (1.56, 2.09) 4.10 (3.31, 5.08) 55–69     University 2089.8 1717.2 −372.5 1.00 1.00 1003.8 680.1 −323.6 1.00 1.00     Upper secondary 2768.3 3196.4 +428.1 1.35 (1.24, 1.46) 1.86 (1.69, 2.05) 1200.0 1159.9 −40.2 1.22 (1.09, 1.36) 1.69 (1.48, 1.92)     Lower secondary or less 3276.3 3889.0 +612.6 1.60 (1.48, 1.72) 2.26 (2.06, 2.48) 1389.1 1539.2 +150.0 1.41 (1.27, 1.56) 2.20 (1.94, 2.50) 70+     University 10 168.0 7482.6 −2685.4 1.00 1.00 6958.2 5051.8 −1906.4 1.00 1.00     Upper secondary 10 008.5 10 292.4 +283.9 0.97 (0.90, 1.05) 1.50 (1.37, 1.65) 6748.9 6585.4 −163.4 0.96 (0.88, 1.03) 1.42 (1.28, 1.58)     Lower secondary or less 11 117.6 10 893.9 −223.7 1.09 (1.02, 1.17) 1.60 (1.47, 1.75) 7979.6 7252.0 −727.6 1.13 (1.03, 1.23) 1.57 (1.42, 1.73) Open in new tab Table 4 Age-standardizeda mortality rates per 100 000 and mortality rate ratios for selected causes of death by educational level in Estonia 1989–2000 in age group 20+ . Men . Women . . Mortality rates . Mortality rate ratios (95% CI) . Mortality rates . Mortality rate ratios (95% CI) . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . a European standard population. Infectious diseases     University 7.9 7.4 −0.5 1.00 1.00 5.3 2.2 −3.1 1.00 1.00     Upper secondary 9.4 16.6 +7.2 1.26 (0.69, 2.32) 3.33 (1.53, 7.22) 4.7 6.1 +1.4 1.29 (0.60, 2.75) 2.61 (0.93, 7.36)     Lower secondary or less 24.0 50.5 +26.5 4.12 (2.34, 7.26) 7.88 (3.67, 16.92) 5.9 22.3 +16.4 1.40 (0.65, 3.02) 4.98 (1.74, 14.29) Stomach cancer     University 46.0 26.8 −19.2 1.00 1.00 21.2 13.9 −7.3 1.00 1.00     Upper secondary 61.0 53.7 −7.2 1.27 (0.98, 1.65) 2.07 (1.40, 3.04) 28.4 23.0 −5.4 1.27 (0.90, 1.79) 1.55 (1.00, 2.40)     Lower secondary or less 66.6 53.1 −13.5 1.55 (1.21, 1.98) 2.12 (1.45, 3.10) 30.7 27.2 −3.5 1.37 (0.97, 1.92) 1.68 (1.09, 2.61) Lung cancer     University 64.3 49.6 −14.7 1.00 1.00 14.4 12.4 −2.0 1.00 1.00     Upper secondary 117.1 126.2 +9.1 1.79 (1.45, 2.22) 2.41 (1.83, 3.17) 20.1 18.3 −1.8 1.42 (0.90, 2.23) 1.55 (0.94, 2.57)     Lower secondary or less 152.2 162.5 +10.3 2.74 (2.24, 3.36) 3.34 (2.56, 4.36) 15.5 19.5 +4.0 1.10 (0.70, 1.72) 1.27 (0.76, 2.11) Breast cancer     University – – – – – 44.0 24.6 −19.4 1.00 1.00     Upper secondary – – – – – 33.4 46.3 +12.9 0.71 (0.56, 0.89) 1.72 (1.26, 2.35)     Lower secondary or less – – – – – 27.3 42.3 +15.1 0.55 (0.44, 0.70) 1.33 (0.95, 1.84) Ischaemic heart disease     University 669.3 371.7 −297.6 1.00 1.00 360.1 200.7 −159.4 1.00 1.00     Upper secondary 660.8 618.4 −42.4 1.07 (0.99, 1.16) 1.84 (1.65, 2.06) 348.0 299.1 −48.9 1.05 (0.93, 1.18) 1.67 (1.45, 1.93)     Lower secondary or less 862.9 781.9 −81.0 1.39 (1.30, 1.50) 2.25 (2.02, 2.50) 504.3 445.5 −58.8 1.50 (1.34, 1.68) 2.36 (2.06, 2.70) Cerebrovascular disease     University 257.6 161.1 −96.5 1.00 1.00 219.2 114.9 −104.3 1.00 1.00     Upper secondary 285.8 282.1 −3.7 1.20 (1.05, 1.36) 1.88 (1.59, 2.23) 230.4 188.7 −41.7 1.17 (1.01, 1.36) 1.80 (1.51, 2.16)     Lower secondary or less 340.4 315.2 −25.2 1.45 (1.28, 1.63) 2.07 (1.76, 2.44) 290.7 244.7 −46.0 1.45 (1.26, 1.67) 2.22 (1.86, 2.64) Chronic respiratory disease     University 18.3 15.8 −2.5 1.00 1.00 6.5 5.1 −1.4 1.00 1.00     Upper secondary 24.4 34.7 +10.3 1.46 (0.93, 2.31) 2.33 (1.36, 3.98) 10.7 6.6 −4.1 2.01 (1.01, 4.01) 1.28 (0.59, 2.76)     Lower secondary or less 48.7 48.1 −0.6 3.28 (2.16, 5.00) 3.32 (2.00, 5.54) 15.5 11.2 −4.3 2.87 (1.46, 5.66) 2.18 (1.04, 4.56) Alcoholic liver cirrhosis     University 1.2 11.3 +10.1 1.00 1.00 0.4 1.6 +1.2 1.00 1.00     Upper secondary 2.6 17.5 +14.9 1.26 (0.42, 3.77) 1.39 (0.82, 2.37) 0.6 5.5 +4.9 1.57 (0.19, 13.07) 3.21 (0.98, 10.47)     Lower secondary or less 3.4 24.7 +21.3 2.15 (0.75, 6.22) 1.66 (0.97, 2.84) 0.5 16.8 +16.3 1.57 (0.17, 14.29) 5.54 (1.64, 18.71) Transport accidents     University 25.3 18.4 −7.0 1.00 1.00 15.8 6.9 −8.8 1.00 1.00     Upper secondary 41.6 38.3 −3.3 1.68 (1.29, 2.18) 2.18 (1.40, 3.40) 12.5 8.4 −4.1 1.18 (0.80, 1.73) 1.34 (0.70, 2.57)     Lower secondary or less 65.9 62.4 −3.5 2.64 (2.03, 3.44) 3.44 (2.20, 5.40) 17.1 20.4 +3.4 1.42 (0.94, 2.13) 2.42 (1.20, 4.86) Alcohol poisoning     University 8.2 11.5 +3.3 1.00 1.00 0.3 2.8 +2.5 1.00 1.00     Upper secondary 15.9 41.6 +25.7 1.69 (1.07, 2.65) 3.14 (1.94, 5.10) 2.9 9.2 +6.3 7.81 (1.07, 57.24) 2.73 (1.18, 6.34)     Lower secondary or less 36.2 62.1 +25.9 4.54 (2.93, 7.04) 3.71 (2.26, 6.07) 8.9 26.7 +17.8 32.43 (4.45, 236.48) 4.91 (2.05, 11.73) Suicide     University 25.6 33.4 +7.8 1.00 1.00 11.5 8.8 −2.7 1.00 1.00     Upper secondary 42.7 71.5 +28.8 1.58 (1.21, 2.06) 1.99 (1.47, 2.69) 16.2 11.6 −4.6 1.13 (0.79, 1.60) 1.34 (0.78, 2.30)     Lower secondary or less 89.7 95.0 +5.2 3.45 (2.67, 4.47) 2.40 (1.76, 3.28) 20.5 20.0 −0.5 1.28 (0.89, 1.85) 2.20 (1.25, 3.85) Homicide     University 6.2 15.7 +9.5 1.00 1.00 1.6 3.5 +1.9 1.00 1.00     Upper secondary 13.2 32.3 +19.1 2.90 (1.61, 5.24) 2.13 (1.35, 3.36) 3.7 5.9 +2.2 2.80 (1.01, 7.79) 2.05 (0.81, 5.22)     Lower secondary or less 25.1 38.6 +13.5 5.71 (3.16, 10.30) 2.21 (1.37, 3.56) 9.0 23.1 +14.1 5.40 (1.90, 15.37) 5.46 (2.09, 14.25) . Men . Women . . Mortality rates . Mortality rate ratios (95% CI) . Mortality rates . Mortality rate ratios (95% CI) . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . a European standard population. Infectious diseases     University 7.9 7.4 −0.5 1.00 1.00 5.3 2.2 −3.1 1.00 1.00     Upper secondary 9.4 16.6 +7.2 1.26 (0.69, 2.32) 3.33 (1.53, 7.22) 4.7 6.1 +1.4 1.29 (0.60, 2.75) 2.61 (0.93, 7.36)     Lower secondary or less 24.0 50.5 +26.5 4.12 (2.34, 7.26) 7.88 (3.67, 16.92) 5.9 22.3 +16.4 1.40 (0.65, 3.02) 4.98 (1.74, 14.29) Stomach cancer     University 46.0 26.8 −19.2 1.00 1.00 21.2 13.9 −7.3 1.00 1.00     Upper secondary 61.0 53.7 −7.2 1.27 (0.98, 1.65) 2.07 (1.40, 3.04) 28.4 23.0 −5.4 1.27 (0.90, 1.79) 1.55 (1.00, 2.40)     Lower secondary or less 66.6 53.1 −13.5 1.55 (1.21, 1.98) 2.12 (1.45, 3.10) 30.7 27.2 −3.5 1.37 (0.97, 1.92) 1.68 (1.09, 2.61) Lung cancer     University 64.3 49.6 −14.7 1.00 1.00 14.4 12.4 −2.0 1.00 1.00     Upper secondary 117.1 126.2 +9.1 1.79 (1.45, 2.22) 2.41 (1.83, 3.17) 20.1 18.3 −1.8 1.42 (0.90, 2.23) 1.55 (0.94, 2.57)     Lower secondary or less 152.2 162.5 +10.3 2.74 (2.24, 3.36) 3.34 (2.56, 4.36) 15.5 19.5 +4.0 1.10 (0.70, 1.72) 1.27 (0.76, 2.11) Breast cancer     University – – – – – 44.0 24.6 −19.4 1.00 1.00     Upper secondary – – – – – 33.4 46.3 +12.9 0.71 (0.56, 0.89) 1.72 (1.26, 2.35)     Lower secondary or less – – – – – 27.3 42.3 +15.1 0.55 (0.44, 0.70) 1.33 (0.95, 1.84) Ischaemic heart disease     University 669.3 371.7 −297.6 1.00 1.00 360.1 200.7 −159.4 1.00 1.00     Upper secondary 660.8 618.4 −42.4 1.07 (0.99, 1.16) 1.84 (1.65, 2.06) 348.0 299.1 −48.9 1.05 (0.93, 1.18) 1.67 (1.45, 1.93)     Lower secondary or less 862.9 781.9 −81.0 1.39 (1.30, 1.50) 2.25 (2.02, 2.50) 504.3 445.5 −58.8 1.50 (1.34, 1.68) 2.36 (2.06, 2.70) Cerebrovascular disease     University 257.6 161.1 −96.5 1.00 1.00 219.2 114.9 −104.3 1.00 1.00     Upper secondary 285.8 282.1 −3.7 1.20 (1.05, 1.36) 1.88 (1.59, 2.23) 230.4 188.7 −41.7 1.17 (1.01, 1.36) 1.80 (1.51, 2.16)     Lower secondary or less 340.4 315.2 −25.2 1.45 (1.28, 1.63) 2.07 (1.76, 2.44) 290.7 244.7 −46.0 1.45 (1.26, 1.67) 2.22 (1.86, 2.64) Chronic respiratory disease     University 18.3 15.8 −2.5 1.00 1.00 6.5 5.1 −1.4 1.00 1.00     Upper secondary 24.4 34.7 +10.3 1.46 (0.93, 2.31) 2.33 (1.36, 3.98) 10.7 6.6 −4.1 2.01 (1.01, 4.01) 1.28 (0.59, 2.76)     Lower secondary or less 48.7 48.1 −0.6 3.28 (2.16, 5.00) 3.32 (2.00, 5.54) 15.5 11.2 −4.3 2.87 (1.46, 5.66) 2.18 (1.04, 4.56) Alcoholic liver cirrhosis     University 1.2 11.3 +10.1 1.00 1.00 0.4 1.6 +1.2 1.00 1.00     Upper secondary 2.6 17.5 +14.9 1.26 (0.42, 3.77) 1.39 (0.82, 2.37) 0.6 5.5 +4.9 1.57 (0.19, 13.07) 3.21 (0.98, 10.47)     Lower secondary or less 3.4 24.7 +21.3 2.15 (0.75, 6.22) 1.66 (0.97, 2.84) 0.5 16.8 +16.3 1.57 (0.17, 14.29) 5.54 (1.64, 18.71) Transport accidents     University 25.3 18.4 −7.0 1.00 1.00 15.8 6.9 −8.8 1.00 1.00     Upper secondary 41.6 38.3 −3.3 1.68 (1.29, 2.18) 2.18 (1.40, 3.40) 12.5 8.4 −4.1 1.18 (0.80, 1.73) 1.34 (0.70, 2.57)     Lower secondary or less 65.9 62.4 −3.5 2.64 (2.03, 3.44) 3.44 (2.20, 5.40) 17.1 20.4 +3.4 1.42 (0.94, 2.13) 2.42 (1.20, 4.86) Alcohol poisoning     University 8.2 11.5 +3.3 1.00 1.00 0.3 2.8 +2.5 1.00 1.00     Upper secondary 15.9 41.6 +25.7 1.69 (1.07, 2.65) 3.14 (1.94, 5.10) 2.9 9.2 +6.3 7.81 (1.07, 57.24) 2.73 (1.18, 6.34)     Lower secondary or less 36.2 62.1 +25.9 4.54 (2.93, 7.04) 3.71 (2.26, 6.07) 8.9 26.7 +17.8 32.43 (4.45, 236.48) 4.91 (2.05, 11.73) Suicide     University 25.6 33.4 +7.8 1.00 1.00 11.5 8.8 −2.7 1.00 1.00     Upper secondary 42.7 71.5 +28.8 1.58 (1.21, 2.06) 1.99 (1.47, 2.69) 16.2 11.6 −4.6 1.13 (0.79, 1.60) 1.34 (0.78, 2.30)     Lower secondary or less 89.7 95.0 +5.2 3.45 (2.67, 4.47) 2.40 (1.76, 3.28) 20.5 20.0 −0.5 1.28 (0.89, 1.85) 2.20 (1.25, 3.85) Homicide     University 6.2 15.7 +9.5 1.00 1.00 1.6 3.5 +1.9 1.00 1.00     Upper secondary 13.2 32.3 +19.1 2.90 (1.61, 5.24) 2.13 (1.35, 3.36) 3.7 5.9 +2.2 2.80 (1.01, 7.79) 2.05 (0.81, 5.22)     Lower secondary or less 25.1 38.6 +13.5 5.71 (3.16, 10.30) 2.21 (1.37, 3.56) 9.0 23.1 +14.1 5.40 (1.90, 15.37) 5.46 (2.09, 14.25) Open in new tab Table 4 Age-standardizeda mortality rates per 100 000 and mortality rate ratios for selected causes of death by educational level in Estonia 1989–2000 in age group 20+ . Men . Women . . Mortality rates . Mortality rate ratios (95% CI) . Mortality rates . Mortality rate ratios (95% CI) . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . a European standard population. Infectious diseases     University 7.9 7.4 −0.5 1.00 1.00 5.3 2.2 −3.1 1.00 1.00     Upper secondary 9.4 16.6 +7.2 1.26 (0.69, 2.32) 3.33 (1.53, 7.22) 4.7 6.1 +1.4 1.29 (0.60, 2.75) 2.61 (0.93, 7.36)     Lower secondary or less 24.0 50.5 +26.5 4.12 (2.34, 7.26) 7.88 (3.67, 16.92) 5.9 22.3 +16.4 1.40 (0.65, 3.02) 4.98 (1.74, 14.29) Stomach cancer     University 46.0 26.8 −19.2 1.00 1.00 21.2 13.9 −7.3 1.00 1.00     Upper secondary 61.0 53.7 −7.2 1.27 (0.98, 1.65) 2.07 (1.40, 3.04) 28.4 23.0 −5.4 1.27 (0.90, 1.79) 1.55 (1.00, 2.40)     Lower secondary or less 66.6 53.1 −13.5 1.55 (1.21, 1.98) 2.12 (1.45, 3.10) 30.7 27.2 −3.5 1.37 (0.97, 1.92) 1.68 (1.09, 2.61) Lung cancer     University 64.3 49.6 −14.7 1.00 1.00 14.4 12.4 −2.0 1.00 1.00     Upper secondary 117.1 126.2 +9.1 1.79 (1.45, 2.22) 2.41 (1.83, 3.17) 20.1 18.3 −1.8 1.42 (0.90, 2.23) 1.55 (0.94, 2.57)     Lower secondary or less 152.2 162.5 +10.3 2.74 (2.24, 3.36) 3.34 (2.56, 4.36) 15.5 19.5 +4.0 1.10 (0.70, 1.72) 1.27 (0.76, 2.11) Breast cancer     University – – – – – 44.0 24.6 −19.4 1.00 1.00     Upper secondary – – – – – 33.4 46.3 +12.9 0.71 (0.56, 0.89) 1.72 (1.26, 2.35)     Lower secondary or less – – – – – 27.3 42.3 +15.1 0.55 (0.44, 0.70) 1.33 (0.95, 1.84) Ischaemic heart disease     University 669.3 371.7 −297.6 1.00 1.00 360.1 200.7 −159.4 1.00 1.00     Upper secondary 660.8 618.4 −42.4 1.07 (0.99, 1.16) 1.84 (1.65, 2.06) 348.0 299.1 −48.9 1.05 (0.93, 1.18) 1.67 (1.45, 1.93)     Lower secondary or less 862.9 781.9 −81.0 1.39 (1.30, 1.50) 2.25 (2.02, 2.50) 504.3 445.5 −58.8 1.50 (1.34, 1.68) 2.36 (2.06, 2.70) Cerebrovascular disease     University 257.6 161.1 −96.5 1.00 1.00 219.2 114.9 −104.3 1.00 1.00     Upper secondary 285.8 282.1 −3.7 1.20 (1.05, 1.36) 1.88 (1.59, 2.23) 230.4 188.7 −41.7 1.17 (1.01, 1.36) 1.80 (1.51, 2.16)     Lower secondary or less 340.4 315.2 −25.2 1.45 (1.28, 1.63) 2.07 (1.76, 2.44) 290.7 244.7 −46.0 1.45 (1.26, 1.67) 2.22 (1.86, 2.64) Chronic respiratory disease     University 18.3 15.8 −2.5 1.00 1.00 6.5 5.1 −1.4 1.00 1.00     Upper secondary 24.4 34.7 +10.3 1.46 (0.93, 2.31) 2.33 (1.36, 3.98) 10.7 6.6 −4.1 2.01 (1.01, 4.01) 1.28 (0.59, 2.76)     Lower secondary or less 48.7 48.1 −0.6 3.28 (2.16, 5.00) 3.32 (2.00, 5.54) 15.5 11.2 −4.3 2.87 (1.46, 5.66) 2.18 (1.04, 4.56) Alcoholic liver cirrhosis     University 1.2 11.3 +10.1 1.00 1.00 0.4 1.6 +1.2 1.00 1.00     Upper secondary 2.6 17.5 +14.9 1.26 (0.42, 3.77) 1.39 (0.82, 2.37) 0.6 5.5 +4.9 1.57 (0.19, 13.07) 3.21 (0.98, 10.47)     Lower secondary or less 3.4 24.7 +21.3 2.15 (0.75, 6.22) 1.66 (0.97, 2.84) 0.5 16.8 +16.3 1.57 (0.17, 14.29) 5.54 (1.64, 18.71) Transport accidents     University 25.3 18.4 −7.0 1.00 1.00 15.8 6.9 −8.8 1.00 1.00     Upper secondary 41.6 38.3 −3.3 1.68 (1.29, 2.18) 2.18 (1.40, 3.40) 12.5 8.4 −4.1 1.18 (0.80, 1.73) 1.34 (0.70, 2.57)     Lower secondary or less 65.9 62.4 −3.5 2.64 (2.03, 3.44) 3.44 (2.20, 5.40) 17.1 20.4 +3.4 1.42 (0.94, 2.13) 2.42 (1.20, 4.86) Alcohol poisoning     University 8.2 11.5 +3.3 1.00 1.00 0.3 2.8 +2.5 1.00 1.00     Upper secondary 15.9 41.6 +25.7 1.69 (1.07, 2.65) 3.14 (1.94, 5.10) 2.9 9.2 +6.3 7.81 (1.07, 57.24) 2.73 (1.18, 6.34)     Lower secondary or less 36.2 62.1 +25.9 4.54 (2.93, 7.04) 3.71 (2.26, 6.07) 8.9 26.7 +17.8 32.43 (4.45, 236.48) 4.91 (2.05, 11.73) Suicide     University 25.6 33.4 +7.8 1.00 1.00 11.5 8.8 −2.7 1.00 1.00     Upper secondary 42.7 71.5 +28.8 1.58 (1.21, 2.06) 1.99 (1.47, 2.69) 16.2 11.6 −4.6 1.13 (0.79, 1.60) 1.34 (0.78, 2.30)     Lower secondary or less 89.7 95.0 +5.2 3.45 (2.67, 4.47) 2.40 (1.76, 3.28) 20.5 20.0 −0.5 1.28 (0.89, 1.85) 2.20 (1.25, 3.85) Homicide     University 6.2 15.7 +9.5 1.00 1.00 1.6 3.5 +1.9 1.00 1.00     Upper secondary 13.2 32.3 +19.1 2.90 (1.61, 5.24) 2.13 (1.35, 3.36) 3.7 5.9 +2.2 2.80 (1.01, 7.79) 2.05 (0.81, 5.22)     Lower secondary or less 25.1 38.6 +13.5 5.71 (3.16, 10.30) 2.21 (1.37, 3.56) 9.0 23.1 +14.1 5.40 (1.90, 15.37) 5.46 (2.09, 14.25) . Men . Women . . Mortality rates . Mortality rate ratios (95% CI) . Mortality rates . Mortality rate ratios (95% CI) . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . 1989 . 2000 . Change from
 1989–2000 . 1989 . . 2000 . . a European standard population. Infectious diseases     University 7.9 7.4 −0.5 1.00 1.00 5.3 2.2 −3.1 1.00 1.00     Upper secondary 9.4 16.6 +7.2 1.26 (0.69, 2.32) 3.33 (1.53, 7.22) 4.7 6.1 +1.4 1.29 (0.60, 2.75) 2.61 (0.93, 7.36)     Lower secondary or less 24.0 50.5 +26.5 4.12 (2.34, 7.26) 7.88 (3.67, 16.92) 5.9 22.3 +16.4 1.40 (0.65, 3.02) 4.98 (1.74, 14.29) Stomach cancer     University 46.0 26.8 −19.2 1.00 1.00 21.2 13.9 −7.3 1.00 1.00     Upper secondary 61.0 53.7 −7.2 1.27 (0.98, 1.65) 2.07 (1.40, 3.04) 28.4 23.0 −5.4 1.27 (0.90, 1.79) 1.55 (1.00, 2.40)     Lower secondary or less 66.6 53.1 −13.5 1.55 (1.21, 1.98) 2.12 (1.45, 3.10) 30.7 27.2 −3.5 1.37 (0.97, 1.92) 1.68 (1.09, 2.61) Lung cancer     University 64.3 49.6 −14.7 1.00 1.00 14.4 12.4 −2.0 1.00 1.00     Upper secondary 117.1 126.2 +9.1 1.79 (1.45, 2.22) 2.41 (1.83, 3.17) 20.1 18.3 −1.8 1.42 (0.90, 2.23) 1.55 (0.94, 2.57)     Lower secondary or less 152.2 162.5 +10.3 2.74 (2.24, 3.36) 3.34 (2.56, 4.36) 15.5 19.5 +4.0 1.10 (0.70, 1.72) 1.27 (0.76, 2.11) Breast cancer     University – – – – – 44.0 24.6 −19.4 1.00 1.00     Upper secondary – – – – – 33.4 46.3 +12.9 0.71 (0.56, 0.89) 1.72 (1.26, 2.35)     Lower secondary or less – – – – – 27.3 42.3 +15.1 0.55 (0.44, 0.70) 1.33 (0.95, 1.84) Ischaemic heart disease     University 669.3 371.7 −297.6 1.00 1.00 360.1 200.7 −159.4 1.00 1.00     Upper secondary 660.8 618.4 −42.4 1.07 (0.99, 1.16) 1.84 (1.65, 2.06) 348.0 299.1 −48.9 1.05 (0.93, 1.18) 1.67 (1.45, 1.93)     Lower secondary or less 862.9 781.9 −81.0 1.39 (1.30, 1.50) 2.25 (2.02, 2.50) 504.3 445.5 −58.8 1.50 (1.34, 1.68) 2.36 (2.06, 2.70) Cerebrovascular disease     University 257.6 161.1 −96.5 1.00 1.00 219.2 114.9 −104.3 1.00 1.00     Upper secondary 285.8 282.1 −3.7 1.20 (1.05, 1.36) 1.88 (1.59, 2.23) 230.4 188.7 −41.7 1.17 (1.01, 1.36) 1.80 (1.51, 2.16)     Lower secondary or less 340.4 315.2 −25.2 1.45 (1.28, 1.63) 2.07 (1.76, 2.44) 290.7 244.7 −46.0 1.45 (1.26, 1.67) 2.22 (1.86, 2.64) Chronic respiratory disease     University 18.3 15.8 −2.5 1.00 1.00 6.5 5.1 −1.4 1.00 1.00     Upper secondary 24.4 34.7 +10.3 1.46 (0.93, 2.31) 2.33 (1.36, 3.98) 10.7 6.6 −4.1 2.01 (1.01, 4.01) 1.28 (0.59, 2.76)     Lower secondary or less 48.7 48.1 −0.6 3.28 (2.16, 5.00) 3.32 (2.00, 5.54) 15.5 11.2 −4.3 2.87 (1.46, 5.66) 2.18 (1.04, 4.56) Alcoholic liver cirrhosis     University 1.2 11.3 +10.1 1.00 1.00 0.4 1.6 +1.2 1.00 1.00     Upper secondary 2.6 17.5 +14.9 1.26 (0.42, 3.77) 1.39 (0.82, 2.37) 0.6 5.5 +4.9 1.57 (0.19, 13.07) 3.21 (0.98, 10.47)     Lower secondary or less 3.4 24.7 +21.3 2.15 (0.75, 6.22) 1.66 (0.97, 2.84) 0.5 16.8 +16.3 1.57 (0.17, 14.29) 5.54 (1.64, 18.71) Transport accidents     University 25.3 18.4 −7.0 1.00 1.00 15.8 6.9 −8.8 1.00 1.00     Upper secondary 41.6 38.3 −3.3 1.68 (1.29, 2.18) 2.18 (1.40, 3.40) 12.5 8.4 −4.1 1.18 (0.80, 1.73) 1.34 (0.70, 2.57)     Lower secondary or less 65.9 62.4 −3.5 2.64 (2.03, 3.44) 3.44 (2.20, 5.40) 17.1 20.4 +3.4 1.42 (0.94, 2.13) 2.42 (1.20, 4.86) Alcohol poisoning     University 8.2 11.5 +3.3 1.00 1.00 0.3 2.8 +2.5 1.00 1.00     Upper secondary 15.9 41.6 +25.7 1.69 (1.07, 2.65) 3.14 (1.94, 5.10) 2.9 9.2 +6.3 7.81 (1.07, 57.24) 2.73 (1.18, 6.34)     Lower secondary or less 36.2 62.1 +25.9 4.54 (2.93, 7.04) 3.71 (2.26, 6.07) 8.9 26.7 +17.8 32.43 (4.45, 236.48) 4.91 (2.05, 11.73) Suicide     University 25.6 33.4 +7.8 1.00 1.00 11.5 8.8 −2.7 1.00 1.00     Upper secondary 42.7 71.5 +28.8 1.58 (1.21, 2.06) 1.99 (1.47, 2.69) 16.2 11.6 −4.6 1.13 (0.79, 1.60) 1.34 (0.78, 2.30)     Lower secondary or less 89.7 95.0 +5.2 3.45 (2.67, 4.47) 2.40 (1.76, 3.28) 20.5 20.0 −0.5 1.28 (0.89, 1.85) 2.20 (1.25, 3.85) Homicide     University 6.2 15.7 +9.5 1.00 1.00 1.6 3.5 +1.9 1.00 1.00     Upper secondary 13.2 32.3 +19.1 2.90 (1.61, 5.24) 2.13 (1.35, 3.36) 3.7 5.9 +2.2 2.80 (1.01, 7.79) 2.05 (0.81, 5.22)     Lower secondary or less 25.1 38.6 +13.5 5.71 (3.16, 10.30) 2.21 (1.37, 3.56) 9.0 23.1 +14.1 5.40 (1.90, 15.37) 5.46 (2.09, 14.25) Open in new tab Figure 1 Open in new tabDownload slide Average life expectancy at birth in Estonia 1989–2000 Source: Statistical Office of Estonia, 2001.11 Figure 1 Open in new tabDownload slide Average life expectancy at birth in Estonia 1989–2000 Source: Statistical Office of Estonia, 2001.11 Figure 2 Open in new tabDownload slide Average life expectancy at age 25 by educational level in Estonia 1989–2000 Figure 2 Open in new tabDownload slide Average life expectancy at age 25 by educational level in Estonia 1989–2000 This study was supported by the Foundation for Baltic and East European Studies (project grant ‘Social and public health developments in Eastern Europe’), and by a grant from the Ministry of Social Affairs of Estonia/the World Bank. We thank three anonymous referees for valuable comments. References 1 Mackenbach JP, Kunst AE, Cavelaars AEJM, Groenhof F, Geurts JJM, The EU Working Group on Socioeconomic Inequalities in Health. Socioeconomic inequalities in morbidity and mortality in Western Europe. Lancet 1997 ; 349 : 1655 –59. 2 Sorlie P, Backlund R, Keller J. US mortality by economic, demographic, and social characteristics: the National Longitudinal Mortality Study. Am J Public Health 1995 ; 85 : 949 –56. 3 Martikainen P, Mäkelä P, Koskinen S, Valkonen T. Income differences in mortality: a register-based follow-up study of three million men and women. Int J Epidemiol 2001 ; 30 : 1397 –405. 4 Marmot MG, McDowall ME. Mortality decline and widening social inequalities. Lancet 1986 ; 2 : 274 –76. 5 Pappas G, Queen S, Hadden W, Fisher G. The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. 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Journal

International Journal of EpidemiologyOxford University Press

Published: Dec 1, 2003

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