Trends and inequalities in mortality of By: Taavi Lai Mall Leinsalu noncommunicable diseases Case study for Estonia Trends and inequalities in mortality of noncommunicable diseases Case study for Estonia By: Taavi Lai Mall Leinsalu ABSTRACT This case study aims to provide a comprehensive overview of trends and inequalities in mortality of noncommunicable diseases in Estonia over the first decade of the 2000s. Decomposition of life expectancy by causes and age groups, and calculation of age-standardized rates for total and cause-specific mortality were used to assess differences over time and across social groups. The findings of the analysis showed significant overall reduction in mortality and increasing life expectancy in Estonia during the 2000s. The considerable improvement in mortality was observed in all groups distinguished by gender, ethnicity, educational level or by place of residence resulting in narrowing absolute inequalities, although the relative inequalities by educational level and by place of residence slightly increased. Despite progress, mortality rates remained higher among non-Estonians, the lower educated and residents of Ida-Viru county. Circulatory diseases and external causes of death contributed the most to the overall life expectancy at birth improvement and to the larger mortality decline among non-Estonians, the lower educated and in Ida-Viru county, with the opposite effect seen for infectious diseases. Keywords CAUSES OF DEATH ESTONIA INEQUALITIES MORTALITY NONCOMMUNICABLE DISEASES TRENDS Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). © World Health Organization 2015 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. 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CONTENTS About the authors ................................................................................................................................................... v Acknowledgements ................................................................................................................................................ v Abbreviations......................................................................................................................................................... vi Executive summary .............................................................................................................................................. vii Introduction............................................................................................................................................................. 1 Methodology ........................................................................................................................................................... 3 Drivers of LE change .......................................................................................................................................... 3 Social inequalities in mortality ............................................................................................................................. 3 Evaluation of data problems ............................................................................................................................... 6 Results .................................................................................................................................................................... 8 Estonia in the EU context .................................................................................................................................... 8 Drivers of LE change ........................................................................................................................................ 11 Social inequalities in mortality ........................................................................................................................... 17 Inequalities by ethnic groups ....................................................................................................................... 17 Inequalities by educational level .................................................................................................................. 19 Inequalities by place of residence ............................................................................................................... 22 Summary ............................................................................................................................................................... 26 References ............................................................................................................................................................ 28 Annex 1. Detailed results of LE decomposition ................................................................................................ 30 Annex 2. Detailed results on social inequalities in mortality ........................................................................... 35 v ABOUT THE AUTHORS Taavi Lai (MD, PhD) is an analyst and consultant at Fourth View Consulting, Tallinn, Estonia. He was responsible for the analysis of drivers of life expectancy change and overall coherence of this publication. Mall Leinsalu (MPH, PhD) is a senior researcher at the Department of Epidemiology and Biostatistics at the National Institute for Health Development in Tallinn, Estonia. She is also an associate professor at the Stockholm Centre for Health and Social Change at Södertörn University, Sweden. She was responsible for the analysis and reporting of social inequalities in mortality. ACKNOWLEDGEMENTS The authors would like to thank Marge Reinap, Head, WHO Country Office, Estonia, for her vision, support and understanding that were crucial in the preparation of this publication. We would also like to thank WHO for the financial support it provided for this project. The authors are grateful to Kaja Sõstra, Head, Methodology and Analysis Department, and Koit Meres, Leading Statistician, both from Statistics Estonia, for methodological and administrative support during the data linkage with the population censuses at their facilities. We thank Gleb Denissov, Head, Estonian Causes of Death Registry, for providing us with cause-specific death data. We also gratefully acknowledge the practical help with data preparation for record linkage we received from Aleksei Baburin (MSc), Researcher, Department of Epidemiology and Biostatistics at the National Institute for Health Development, Tallinn, Estonia. Taavi Lai, Mall Leinsalu vi Trends and inequalities in mortality of noncommunicable diseases ABBREVIATIONS ASMR age-standardized mortality rate CI confidence interval CVD cardiovascular disease EU European Union HFA DB European Health for All database IDU injecting drug users ICD-10 International Classification of Diseases, revision 10 ISCED International Standard Classification of Education LE life expectancy at birth NCD noncommunicable disease NUTS3 nomenclature of territorial units for statistics for small regions RR rate ratio Executive Summary vii EXECUTIVE SUMMARY Background Noncommunicable diseases (NCDs) are currently responsible for over 60% of global deaths and are thus one of the major public health challenges facing all countries regardless of their economic status. In Europe, NCDs account for nearly 86% of all deaths and 77% of the disease burden, putting increasing strain on health systems, economic development and the well-being of large parts of the population. In light of the general improvement in living standards, Estonia witnessed a remarkable life expectancy at birth (LE) increase over the 2000s. Aims Little is known whether the changes in NCDs mortality in Estonia have been equal across all population groups and what cause-of-death groups and socioeconomic determinants should be targeted foremost