This evidence review analyses data from the World Health Organisation’s Detailed Mortality Database, and summarises the literature to show that:
- the leading causes of death change across the life course
- there are marked social inequalities in each of the leading causes of death (within top 5 broad causes), by total number of deaths, across the life course
- social and economic circumstances from birth accumulate and impact a person’s likelihood of an early death
- different mortality rates for the leading causes of death are evident across comparative European countries.
This evidence is summarised for specific age groups across the life course below:
Stillbirths
The leading cause of stillbirth is short gestation and low birth weight. There are social inequalities in stillbirth associated with differences in:
- access to care and early detection rates
- termination rates (women from disadvantaged areas and from some ethnic groups are less likely to terminate a pregnancy affected by a severe congenital anomaly)
- maternal lifestyle behaviours, such as unhealthy diet and smoking, which are associated with an increased risk of stillbirth
- psychological stress, which is again positively associated with increased risk of stillbirth
Infants
(1.8% of all premature deaths, 2010)
Over half of infant deaths are attributed to conditions originating in the perinatal period, with the leading cause being short gestation and low birth weight. Congenital anomalies, birth asphyxia and Sudden Death Syndrome are other leading causes. There are social inequalities evident for all leading causes of infant death, such that increased risk of infant death is associated with risky lifestyle behaviours and lower uptake of health-protective behaviours. Mechanisms suggested as underlying these inequalities are differences in:
- maternal lifestyle behaviours during pregnancy and breastfeeding rates
- termination rates (see above)
- uptake of recommended infant sleeping position (prone position).
Children, ages 1–4
(0.3% of all premature deaths, 2010)
‘Injuries and poisoning’ is the leading cause of death for boys whereas cancer is the leading cause for girls. Social inequalities are found in all leading causes of death among young children, including unintentional drowning and suffocation, and deaths from leukaemia, Hodgkin lymphoma and cerebral palsy. The mechanisms suggested as underlying these social inequalities include social differences in:
- adherence to treatment
- intake of vitamin, folate or iron supplementation
- birth weight, linked to lifestyle behaviours
Children, ages 5–9
(0.2% of all premature deaths, 2010)
Cancer, particularly brain cancer, is the leading cause of death for both girls and boys of this age group, causing around one in four of all deaths. Deaths by injury and poisoning cause more deaths in this age group for boys than girls. Deaths from congenital anomalies and child homicide are other leading causes. There is limited evidence on social inequalities in childhood brain cancers. Research reveals socioeconomic inequalities in child homicide rates. The association between poverty, child maltreatment and homicide is most commonly explained by stress factors linked to unemployment, low income and depleted resilience, as well as prior experience of being a victim of or witnessing violence.
Children, ages 10–14
(0.2% of all premature deaths, 2010)
More than twice as many boys than girls die from external causes (particularly road crashes and unintentional drowning) between the ages of 10 and 14. Brain cancer and cancer of the blood, bone marrow and lymph nodes, as well as diseases of the nervous system, epilepsy and cerebral palsy are other leading causes of deaths for this age group. There is evidence of social inequalities in epilepsy and cerebral palsy, attributed in differences in short gestation and low birth weight, and infections during pregnancy. Variations in emergency admission rates, believed to be because of differences in the availability of communitybased support, effective ongoing management of conditions and thresholds for seeking admission, contribute to social inequalities.
Young people, ages 15–19
(0.6% of all premature deaths, 2010)
External causes of death – particularly road crashes, suicide and self-harm – are the leading causes of death for both sexes at this age. Other European countries, however, have comparatively higher rates of mortality than the UK. Socioeconomic inequalities in the leading causes of death for young people aged 15–19 are attributed to differences in:
- housing conditions and housing density
- proximity to traffic, exposure to hazardous or illegal driving
- parental mental health, employment, income, education/ skills and relationship status
- Exposure to stressful life events
- Adolescent mental health
Young adults, ages 20–34
(3.5% of all premature deaths, 2010)
Suicide and intentional self-harm is the leading cause of death for young adults. Compared with EU19 countries (the 15 EU countries prior to the accession of the 10 new members in May 2004 plus the four eastern European members of the OECD), the UK has the sixth lowest suicide and self-harm mortality rate for young adults (aged 20–34). Road crashes, brain cancer, cancer of the blood, bone marrow and lymph nodes, cervical cancer and breast cancer are the other leading causes of death. Social inequalities in these leading causes of death are attributed to differences in:
- employment status/work quality
- perceived acculturation (The degree to which ethnic-cultural minorities engage in the customs, tenets, principles and behaviours of their own culture versus the dominant)
- mental health and self-harm rates
- exposure to adverse experiences in childhood
- lifestyle behaviours
- use of preventive services
- uptake of HPV vaccinations
- tobacco use
- alcohol consumption
- early sexual experiences
- screening rates
- shift work
Adults, ages 35–64
(45% of all premature deaths, 2010)
Deaths as a result of disease and related causes, specifically cancer, ischaemic (coronary) heart disease, heart attacks, chronic liver disease and cirrhosis are the leading causes of death among adult men and women. Suicide and intentional self-harm remain a leading cause of death among adult men. Mechanisms posited as underlying social inequalities in leading causes of death in adults include social differences in:
- diet and lifestyle behaviours
- access to care and uptake of preventive services
- childhood cognitive development
- obesity
- mental health, and physiological and psychological responses to adverse circumstances
- social isolation/loneliness
Adults, ages 65–74
(48.4% of all premature deaths, 2010)
Cancer – particularly lung cancer and cancer of the colon, rectum and anus – and ischaemic (coronary) heart disease continue to be the leading causes of death among older adults. Cerebrovascular disease, chronic lower respiratory diseases and pneumonia emerge as other leading causes. The mechanisms suggested as underlying social inequalities in the leading causes of death in older adults include social differences in:
- lifestyle behaviours – unhealthy behaviours associated with increased risk of early death
- disease awareness, with lower awareness associated with increased risk of early death
- health professionals’ cultural competence
- housing conditions, with poorer conditions associated with increased risk of early death
Conclusion
This evidence review shows marked social inequalities for the leading causes of death across the life course. Risk factors associated with premature mortality are also known to accumulate over time. A sizeable proportion of the burden of disease and premature death is therefore estimated to be a result of social inequalities throughout life, and differences in access to and use of healthcare services, which are amenable to policy and practice interventions. Social inequalities in mortality are unjust. It is unacceptable that we can identify which children are more likely to have an early death because of the conditions in which they are born. Health care systems along with other sectors, including education, welfare, social care, employment, transport, community and voluntary, and the built environment, need to continue to work together to build on promising policies and practices to prevent early death across the life course, and from the earliest possible opportunity.
This report was written for the Department of Health by Jill Roberts and Ruth Bell of the UCL Institute of Health Equity. Full report here.