Causes of widening life expectancy inequalities in Quebec, Canada, 1989-2004.

Adam-Smith, Jessica ; Harper, Sam ; Auger, Nathalie 等

There is an increasingly recognized relationship between health and the socio-economic context in which people live. Material deprivation of areas, whether measured for census tracts, neighbourhoods or regions, has been associated with increased mortality, even after adjusting for individual-level socioeconomic differences. (1) In the province of Quebec, Canada, socioeconomic inequalities in health outcomes have been demonstrated at several geographic scales. (2-5) Neighbourhood characteristics may shape social and economic opportunities and health-related behaviours. Socio-economic context may also influence health more directly through stress, psychosocial factors, food availability, crowding or pollution. (1,6)

Recent studies in several industrialized settings, including Quebec, have found that inequalities in life expectancy between affluent and deprived areas have grown. (7-9) Understanding which causes of death are contributing to the growth of these inequalities is important for public health initiatives aiming to equitably improve mortality rates. (10) Potential for these initiatives to succeed is enhanced when there are clear targets for intervention. The objective of this study was to evaluate the age- and cause-specific components contributing to trends in life expectancy inequality between the most- and least-deprived areas in Quebec.

METHODS

Death information was extracted from vital statistics of the Quebec health ministry, which provided age, sex, cause of death, and place of residence of decedents. We analyzed three periods: 1989-1992, 1995-1998 and 2001-2004. Population counts were obtained from census projections for the central year of each period, adjusted for under-enumeration. (11)

We ranked areas of Quebec into deciles of material deprivation and calculated estimates of life expectancy at birth for each decile and period. Areas of analysis were territories of the Local Community Service Areas (CLSCs). Material deprivation level was based on a widely used composite index developed for Quebec. (12) Further details about area classification are indicated in Appendix 1. Life expectancy was calculated using standard life tables (13) with 20 age groups (<1, 1-4, 5-9.... 85-89, 90+ years).

Examination of trends in life expectancy revealed that the most striking inequality was present between the most- and least-deprived deciles (Table 1b), and that life expectancy in the leastdeprived decile was well above the life expectancy in other deciles in every period. To avoid masking this difference, data were not aggregated into quintiles. Inequality in life expectancy was defined as the absolute difference between life expectancy of the least- and most-deprived deciles. We used Arriaga's decomposition method to calculate the contribution of age group and cause of death to the change in inequality over time. (14,15) This method uses differences in all-cause and cause-specific mortality rates within each age group to estimate the contribution of each age-cause group to the total inequality in life expectancy at birth between two populations. For any given period, the total inequality in life expectancy at birth between the first and tenth deciles is the sum of the age-cause specific components. The total contribution of a particular age group to the inequality in life expectancy is the sum of its contributions across all causes of death, and the contribution of a particular cause of death is the sum of its contributions across age groups.

We analyzed ten leading causes of death for men and women in Quebec. (16) Important cancers (prostate, lung, breast, colorectal), motor vehicle accidents, and causes of infant mortality were analyzed separately. Human immunodeficiency virus (HIV) was included as a separate category because HIV incidence and mortality peaked in Canada during the period under study. (17) We used the primary cause of death, defined as "the disease or injury which initiated the train of events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury." (18) Appendix 2 lists the International Classification of Diseases codes.

Statistical analyses were performed using R and Microsoft Excel. Research ethics approval requirement was waived by the institutional review board of the University of Montreal Hospital Centre.

RESULTS

Life expectancy increased in all deciles between 1989-92 and 20012004, but the increase was larger for the least-deprived decile (Table 1b). It is notable that Quebec does not experience a strictly stair-stepped gradient in life expectancy by material deprivation. For example, some of the middle deciles (e.g., decile 5) enjoyed higher life expectancies than less-deprived deciles. However, the least-deprived decile consistently had a higher life expectancy than any other, and the difference between the least- and most-deprived deciles constituted the largest inequality.

Between 1989-92 and 1995-98, the life expectancy gap between the most- and least-deprived deciles increased by 19% (0.44 years) for women and 21% (0.76 years) for men (Table 2). Between 199598 and 2001-04, inequality among females grew by a further 7%, to 3.0 years. Among males, on the other hand, life expectancy inequality decreased very slightly.

Contributions to life expectancy inequality in each period by cause of death and age

Among males, cancer made the largest contribution to inequality in each period (Table 2). Lung cancer alone accounted for 16-18% of the total gap. Among females, the contribution of cancer, which was only 5.6% in the first period, became the second-largest component of inequality (15.4%) in 2001-04. This was largely due to lung cancer mortality, which rose more among women in the most-deprived decile. During the first period, breast cancer mortality was higher in the least-deprived decile, making inequality between the most- and least-deprived deciles 0.13 years smaller than it would have been otherwise. In the second and third periods, this difference decreased, reflecting slower reductions in breast cancer mortality among women in the most-deprived decile than in the least-deprived.

Heart disease contributed a large share to life expectancy inequality in each period (women 24-32%, men 15-18%). Unintentional injuries (primarily motor vehicle accidents) were also major contributors (men 17-24%, women 7-13%).

Mortality attributable to HIV among men was higher in the least-deprived decile than in the most-deprived in 1989-92, thereby reducing the life expectancy gap. By 1995-98, however, HIV no longer had a 'reverse' socio-economic gradient, and in 2001-04, HIV contributed positively to inequality between the most- and least deprived decile. Other important components of inequality among males were heart disease and suicide. In the first period, deaths in middle-aged men (45-64 years) made the largest contribution, accounting for 38% of life expectancy inequality (Table 3). By the third period, however, deaths in men 65 years and over made the largest contribution (40%). The share of inequality resulting from deaths in the 15-44 age category was relatively stable over time.

Among females, mortality in the over 65 age group was the largest contributor to life expectancy inequality. The share of inequality due to deaths in this age group increased over time from 48% to 60%. The proportion of inequality due to deaths in middle age (45-64 years) also rose over time. The contribution to inequality in life expectancy from 15-44 year olds was much lower among females than it was among males, and fell over the three periods.

Change in life expectancy inequality over time by cause of death

Roughly 25% of the increase in inequality among males from 198992 to 1995-98 was due to reductions in HIV mortality that favoured males in the least-deprived decile (Figure 1). Among females, the growth of inequality over time was largely driven by increases in lung cancer mortality in the most-deprived decile. Lung cancer increased life expectancy inequality by 0.17 years from 1989-92 to 1995-98, and again by 0.20 years from 1995-98 to 2001-04. Unintentional injuries reduced inequality over time for both men and women, due to greater reductions in mortality from motor vehicle accidents in the most- than in the least-deprived decile.

Between 1995-98 and 2001-04, the total inequality in life expectancy among males marginally decreased due to offsetting trends for different causes of death.

DISCUSSION

Our analysis indicates that the widening life expectancy gap between advantaged and disadvantaged areas in Quebec from 19892004 was driven by relatively few causes of death. Among men, HIV was an important cause of the growth in inequality. Among women, lung cancer drove the steady increase in inequality between the most- and least-deprived areas. Heart disease accounted for a sizeable portion of inequality among both sexes in each period. Inequality among both sexes was reduced by a decrease in mortality from unintentional injuries. Contrary to the findings of a previous Canada-wide study, most causes of life expectancy inequality were amenable to public health intervention rather than medical care. (19)

Since 1989, heart disease mortality decreased more among people living in the least-deprived decile compared to the most deprived, which is consistent with data linking heart disease with area-level socio-economic status in several contexts. (1) Rurality of the most-deprived decile (Table 1a) may also play a role in the continued contribution of heart disease mortality to life expectancy inequality. Other Canadian studies have found that risk factors for heart disease such as smoking and obesity are higher in rural areas, (20,21) but a Quebec study found that mortality rates from heart disease were actually lower in rural areas than urban centres. (22) Thus, socio-economic differences in risk factors and access to specialized services may be more important to ongoing inequality in heart disease mortality. Although heart disease did not play a major role in widening inequality over time, it was a large component of inequalities among both sexes in each period. This suggests that heart disease would be a useful target for interventions seeking to reduce inequality between the most- and least-deprived areas in Quebec.

Growing inequality among Quebec women has primarily been driven by lung cancer mortality. This finding is consistent with previous research showing that differences in lung cancer mortality between the most- and least-deprived women in Quebec grew over the 1990s.4 Lung cancer mortality in Quebec is rising among all women, but decreasing among men. These mortality trends may reflect historical changes in smoking behaviour. Whereas smoking began to decline among men in Quebec in the mid-1960s, the percentage of women who smoked did not decrease until the early 1980s. (4) Growth in female life expectancy inequality from lung cancer mortality, and the ongoing contribution made by lung cancer to inequality among males in each period, suggest that smoking trends have differed between the most- and least-deprived areas. It is possible that public health measures and changing social norms that encouraged a decline in tobacco consumption had a greater impact on the population living in least-deprived areas than in the most-deprived. (23,24) Geographic patterns of smoking behaviour may have also contributed to the increasing discrepancies in lung cancer mortality we observed. Surveys in Quebec in the late 1980s and early 1990s found higher smoking rates in mid-sized cities, small towns and rural areas compared to urban centres. (4) Screening for lung cancer is unlikely to explain inequalities as it has not been reliably shown to reduce lung cancer mortality. (25) In recent years, the prevalence of smoking among women in Quebec has not fallen as much as for men. Among those aged 15-24, more females than males are current smokers. (26) Considering these trends, rising mortality from lung cancer among women in Quebec and disparities between women in the most- and least-deprived areas seem likely to continue.

HIV mortality worsened inequality between men in the most- and least-deprived areas. This was surprising because HIV is a relatively uncommon cause of death. Deprived areas are primarily rural (although some are located in Montreal and Quebec City), and HIV in Quebec has been concentrated in urban centres. (27) Subanalyses indicated that growing inequality due to HIV among men reflected the high concentration of HIV mortality in urban deprived areas (data not shown). In Quebec, as in other industrialized countries, HIV mortality peaked in the mid-1990s and then rapidly declined following the introduction of highly active antiretroviral treatment. (28) However, mortality fell more among men in the most-affluent areas than among those in deprived urban neighbourhoods. Poverty and deprivation may place people in vulnerable positions that constrain opportunities for protection from infection or treatment, even in the context of universal publicly-funded health insurance. (29,30)

Several limitations of this study should be mentioned. Previous research has shown that results of area-level analyses often differ depending on spatial unit. (1,6) It is possible that alternative area boundaries in Quebec could produce different results. In particular, analyses based on smaller, more homogenous areal units would come closer to capturing the inequalities that exist at an individual level. (31) Nonetheless, we chose to analyze CLSCs because they are meaningful administrative units with an important role in implementing policies and delivering health and social services that may reduce health disparities. However, analyses based on smaller geographical units may give different results. Another limitation for the interpretation of results is the rural/urban composition of deprivation deciles. The most-deprived decile is primarily rural, but includes some urban CLSCs in Montreal and Quebec City. The least-deprived decile is almost exclusively urban. Thus, differences between the most- and least-deprived deciles also reflect rural-urban differences, but we view the fact that rural areas are more materially deprived as an important feature of socio-economic disparities in Quebec. The exclusion of four northern CLSCs--primarily First Nations and Inuit settlements--due to incomplete census data could have led to underestimates of the magnitude of life expectancy inequalities since Aboriginal Canadians experience poorer health outcomes than the non-indigenous population. (32,33) Finally, we could not account for the change in mortality coding from ICD-9 to ICD-10 in year 2000, which could have influenced results. However, any systematic error introduced by the coding shift would have had to be different between the advantaged and disadvantaged areas to seriously affect our results. Given that mortality coding is performed at a provincial rather than a regional level, this seems unlikely. (34)

Absolute inequalities in life expectancy at birth between the least- and most-deprived areas of Quebec have increased over time, particularly among women. Much of the increase in inequality was driven by diseases best addressed by preventive public health measures. Public health initiatives that do not widen inequalities by disproportionately benefiting the most well off are necessary to reverse this trend.

Appendix 1.

Population statistics and death counts are available for each CLSC in Quebec, facilitating the calculation of CLSC-specific mortality rates. These areas also represent useful, coherent divisions that capture the geographical pattern of deprivation in Quebec. Resembling the Townsend index in methodology and concept, the deprivation index uses census measures of employment, average income, and persons without a high school diploma. (1) It is available for 1996 census enumeration areas. Four northern CLSCs were excluded due to missing census data. The remaining 162 CLSCs were classified into deciles of material deprivation using the deprivation index of enumeration areas to calculate a population-weighted index for each CLSC. (2) The deprivation index based on census data from 1996 (the central year of the data being considered) was used for all study periods, under the assumption that the geographical distribution of deprivation in Quebec has been stable over the short time period considered here. This is a reasonable assumption given that another analysis found that the geographic pattern of material deprivation in Quebec was the same whether the deprivation index was calculated using 1991 Census data or 2001 Census data. (3) Work in other industrialized countries, such as Britain and the United States, has also found little change in the geography of material deprivation over time. (4-6)

REFERENCES

(1.) Townsend P. Deprivation. J Soc Policy 1987;16(2):125-46.

(2.) Auger N, Alix C, Zang G, Daniel M. Sex, age, deprivation and patterns in life expectancy in Quebec, Canada: A population-based study. BMC Public Health 2010;10(1):161.

(3.) Pampalon R, Hamel D, Gamache P. Recent changes in the geography of social disparities in premature mortality in Quebec. Soc Sci Med 2008;67:1269-81.

(4.) Dorling D, Mitchell R, Shaw M, Orford S, Smith GD. The ghost of Christmas past: Health effects of poverty in London in 1896 and 1991. BMJ 2000;321(7276):1547-51.

(5.) Singh G, Siahpush M. Widening socioeconomic inequalities in US life expectancy, 1980-2000. Int J Epidemiol 2006;35:969-79.

(6.) McCarthy M. Urban development and health inequalities. Scand J Public Health Suppl. 2002;59:59-62.

Appendix 2. ICD Codes for Cause of Death Categories

                            ICD-9                  ICD-10

All Cancers                 140-208                C00-C97
  Lung Cancer               162                    C33-C34
  Breast Cancer             174                    C50
  Prostate Cancer           185                    C61
  Colorectal Cancer         153-154                C18-C21
Heart Disease               390-398, 402, 404,     I00-I09, I11,
                              410-429, 115,          I13, I20-I51
                              999.1, 093.81,
                              098.83, 093.21,
                              032.82, 130.3,
                              093.22, 093.23,
                              093.24, 093.20,
                              093.82
Unintentional Injury        E800-E869, E880-E929   V01- X59, Y85-Y86
  Motor Vehicle Accidents   E810-E825              V02-V04, V09.0,
                                                     V09.2, V12-V14,
                                                     V19.0-V19.2,
                                                     V19.4-V19.6, V20
                                                     V79,V80.3-V80.5,
                                                     V81.0-V81.1,
                                                     V82.0-V82.1,
                                                     V83-V86,
                                                     V87.0-V87.8,
                                                     V88.0-V88.8,
                                                     V89.0, V89.2
  Falls                     E880-E888              W00-W19
Suicide                     E950-E959              X60-X84, Y87.0
Cerebrovascular Diseases    430-434, 436-438       I60-I69
Chronic Lower Respiratory   490-494                J40-J47
  Diseases
HIV                         42-44                  B20-B24
Diabetes                    250                    E10-E14
Influenza and Pneumonia     480-487                J10-J18
Alzheimer's                 331.0                  G30
Nephritis, Nephrosis,       580-583, 584-586,      N00- N07, N17-N19,
  Nephritic Syndrome          588-589                N25-N27
Homicide                    960-968, 904, 969.08   X85-Y09, Y87.1
Infant Mortality
  Congenital Anomalies      740-759                Q00-Q99
  Other Major Causes        761, 763-763.4,        P01, P02, P03,
                              763.6-763.9, 762,      R95, P07
                              798.0, 765

Conflict of Interest: None to declare.

Received: October 20, 2010

Accepted: March 24, 2011

REFERENCES

(1.) Diez Roux A. Neighborhoods and health: Where are we and where do we go from here? Rev Epidemiol Sante Publique 2007;55(1):13-21.

(2.) Lebel A, Pampalon R, Villeneuve PY. A multi-perspective approach for defining neighbourhood units in the context of a study on health inequalities in the Quebec City region. Int J Health Geogr 2007;6:27.

(3.) Pampalon R, Lebel A, Hamel D. Exploring rural health inequalities at a local scale: The case of Portneuf, Quebec. Can J Public Health 2007;98(2):143-48.

(4.) Pampalon R, Denis H, Gamache P. Recent changes in the geography of social disparities in premature mortality in Quebec. Soc Sci Med 2008;67:1269-81.

(5.) Ross N, Tremblay S, Graham K. Neighbourhood influences on health in Mon treal, Canada. Soc Sci Med 2004;59(7):1485-94.

(6.) Pickett KE, Pearl M. Multilevel analyses of neighbourhood socioeconomic context and health outcomes: A critical review. J Epidemiol Community Health 2001;55(2):111-22.

(7.) Mooney H. Life expectancy in England between the rich and poor widens for both men and women. BMJ 2009;339:b2775.

(8.) Singh G, Siahpush M. Widening socioeconomic inequalities in US life expectancy, 1980-2000. Int J Epidemiol 2006;35:969-79.

(9.) Auger N, Alix C, Zang G, Daniel M. Sex, age, deprivation and patterns in life expectancy in Quebec, Canada: A population-based study. BMC Public Health 2010;10(1):161.

(10.) The Chief Public Health Officer's Report on the State of Public Health in Canada 2008: Addressing Health Inequalities. Ottawa, ON: Public Health Agency of Canada, 2008.

(11.) Pelletier G. La population du Quebec par territoire des centres locaux de services communautaires, par territoire des reseaux locaux de services et par region sociosanitaire de 1981 a 2026. Direction des communications, Ministere de la Sante et des Services sociaux du Quebec, 2005.

(12.) Pampalon R, Raymond G. A deprivation index for health and welfare planning in Quebec. Chron Dis Can 2000;21(3):104-13.

(13.) Preston S, Heuveline P, Guillot M. Demography: Measuring and Modeling Population Processes. Padstow, Cornwall: Blackwell Publishing, 2001.

(14.) Arriaga EE. Measuring and explaining the change in life expectancies. Demography 1984;21(1):83-96.

(15.) Arriaga EE. Changing trends in mortality decline during the last decades. In: Ruzicka L, Wunsch G, Kane P (Eds.), Differential Mortality: Methodological Issues and Biosocial Factors. Oxford, UK: Clarendon Press, 1989.

(16.) Leading Causes of Death in Canada. Ottawa, ON: Statistics Canada, 2005.

(17.) The Centre for Health Promotion UoT. Techinical Report 2: Key Trends in HIV/AIDS in Canada. Ottawa, ON: Health Canada, 2000.

(18.) International Statistical Classification of Diseases, 10th Revision (ICD-10). Geneva, Switzerland: World Health Organization, 1992.

(19.) James PD, Wilkins R, Detsky AS, Tugwell P, Manuel DG. Avoidable mortality by neighbourhood income in Canada: 25 years after the establishment of universal health insurance. J Epidemiol Community Health 2007;61(4):287-96.

(20.) Lagace C, Desmeules M, Pong RW, Heng D. Non-communicable disease and injury-related mortality in rural and urban places of residence: A comparison between Canada and Australia. Can J Public Health 2007;98(Suppl 1):S62-S69.

(21.) Mitura V, Bollman R. The health of rural Canadians: A rural-urban comparison of health indicators. Rural and Small Town Canada Analysis Bulletin 2003;4(6):1-23.

(22.) Pampalon R, Martinez J, Hamel D. Does living in rural areas make a difference for health in Quebec? Health & Place 2006;12(4):421-35.

(23.) Jarvis MJ, Wardle J. Social patterning of individual health behaviours: The case of cigarette smoking. In: Marmot M, Wilkinson R (Eds.), Social Determinants of Health. Oxford, UK: Oxford University Press, 2006.

(24.) Flint AJ, Novotny TE. Poverty status and cigarette smoking prevalence and cessation in the United States, 1983-1993: The independent risk of being poor. Tobacco Control 1997;6(1):14-18.

(25.) Black C, de Verteuil R, Walker S, Ayres J, Boland A, Bagust A, et al. Population screening for lung cancer using computed tomography, is there evidence of clinical effectiveness? A systematic review of the literature. Thorax 2007;62(2):131-38.

(26.) Bernier S, Hamel D. Evolution de l'usage de la cigarette chez les Quebecois de 15 ans et plus de 1994-1995 a 2003. Institut national de sante publique du Quebec, 2006.

(27.) A National Portrait--A Report on Governments' Responses to the HIV/AIDS Epidemic in Canada. Ottawa, ON: Public Health Agency of Canada, 2005.

(28.) Schanzer D. Trends in HIV/AIDS mortality in Canada, 1987-1998. Can J Public Health 2003;94(2):135-39.

(29.) Wood E, Montaner JS, Tyndall MW, Schechter MT, O'Shaughnessy MV, Hogg RS. Prevalence and correlates of untreated human immunodeficiency virus type 1 infection among persons who have died in the era of modern antiretroviral therapy. J Infect Dis 2003;188(8):1164-70.

(30.) Wood E, Montaner JS, Chan K, Tyndall MW, Schechter MT, Bangsberg D, et al. Socioeconomic status, access to triple therapy, and survival from HIV-disease since 1996. AIDS 2002;16(15):2065-72.

(31.) Murray CJ, Frenk J, Gakidou EE. Measuring health inequality: Challenges and new directions. In: Leon DA, Walt G (Eds.), Poverty, Inequality and Health: An International Perspective. Oxford: Oxford University Press, 2001.

(32.) Wilkins R, Uppal S, Fines P, Senecal S, Guimond E, Dion R. Life expectancy in the Inuit-inhabited areas of Canada, 1989 to 2003. Health Rep 2008;19(1): 7-19.

(33.) A Statistical Profile on the Health of First Nations in Canada in 2000. Ottawa, ON: Health Canada, 2005.

(34.) Geran L, Tully P, Wood P, Thomas B. Comparability of ICD-10 and ICD-9 for Mortality Statistics in Canada. Ottawa, ON: Statistics Canada, 2005.

Jessica Adam-Smith, MSc, [1] Sam Harper, PhD, [1] Nathalie Auger, MD, MSc, FRCPC [2-4]

Author Affiliations

[1.] Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC

[2.] Institut national de sante publique du Quebec, Montreal, QC

[3.] Department of Social and Preventive Medicine, Universite de Montreal, Montreal, QC

[4.] Centre de recherche du Centre hospitalier de l'Universite de Montreal, Montreal, QC

Correspondence: Jessica Adam-Smith, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Purvis Hall, 1020 Pine Ave West, Room 17B, Montreal, QC H3A 1A2, Tel: 514-398-5805, Fax: 514-398-4503, E-mail: jessica.adam-smith@mcgill.ca

Table 1a. Descriptive Characteristics of Local Community
Service Centres (CLSCs), Quebec

                                 Least Deprived   Most Deprived
                                     (Decile 1)     (Decile 10)

Population, Male
  1989-1992                             340,329         376,361
  1995-1998                             347,685         381,197
  2001-2004                             358,817         381,537
Population, Female
  1989-1992                             364,761         373,138
  1995-1998                             374,038         374,833
  2001-2004                             385,345         373,733
Number of Deaths, Male
  1989-1992                                9406          14,239
  1995-1998                                9636          14,467
  2001-2004                                9758          13,979
Number of Deaths, Female
  1989-1992                                9130          10,351
  1995-1998                              10,260          11,625
  2001-2004                              11,116          12,233
Average Population per CLSC
  Mean                                   62,430          19,326
  Range                          31,541-107,905     2540-52,099
Proportion of Rural CLSCs
  All rural                                   0            72.2
  Some rural                                9.1            13.9
  No rural                                 90.9            13.9
Proportion of Aboriginal CLSCs                0            19.4

                                    All Deciles

Population, Male
  1989-1992                           3,464,734
  1995-1998                           3,575,749
  2001-2004                           3,682,658
Population, Female
  1989-1992                           3,569,497
  1995-1998                           3,685,014
  2001-2004                           3,781,985
Number of Deaths, Male
  1989-1992                             107,152
  1995-1998                             111,919
  2001-2004                             111,198
Number of Deaths, Female
  1989-1992                              88,041
  1995-1998                             101,668
  2001-2004                             109,508
Average Population per CLSC
  Mean                                   42,212
  Range                            1355-133,475
Proportion of Rural CLSCs
  All rural                                30.2
  Some rural                               31.5
  No rural                                 30.2
Proportion of Aboriginal CLSCs             17.9

Table 1b. Life Expectancy at Birth According to Time Period and
CLSC Deprivation Decile, Quebec

                      Life Expectancy at Birth (years)

                                    Males

Decile               1989-1992    1995-1998    2001-2004

1 (least deprived)      75.9         77.6         79.8
2                       74.2         75.4         77.8
3                       73.9         75.1         77.2
4                       73.1         74.4         76.4
5                       74.4         75.7         77.7
6                       73.1         74.2         76.5
7                       73.2         74.6         76.4
8                       72.8         74.0         76.2
9                       72.5         73.3         75.6
10 (most deprived)      72.3         73.3         75.6

                      Life Expectancy at Birth (years)

                                   Females

Decile               1989-1992    1995-1998    2001-2004

1 (least deprived)      82.4         83.2         84.4
2                       81.2         81.2         82.3
3                       80.7         80.9         82.0
4                       80.3         80.5         81.8
5                       81.1         81.3         82.5
6                       80.6         81.0         81.9
7                       80.5         80.6         81.8
8                       80.2         80.9         82.2
9                       80.4         80.5         81.3
10 (most deprived)      80.0         80.4         81.4

Table 2. Contribution of Major Causes of Death to Inequality
in Life Expectancy Between the Bottom and Top
Area-Socio-economic Deciles in Each Period, Quebec

                                              Males

Cause of Death                      1989-1992         1995-1998

Cancer                              0.91 (25.5)       0.98 (22.5)
  Lung                              0.66 (18.5)       0.68 (15.7)
  Breast                               0                 0
  Colorectal                        0.04 (1.0)        0.01 (0.3)
  Prostate                          0.02 (-0.5)       0.03 (0.6)
  Other cancers                     0.23 (6.5)        0.26 (5.9)
Heart Disease                       0.65 (18.2)       0.78 (17.8)
  Cerebrovascular diseases          0.17 (4.8)        0.05 (1.1)
  Chronic lower respiratory         0.27 (7.6)        0.35 (8.0)
    diseases
  Diabetes                          0.04 (1.0)        0.06 (1.4)
  Nephritis, Nephrosis,             0.02 (-0.7)       0.03 (0.8)
    Nephritic syndrome
  Alzheimer's                      0.006 (0.2)        0.03 (0.7)
Unintentional Injury                0.87 (24.2)       0.91 (21.0)
  Motor vehicle accidents           0.54 (15.2)       0.60 (13.8)
  Falls                             0.03 (1.0)        0.02 (0.5)
  Other unintentional injuries      0.29 (8.0)        0.29 (6.6)
Suicide                             0.40 (11.3)       0.51 (11.8)
Homicide                           0.004 (-0.1)       0.01 (0.2)
HIV                                 0.23 (-6.3)      -0.03 (-0.7)
Influenza and Pneumonia            0.001 (0.03)       0.05 (1.0)
Infant Mortality                    0.03 (0.8)        0.10 (2.3)
  Congenital anomalies              0.02 (-0.6)       0.03 (0.8)
  Other causes                      0.05 (1.5)        0.07 (1.6)
Residual                            0.48 (13.4)       0.53 (12.1)
Total                               3.60 (100)        4.36 (100)

                                      Males            Females

Cause of Death                      2001-2004         1989-1992

Cancer                             1.10 (25.8)        0.13 (5.6)
  Lung                             0.69 (16.3)        0.06 (2.7)
  Breast                         -0.001 (-0.03)      -0.13 (-5.7)
  Colorectal                       0.07 (1.7)         0.07 (2.8)
  Prostate                         0.04 (0.9)            0
  Other cancers                    0.30 (6.9)         0.13 (5.7)
Heart Disease                      0.63 (14.8)        0.76 (32.2)
  Cerebrovascular diseases         0.09 (2.1)         0.21 (8.8)
  Chronic lower respiratory        0.38 (8.8)         0.11 (4.8)
    diseases
  Diabetes                         0.12 (2.7)         0.12 (5.2)
  Nephritis, Nephrosis,            0.03 (0.7)         0.07 (2.8)
    Nephritic syndrome
  Alzheimer's                     0.001 (0.03)        0.03 (1.3)
Unintentional Injury               0.73 (17.1)        0.32 (13.4)
  Motor vehicle accidents          0.50 (11.7)        0.30 (12.8)
  Falls                            0.05 (1.1)        0.004 (0.2)
  Other unintentional injuries     0.18 (4.3)         0.01 (0.4)
Suicide                            0.47 (11.1)        0.03 (1.4)
Homicide                           0.01 (0.3)       0.0004 (0.02)
HIV                                0.04 (0.9)        0.006 (0.2)
Influenza and Pneumonia            0.05 (1.3)        0.004 (0.2)
Infant Mortality                   0.07 (1.6)         0.14 (5.7)
  Congenital anomalies             0.05 (1.2)         0.04 (1.7)
  Other causes                     0.02 (0.5)         0.10 (4.0)
Residual                           0.54 (12.6)        0.43 (18.4)
Total                              4.25 (100)         2.37 (100)

                                             Females

Cause of Death                     1995-1998         2001-2004

Cancer                             0.43 (15.4)       0.60 (19.9)
  Lung                             0.24 (8.5)        0.44 (14.7)
  Breast                           0.02 (-0.7)      -0.03 (-0.9)
  Colorectal                       0.05 (1.8)        0.05 (1.8)
  Prostate                            0                 0
  Other cancers                    0.16 (5.8)        0.14 (4.3)
Heart Disease                      0.80 (28.4)       0.71 (23.7)
  Cerebrovascular diseases         0.07 (2.4)        0.22 (7.3)
  Chronic lower respiratory        0.14 (5.0)        0.18 (6.0)
    diseases
  Diabetes                         0.15 (5.3)        0.18 (6.0)
  Nephritis, Nephrosis,            0.04 (1.5)        0.09 (3.0)
    Nephritic syndrome
  Alzheimer's                      0.06 (2.1)        0.08 (2.8)
Unintentional Injury               0.29 (10.2)       0.22 (7.3)
  Motor vehicle accidents          0.24 (8.5)        0.17 (5.7)
  Falls                            0.02 (0.7)       -0.01 (-0.3)
  Other unintentional injuries     0.03 (1.0)        0.06 (1.9)
Suicide                            0.06 (2.2)        0.07 (2.2)
Homicide                          0.003 (-0.1)      -0.02 (-0.5)
HIV                                0.01 (0.5)        0.01 (0.4)
Influenza and Pneumonia            0.06 (2.1)        0.07 (2.3)
Infant Mortality                   0.07 (2.6)        0.07 (2.3)
  Congenital anomalies             0.01 (0.4)       -0.01 (-0.4)
  Other causes                     0.06 (2.2)        0.08 (2.7)
Residual                           0.63 (22.3)       0.52 (17.3)
Total                              2.81 (100)        3.01 (100)

Table 3. Contribution of Age Groups to Inequality in Life Expectancy
Between the Bottom and Top Area-Socio-economic Deciles in Each
Period, Quebec

                         Inequality in Life Expectancy, Years (%)

                                           Males

Age Group               1989-1992        1995-1998       2001-2004

<1                       0.1 (2.6)       0.16 (3.7)      0.08 (1.92)
1-14                     0.1 (2.7)       0.22 (5.1)      0.11 (2.5)
  1-4                   0.01 (0.2)       0.09 (2.1)      0.04 (0.9)
  5-9                   0.05 (1.5)       0.07 (1.6)      0.04 (1.0)
  10-14                 0.04 (1.0)       0.07 (1.5)      0.03 (0.6)
15-44                   0.94 (25.9)      1.17 (27.0)     1.03 (24.2)
  15-19                 0.17 (4.6)       0.15 (3.5)      0.17 (3.9)
  20-24                 0.22 (6.1)       0.31 (7.1)      0.21 (4.8)
  25-29                 0.21 (5.8)       0.21 (4.8)      0.13 (3.1)
  30-34                 0.11 (3.0)       0.16 (3.6)      0.11 (2.6)
  35-39                 0.13 (3.6)       0.14 (3.3)      0.19 (4.3)
  40-44                 0.10 (2.8)       0.20 (4.6)      0.23 (5.4)
45-64                   1.38 (38.0)      1.49 (34.4)     1.34 (31.5)
  45-49                 0.31 (8.4)       0.27 (6.3)      0.24 (5.6)
  50-54                 0.31 (8.7)       0.39 (8.9)      0.32 (7.4)
  55-59                 0.39 (10.7)      0.44 (10.1)     0.35 (8.1)
  60-64                 0.37 (10.3)      0.39 (9.1)      0.44 (10.3)
[greater than           1.12 (30.7)      1.30 (29.9)     1.70 (39.9)
  or equal to] 65
  65-69                 0.38 (10.6)      0.33 (7.5)      0.45 (10.6)
  70-74                 0.22 (6.0)       0.28 (6.5)      0.39 (9.1)
  75-79                 0.25 (6.9)       0.29 (6.8)      0.29 (6.7)
  80-84                 0.13 (3.5)       0.20 (4.5)      0.27 (6.5)
  85-89                 0.04 (1.1)       0.12 (2.8)      0.15 (3.6)
  [greater than         0.10 (2.6)       0.07 (1.7)      0.15 (3.4)
    or equal to] 90
Total                   3.60 (100)       4.36 (100)      4.25 (100)

                         Inequality in Life Expectancy, Years (%)

                                          Females

Age Group               1989-1992        1995-1998       2001-2004

<1                      0.20 (8.5)       0.10 (3.4)      0.08 (2.7)
1-14                    0.12 (4.9)       0.11 (3.9)      0.04 (1.3)
  1-4                   0.08 (3.2)       0.09 (3.1)      0.02 (0.7)
  5-9                   0.04 (1.7)      -0.01 (-0.5)    -0.01 (-0.3)
  10-14               -0.001 (-0.05)     0.04 (1.3)      0.03 (0.9)
15-44                   0.35 (14.6)      0.41 (14.5)     0.25 (8.4)
  15-19                 0.01 (0.4)       0.05 (1.6)      0.05 (1.7)
  20-24                 0.08 (3.3)       0.08 (2.9)      0.01 (0.3)
  25-29                 0.01 (0.5)     -0.002 (-0.08)   0.003 (0.08)
  30-34                 0.07 (3.0)       0.09 (3.2)      0.03 (0.9)
  35-39                 0.07 (3.1)       0.11 (4.0)      0.09 (3.0)
  40-44                 0.10 (4.2)       0.08 (2.8)      0.07 (2.4)
45-64                   0.58 (24.5)      0.73 (26.1)     0.83 (27.7)
  45-49                 0.04 (1.7)       0.16 (5.8)      0.15 (5.1)
  50-54                 0.11 (4.8)       0.18 (6.5)      0.23 (7.5)
  55-59                 0.22 (9.4)       0.18 (6.4)      0.26 (8.7)
  60-64                 0.20 (8.6)       0.21 (7.4)      0.20 (6.5)
[greater than           1.13 (47.6)      1.47 (52.1)     1.81 (59.9)
  or equal to] 65
  65-69                 0.15 (6.2)       0.17 (6.2)      0.26 (8.6)
  70-74                 0.15 (6.4)       0.20 (7.2)      0.23 (7.7)
  75-79                 0.20 (8.5)       0.34 (12.2)     0.23 (7.6)
  80-84                 0.17 (7.0)       0.20 (7.1)      0.31 (10.3)
  85-89                 0.20 (8.4)       0.24 (8.6)      0.35 (11.7)
  [greater than         0.26 (11.0)      0.30 (10.6)     0.42 (14.0)
    or equal to] 90
Total                   2.37 (100)       2.81 (100)      3.01 (100)

Figure 1. Contribution of each cause of death to the change
in inequality in life expectancy between the bottom and top
area-socio-economic deciles over time

Males

1989-92 to 1995-98 (Total Change: +0.76 y)

                            Change in Life Expentancy Gap (years)

                             Reduced    Increased
                          Inequality   Inequality   % of total change

Cancer
  Lung                                                      2.9
  Breast                                                      0
  Colorectal                                               -3.0
  Prostate                                                  5.8
  Other                                                     2.6
Heart Disease                                              16.7
Cerebrovascular                                           -16.3
CLRD                                                       10.1
Diabetes                                                    3.1
Kidney Diseases                                             7.6
Alzheimer's                                                 3.3
Unintentional Injury
  MVAs                                                      7.7
  Falls                                                    -1.5
  Other                                                     0.1
Suicide                                                    14.1
Homicide                                                    1.7
HIV                                                        25.7
Flu/Pneumonia                                               5.8
Infant Mortality
  Congenital Anomalies                                      7.4
  Other Causes                                              0.2
Residual                                                    6.0

1995-98 to 2001-04 (Total Change: -0.11 y)

                              Change in Life Expentancy Gap (years)

                             Reduced    Increased
                           Inequality   Inequality   % of total change

Cancer
  Lung                                                     -8.5
  Breast                                                    1.5
  Colorectal                                              -62.5
  Prostate                                                -14.4
  Other                                                   -42.6
Heart Disease                                             156.9
Cerebrovascular                                           -44.3
CLRD                                                      -29.2
Diabetes                                                  -58.9
Kidney Diseases                                             6.9
Alzheimer's                                                32.2
Unintentional Injury
  MVAs                                                    110.5
  Falls                                                   -23.4
  Other                                                   112.3
Suicide                                                    42.6
Homicide                                                   -4.5
HIV                                                       -74.5
Flu/Pneumonia                                             -10.1
Infant Mortality
  Congenital Anomalies                                    -16.5
  Other Causes                                             37.5
Residual                                                  -11.0

Females

1989-92 to 1995-98 (Total Change: +0.76 y)

                           Change in Life Expentancy Gap (years)

                             Reduced    Increased
                          Inequality   Inequality   % of total change

Cancer
  Lung                                                     38.3
  Breast                                                   25.1
  Colorectal                                               -3.5
  Prostate
  Other                                                     8.8
Heart Disease                                               8.3
Cerebrovascular                                           -31.2
CLRD                                                        6.3
Diabetes                                                    5.4
Kidney Diseases                                            -5.1
Alzheimer's                                                 6.1
Unintentional Injury
  MVAs                                                    -13.7
  Falls                                                     3.3
  Other                                                     3.8
Suicide                                                     6.5
Homicide                                                   -0.8
HIV                                                         1.6
Flu/Pneumonia                                              12.4
Infant Mortality
  Congenital Anomalies                                     -6.4
  Other Causes                                             -7.1
Residual                                                   42.1

1995-98 to 2001-04 (Total Change: -0.11 y)

                       Change in Life Expentancy Gap (years)

                             Reduced    Increased
                          Inequality   Inequality   % of total change

Cancer
  Lung                                                     99.9
  Breast                                                   -4.2
  Colorectal                                                2.2
  Prostate                                                -14.8
  Other                                                   -42.9
Heart Disease                                              76.0
Cerebrovascular                                            19.0
CLRD                                                       16.1
Diabetes                                                   23.4
Kidney Diseases                                            12.4
Alzheimer's                                                32.2
Unintentional Injury
  MVAs                                                     34.1
  Falls                                                   -14.5
  Other                                                    15.2
Suicide                                                     2.0
Homicide                                                   -6.2
HIV                                                        -0.1
Flu/Pneumonia                                               5.2
Infant Mortality
  Congenital Anomalies                                    -11.2
  Other Causes                                              8.9
Residual                                                  -52.0

Note: Table made from bar graph.