摘要：Objectives. We investigated the contributions of gender, caste, and standard of living to inequalities in mortality across the life course in India. Methods. We conducted a multilevel cross-sectional analysis of individual mortality, using the 1998–1999 Indian National Family Health Survey data for 529321 individuals from 26 states. Results. Substantial mortality differentials were observed between the lowest and highest standard-of-living quintiles across all age groups, ranging from an odds ratio (OR) of 4.61 (95% confidence interval [CI]=2.98, 7.13) in the age group 2 to 5 years to an OR of 1.97 (95% CI=1.68, 2.32) in the age group 45 to 64 years. Excess mortality for girls was evident only for the age group 2 to 5 years (OR=1.33, 95% CI=1.13, 1.58). Substantial caste differentials were observed at the beginning and end stages of life. Area variation in mortality is partially a result of the compositional effects of household standard of living and caste. Conclusions. The mortality burden, across the life course in India, falls disproportionately on economically disadvantaged and lower-caste groups. Residual state-level variation in mortality suggests an underlying ecology to the mortality divide in India. Interpreting health inequalities in relation to the socioeconomic circumstances of individuals and populations provides a useful assessment of potentially avoidable inequalities. 1 In particular, socioeconomic inequalities in mortality suggest not only contemporaneous exposure to disadvantaged individual and ecological circumstances but also cumulative exposure to adverse circumstances. 2 A necessary prerequisite for reducing health disparities, consequently, is to ascertain the socioeconomic distribution of health and mortality. 3 Much of the current evidence on socioeconomic inequalities in health and mortality is restricted to developed countries, 4 – 10 and there has been little systematic effort to document the different socioeconomic dimensions along which health and mortality are patterned in developing countries. 11 Using the most recent nationally representative survey data, the 1998–1999 Indian National Family Health Survey (INFHS), we investigated the different socioeconomic and geographic dimensions along which inequalities in mortality exist in India. Research on mortality in India has almost exclusively focused on the determinants of infant and child mortality. 12 – 14 Given India’s high infant and child mortality rates—67 and 93 per 1000, respectively—this emphasis is legitimate and understandable. 15 Furthermore, given that girls have a higher mortality than boys, inequalities in infant and child mortality have mainly been studied from a gender perspective. 14 , 16 – 19 Crucially, most analyses of mortality are based either exclusively on aggregate data, typically at the level of Indian districts or states, 14 or exclusively on individual data. 16 , 20 In this study, we extended the current understanding of mortality differentials in India in the following ways. First, we investigated the differential patterning of mortality across different stages of the life course, from infancy and childhood through adult mortality to mortality at older ages. Second, in addition to gender differences, we examined inequalities in mortality across socioeconomic dimensions to evaluate the independent contributions of gender, caste, and standard of living in shaping patterns of mortality. Such an evaluation, across the life course, is likely to be indicative of the processes that generate health inequalities. 21 Finally, analyses of exclusively aggregate or exclusively individual data conflate the different sources of variation in mortality. 22 – 24 Using a multilevel analytic perspective, 25 , 26 we examined the simultaneous contribution of individual, household, and area levels in producing variation in mortality, thus estimating the importance of geographic contexts for individual mortality. We addressed the following questions about the mortality divide in India: What is the relative importance of gender, of caste, and of standard of living in shaping unequal patterns of mortality? To what extent do unequal patterns of mortality by gender, caste, and standard of living vary across different stages of the life course? What is the extent of geographic variation in mortality at the level of local areas, districts, and states after allowance is made for the effects of individual and household demographic and socioeconomic markers? To what extent does the geographic variation in mortality, at the levels of states, districts, and local areas, vary across different stages of the life course?
