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Journal of Public Health Advance Access first published online on July 23, 2008
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Journal of Public Health, doi:10.1093/pubmed/fdn061
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© The Author 2008, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved

Survival and cause-specific mortality among unemployed individuals in Poland during economic transition


Pawel Zagozdzon, Adjunct Assistant Professor, Lecturer in Epidemiology
Leszek Zaborski, Emeritus Professor of Hygiene and Epidemiology
Jan Ejsmont, Senior Lecturer in Environmental Health, Head of Department of Hygiene and Epidemiology

Department of Hygiene and Epidemiology, Medical University of Gdansk, ul. Powstania Styczniowego 9B, 81-519 Gdynia, Poland


Address correspondence to Pawel Zagozdzon, E-mail: pzagoz{at}amg.gda.pl

Background There were few reports about the relationship between unemployment and mortality in Central Eastern European countries experiencing economic transition.

Methods This study measures overall and cause-specific mortality rates in 47 247 subjects registered as unemployed in Danzig City and Danzig County for the period of 1999 and 2004 and compares them with the age-matched general population.

Results In unemployed male subjects, the age-standardized all-cause mortality rate was significantly higher than in men from the general population: 8.36 per 1000, 95% confidence interval (95% CI) 7.71–9.0 compared with 5.1 per 1000, 95% CI 4.94–5.21. The age-standardized mortality in unemployed women was also higher than in the reference population data: 5.55 per 1000, 95% CI 4.77–6.34 and 1.89 per 1000, 95% CI 1.81–1.97, respectively. External causes, suicides, alcohol and smoking-related causes explain the excess mortality among both men and women. Unemployment status was associated with a greater risk of death in men than in women: hazard ratio (HR) 2.02, 95% CI 1.33–3.08 and HR 0.74, 95% CI 0.37–1.5, respectively.

Conclusions Possible explanations for this disparity may be the current regulations and sociocultural context in Poland. More research is needed to understand the differences in mortality risk associated with unemployment observed between men and women in Poland.

Keywords: gender, mortality, unemployment


   Introduction
TOP
 Introduction
Methods
 Results
 Discussion
 Funding
 References
 
It is well known that losing one's job puts one's health at risk. The long-term effects of unemployment underlying this susceptibility are poverty and social inequality. The health consequences of social inequality and poverty measured as relative deprivation have increased in East European countries after their economic transition.1–4 Increasing health discrepancies observed in the last decade in Poland could be attributed in part to the social consequences of unemployment. Important pathways which can operate between unemployment and health status may run through health-related behaviour and psychological stress.5 Epidemiological reports, including several cohort studies, have suggested the relationship between unemployment and increased mortality.6–8 Some time aspects of work like temporary employment or excessive overtime work were also associated with subsequent increased mortality.9,10 The strongest association between unemployment and death by specific causes was observed for death by external causes that resulted to a large extent from suicides.11,12 These relationships have received little attention in Central Eastern Europe, where double digit unemployment rates commonly occurring during transition was assessed mainly from an economic perspective. In CEE countries, the salient feature of unemployment is its long duration and prevalence among the young and the less educated. More than 50% of the unemployed in many CEE countries have been without a job for more than one year.13

Poland began its transition period in the beginning of the 1990s when free competition was introduced and new laws and economic regulation were accepted. The transition brought overall positive results in the economy; it was, nevertheless, accompanied by unemployment, a phenomenon that was officially unknown prior to it. The unemployment rate rose rapidly during the early years of the transition period starting from 6.5% in 1991 and reaching its first maximum of 16.4% in 1993.14 In 1998, unemployment had lowered to some 10%. The implementation of new health reforms in 1999 resulted in registering of non-working individuals not actively seeking jobs as unemployed in order to secure health insurance for them.15 This reform of the pension and health insurance system contributed to an increase in the number of registered unemployed in Poland in 1999. The restructuring of heavy industry, specifically shipyards in Danzig, and the agricultural sector has worsened the situation. In 2003, unemployment peaked at 20% in Poland, 12.7% in Danzig City and 21% in Danzig County (Fig. 1). Soon after Poland's entry into the EU in May 2004, unemployment dropped to 19% in Poland, 11.5% in Danzig City and 20.6% in Danzig County.14,16


Figure 1
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  		Fig. 1 Trends in unemployment rates in Poland (1990–2007), Danzig City and Danzig County (1999–2004).

 
The great majority of employers in the region represent the private sector, which was dominated, above all, by companies from the following sectors: trade and repairs, industrial processing, construction, shipbuilding, petroleum refining, food, transport, services, as well as hotels and restaurants. The shipbuilding industry underwent significant restructuring, it being an important element of the maritime sector, which still represented a substantial proportion (10% in 1999) of the city's employment base. In 2000, the city's three shipyards employed about 5% of the working population. The concentration of workers in individual companies is less significant, with the largest company, Gdansk Shipyard, accounting for 2.5% of employment and the city's five largest companies accounting for 8% of the total employment.17 As a reflection of the transition from a planned to market economy and the privatization of state-owned companies, public sector employment has decreased considerably, to 19% in mid 2001 from 32% in 1996. After the crisis in 2002 in the city's historic shipyard, the Gdansk Overhaul Shipyard SA (Gdanska Stocznia Remontowa SA) came under a restructuring regime with public support. Due to political instability, this process was delayed, incomplete and only partially successful. In contrast, a few smaller shipbuilding yards already privatized were operating successfully with good profitability. All these processes were accompanied by wide-scale lay-offs.

It has been suggested that the high unemployment in Poland can contribute to differences in adult mortality although there are no longitudinal data to support this hypothesis.5 We hypothesize that unemployment influences the mortality of individuals and they are affected by unemployment in both contexts: as an experience of the harmful effects of unemployment and as a state of being unemployed.

The aim of this study was to examine the all-cause and cause-specific mortality relative to unemployment, including the emphasis on the importance of temporary unemployment in one region of Northern Poland in a typical economic transition context of high and persistent unemployment. The study cohort consists of inhabitants of Danzig City and Danzig County, who were registered as unemployed in the period of 1999–2004.


   Methods
TOP
 Introduction
 Methods
Results
 Discussion
 Funding
 References
 
Study population
The study population consists of subjects registered by the Labour Office as unemployed in Danzig City and Danzig County between 1 January 1999 and 31 December 2004. The Labour Offices collect data on people eligible for unemployment compensation and covers the cost of health insurance for those unemployed, who fulfilled the criteria of unemployment. The right to unemployment benefit is granted to a person registered as unemployed, able and ready to take up employment on a full-time basis, according to the working time rate applied in a given occupation or service, who has reached the age of 18 years and has not reached the retirement age (60 years for women and 65 years for men). Persons applying for unemployment benefits may not be owners or possessors of an agricultural estate, with arable land exceeding the area of 2 ha taken for the purposes of calculation nor have monthly income of an amount exceeding half the minimum pay. They should not be recipients of permanent compensatory allowance, guaranteed periodic allowance or social pension, on the basis of social assistance legislation. Additional eligibility criterion for unemployment compensation is a history of at least 1 year of employment within the last 18 months before registration. In the light of former regulation there would be no person younger than 20 years old in the study population. There were 47 247 unemployed men and women registered during that period. Multiple registrations were allowed when the right to the unemployment benefit expired after six months. Among those, there were 12 266 subjects whose unemployment duration was one year or more during the study period.

Unfortunately records from the Labour Office do not provide data on education, job title or marital status. Therefore, we were unable to adjust for these potential confounders. This lack of control for education would be the potential source of bias that could attenuate the risk of death associated with unemployment. Unemployed women are better educated than men: 60% of the university graduates are women, more than 70% of the women have graduated post-secondary school. However, as statistics on Poland indicate, the highest unemployment rate is among women with vocational education or lower.14 Gender-specific selection effects may play a role also with regard to social and disability pensions. Among those, there were more women who obtained earlier pension authorizations or rights to disability pension.14 This easier access to social benefits may reduce the health hazard of unemployment in women. The study period 1999–2004 has been chosen in order to assure the reliability and validity of unemployment registrations and coded causes of death during the study follow-up. The implementation of the 1997 General Health Insurance Act from 1999 encouraged people working in the ‘grey economy’ to register with labour offices in order to obtain health insurance coverage.15 The year 2004 could be considered as the time of symbolic termination of the transition period as in May 2004 Poland joined the European Union. Outflow of population from Poland increased after 1 May 2004 when three countries of EU15 (i.e. Ireland, UK and Sweden) allowed a free access to their labour markets for citizens of new EU members. Migration may be the source of bias in our study due to the method of follow-up that could result in underascertainment of deaths.

Reference population
The geographically and age-matched general population of Danzig City and Danzig County has been chosen as a reference population for subjects under the study. All data on deaths and population sizes from the period 1999–2004 for women at the age of >20 and <60 years and for men at the ages of >20 and <65 years were merged and included into the analysis. There were 534 719 and 542 327 people living in the whole region in 1999 and 2004, respectively. The age-matched reference population in 1999 consists of 159 267 women at the age of >20 and <60 years, and 161 334 men at the ages of >20 and <65 years. Data from 2004 shows that there were 168 705 women and 171 660 men in the control population. Inhabitants of small towns and rural areas make up a minority of the reference population. There were approximately 85% of Danzig city citizens in the age-matched reference general population. Data on the number and age structure of the general population in Danzig City and Danzig County were collected from the Central Statistical Office in Poland.14

Survival status and mortality
Participants' personal identification numbers of unemployed individuals (a unique number assigned to each Polish citizen) were used to collect mortality data from the regional mortality register kept by the Statistical Office in Danzig. This database provides complete population mortality data for the Pomeranian District, for which Danzig City is capital. The date and cause of death for all subjects who died between 1 January 1999 and 31 December 2004 was obtained. We examined all-cause mortality as well as deaths from a dozen major causes: (1) cardiovascular disease (International Classification of Diseases, Tenth Revision (ICD-10) codes I00–I99); (2) coronary heart disease (ICD-10 codes I20-I25); (3) neoplasms (ICD-10 codes C00–C97); (4) lung cancer (ICD-10 code C34); (5) breast cancer (ICD-10 code C50); (6) external causes (ICD-10 codes S00–Y91); (7) suicides (ICD-10 code X60-X84); (8) infectious diseases ((ICD-10 code A00-B99); (9) disease of the digestive system (ICD-10 code K00-K93); (10) disease of liver (ICD-10 code K70-K77); (11) psychiatric disease (ICD-10 code F00-F99); and (12) symptoms not classified (ICD-10 code R00-R99). In addition, deaths from smoking-related cancer (ICD-10 codes C00–C06, C09–C15, C25, C30–C34, C38, C64–C68) and alcohol-related causes (ICD-10 codes C01–C06, C09, C10, C12–C15, C22, C32, F10, K70) were analysed.

Statistical analysis
To estimate the risk of death from all and specific causes in relation to the experience of unemployment, we calculated the risk ratios and 95% confidence intervals (95% CIs) for unemployed subjects; the geographically and age-matched general population was considered the reference group. Age-adjusted annual overall and cause-specific mortality rates and 95% confident intervals were calculated for unemployed men and women as well as for men and women in the reference general population. The age criteria for the reference-matched general population were 20–59 years for women and 20–64 years for men. The differences in age criteria between men and women were consequences of the retirement eligibility at an earlier age of 60 years in women. Age adjustment was performed by direct standardization with the use of the new WHO Standard age structure.18 To assess the effect of gender on survival in unemployed subjects, we calculated the age-adjusted hazard ratio (HR) and 95% CIs by conducting Cox proportional hazard analyses for men in relation to women. Age has been included into the model. The effect of the unemployment compensation duration calculated as a cumulative duration of unemployment compensation during the study period has been tested with the Cox proportional hazard model. To calculate the strength of association between the state of being unemployed and risk of death in the analysed cohort, unemployment status as a time-varying covariate was included into the Cox proportional hazard model. The analyses were performed using the STATA 9.0 software.


   Results
TOP
 Introduction
 Methods
 Results
Discussion
 Funding
 References
 
The Labour Office in Danzig registered 47 247 unemployed men and women as new entries during the analysed period from 1 January 1999 to 31 December 2004. Over these six years, there were 980 deaths in people who were registered as unemployed in Danzig City and Danzig County population. The 47 247 participants accrued 129 570 person-years of follow-up (mean follow-up: 33.4 months).

The mean age at the time of the first registration was 46 years. There were 51% men in the analysed unemployed population. Among those who died, the vast majority constituted men: 79.4% (Table 1).


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  		Table 1 Baseline demographic characteristics and unemployment duration in subjects who experienced unemployment in population of Danzig City and Danzig County between 1999 and 2004 compared with merged data from geographically and age-matched general population from the period 1999 to 2004

 
The overall mortality in a cohort of unemployed people was 7.56 per 1000 person-years and was two times higher than in the age-matched general population (Table 2). The highest cause-specific mortality was related to death from neoplasms: 2.36 per 1000 person-years. Cardiovascular mortality was 1.71 per 1000 person-years and was comparable with mortality from external causes (1.67 per 1000 person-years). The lowest risk among the analysed causes of death was observed for breast cancer and psychiatric diseases. Overall mortality and each of analysed cause-specific mortality rates in unemployed subjects was higher than the corresponding crude indicators for the age-matched general population, except for death by breast cancer (Table 2).


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  		Table 2 Overall and cause-specific mortality in unemployed population, corresponding risk ratios for both sexes, men and women with reference group as geographically age-matched general population from area of Danzig city and Danzig County in the period 1999–2004

 
The most pronounced excess of risk associated with unemployment was observed for diseases of the liver and alcohol-related causes [risk ratio (RR) = 3.41, 95% CI: 2.59–4.44 and RR = 2.92, 95% CI: 2.25–3.74, respectively]. The risk of suicides was also elevated: RR = 2.76, 95% CI: 2.08–3.62. The effect of unemployment on mortality from the two leading causes of death in Poland, coronary artery disease and pulmonary cancer, was also pronounced (RR = 1.54, 95% CI: 1.14–2.04 and RR = 2.36, 95% CI: 1.91–2.9, respectively).

The analysis of age-standardized mortality rates in unemployed subjects and the matched general population also shows an excess risk of death by major causes among those who lost their jobs (Table 3).


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  		Table 3 Age-standardized all and cause-specific mortality with 95% CI in unemployed population, corresponding age-standardized annual mortality rates in general population at working age (20–64 years for men and 20–59 for women) from the area of Danzig City and Danzig County in the period 1999–2004

 
The age-standardized mortality rate in the study cohort was 5.77 per 1000, 95% CI 5.29–6.25, whereas in the general population the standardized rate was 4.07 per 1000, 95% CI 3.99–4.15. However, the magnitude of difference in the overall and cause-specific age-adjusted mortality rates between unemployed individuals and the general population differs significantly depending on gender. Unemployed women suffer more frequently from fatal conditions compared with the age-matched female general population. The age-standardized mortality rate in unemployed women was much higher than in women from the age-matched general population: 5.55 per 1000, 95% CI 4.77–6.34 and 1.89 per 1000, 95% CI 1.81–1.97, respectively. The age-standardized mortality rate from neoplasms in women affected by unemployment was two times higher than that in women from the general population. The biggest difference of mortality rate in unemployed women was observed for diseases of the liver: the age-adjusted mortality rate in the unemployed was 0.36 per 1000 (95% CI 0.16–0.57), whereas in the general population it was 0.05 per 1000 (95% CI 0.04–0.06). Among men, the age-standardized mortality rate from coronary heart disease, lung cancer, diseases of the liver, suicides, smoking-related causes and alcohol-related causes was consistently two times higher for subjects who lost their jobs than in the general population.

Male gender was associated with significantly worse overall age-adjusted survival in the unemployed group: HR 3.4, 95% CI 2.9–4.0.

Unemployment status as a time-dependent variable was an indicator of a significantly increased risk of death within the cohort of unemployed subjects: HR 1.63, 95% CI 1.14–2.34. Unemployment status in men was associated with a greater risk of death than in the whole cohort: HR 2.02, 95% CI 1.33–3.08. There was no effect of the unemployment spell on the risk of death in women: HR 0.74, 95% CI 0.37–1.5 (Table 4).


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  		Table 4 Association of unemployment status as time-dependent variable and cumulative duration of unemployment compensation with risk of death, expressed as hazard ratios and their 95% confidence intervals and adjusted for age and sex in Cox proportional hazard model in population of Danzig City and Danzig County between 1999 and 2004

 
The longer duration of unemployment compensation expressed in years was significantly associated with a decreased risk of death: HR 0.72, 95% CI 0.6–0.87. This effect of the cumulative duration of unemployment compensation was present in men but not in women: HR 0.66, 95% CI 0.53–0.82 compared with HR 1.03, 95% CI 0.7–1.51 (Table 4).


   Discussion
TOP
 Introduction
 Methods
 Results
 Discussion
Funding
 References
 
Main finding of this study
The analysis of survival during 6 years of observation in a cohort of subjects who experienced unemployment in one county of Northern Poland showed significantly increased risk of death compared with the local general population. Additionally, in the men of our study cohort, we found a significant negative association between unemployment status and survival.

The overall risk of death in subjects affected by unemployment was twice higher than in the corresponding age-matched general population in this study. A comparable association between unemployment and increased mortality was observed in previous studies where the control group consisted of employed subjects.6,8,10 Similarly, the relationship between the standardized mortality rate in unemployed men and in the male general population was consistent with the findings from the OPCS Longitudinal Study.7

As the study population consisted of subjects who were registered at least once as unemployed, the exposure reflects more of temporary unemployment rather than permanent unemployment. The negative effect of non-permanent employment in the study cohort was observed only in men and was almost identical to that observed in other studies where men with no job were twice as likely to die as men who remained employed.8,9 The increased risk of death associated with non-permanent employment and distribution of the causes of death in this study was in accordance with the findings from an investigation on the effects of a temporary job on cause-specific mortality.10

The finding on the significant effect of the cumulative duration of unemployment benefit on mortality in men but not in women is consistent with the evidence on the risk of death due to unemployment status in men. A selection bias in relation to health may be driving the observed gap between the hazards in men and women. The relationship between unemployment status as time-dependent as opposed to not time-dependent underlines the role of gender-specific factors operating between unemployment and health. The analysis restricted only to an unemployed cohort with unemployment as a time-dependent variable seems to minimize the impact of this potential bias and shows men as more prone to unemployment hazards.

What is already known on this topic
The increased risk of death from injuries and suicides among the unemployed is in accordance with other studies linking unemployment and external causes of death.10,12,19 According to longitudinal assessments, unemployment is a risk factor for psychological symptoms of depression requiring medical attention, even in those men without previous psychological vulnerability.20 This would be a possible explanation for higher rates of suicidal deaths among unemployed subjects with deteriorated psychological heath and depression attributable to a lack of job.

A similar discrepancy between the subjects who experienced unemployment and the general population was noticed with regard to cardiovascular causes, a finding being in accordance with observations indicating the negative impact of poor socioeconomic conditions on cardiovascular morbidity and mortality.21–23

Reasons for decreased survival after losing one's job could be related to those psychosocial factors that are closely associated with unemployment. Behavioural and lifestyle risk factors, such as smoking, poor diet, alcohol consumption or lack of exercise were found more frequently among unemployed people according to cross-sectional data.24,25 This characteristic pattern of risk factors raises a well known problem of selection: those who are ill due to bad habits may be more likely to lose their jobs and find it harder to regain employment because of their condition. This selection mechanism was not confirmed by findings from a study examining changes in the health status of civil servants whose employment security was threatened. Threats to employment security had adverse consequences for health status, which were unexplained by health selection or health-related behaviours.26 After adjustment for smoking in men and obesity in women, poor health at baseline was found to be a significant precursor of unemployment in both genders.27 The British Regional Heart Study showed that higher levels of smoking and alcohol drinking were predictive of a higher probability of subsequent unemployment. There were also findings that men who had experienced unemployment in the year prior to the interview, compared with those who had not, were more likely to smoke and to have a drinking problem.28 There were data on unemployment among young men that showed a significant explanatory effect on smoking, psychological and somatic symptoms but not on excess alcohol consumption after long-term follow-up.29 The tentative conclusion is that both causation and selection mechanisms are involved in the relationship between unemployment and health problems related to substance abuse. Higher prevalence of smoking among the unemployed may contribute to an increased risk of death from lung cancer and other smoking-related causes. Those among the unemployed, who drink heavily, are at an increased risk of death from hepatic cirrhosis and external causes. Different distributions of cigarette and alcohol use may be a major determinant of differences in cause-specific mortality and the risk of death between unemployed people and the general population.

What this study adds
The added value of this study was the confirmation of the negative impact of the unemployment status on mortality in the environment of a transition economy in a Central Eastern European country.

The lack of significant negative effect of an unemployment status on mortality in women in this study was not in accordance with findings on female participants in other studies.6,9,10 It has been suggested that the work role was less important for women than for men and that losing a job had less importance for women.30 This can be true for societies at a certain stage of social development or communities in transition like the source population in this study. The possible explanation of this observation could be related to traditional social roles of men and women in Poland. Consequently unemployment could lay a bigger psychological burden on men than on women.

There was a discrepancy between findings on the lack of effect of an unemployment status on the risk of death in women and higher mortality in the unemployed female cohort compared to the matched general female population. This divergence with regard to women could be determined by a higher possibility of health selection in females.31 The hazard of a labour market exit in the context of perceived ill-health may be higher in the case of women. These patterns may reflect differential access by gender to disability pensions or other work-related benefits in Poland. The majority (70%) of individuals who were eligible for family pension in Poland in 2004 were women.14 Most of those women were widows. Among those who received disability pensions, there were more women from younger age groups. Women reach full retirement at the age of 60, but men at 65. The finding on women's resistance to unemployment and current data on 9 years longer life expectancy in women when compared to men should be important evidence for decision makers in the current debate on increasing the retirement age for women in Poland.

Higher proportion of deaths from unclassified diseases among the unemployed resulted from a limited availability of health services during unemployment. Exclusion and deprivation are other factors associated with being unemployed, which made them less thoroughly diagnosed and examined than people with preserved employment.32 The new regulations establishing general health insurance were introduced in Poland in 1999. System reorganization has appeared to be missing the expectations of health-care participants. The limited financial resources on health care in Poland, especially in the recession period, and high level of public debt show that it is almost impossible to spend more than 6% GDP on health care. Systemic transformations in health care in Poland has considerably increased the significance of household income and education as factors that differentiate inequalities in patients.33

The observations that we have made indicate the role of unemployment in Poland as an exposure in itself and a proxy of different psychosocial characteristics and environmental exposures that strongly determine the risk of death from specific causes. Persistent unemployment could be used as an indicator for susceptibility to specific diseases and should necessitate specific preventive measures among individuals who have lost their jobs.

Limitations of this study
The major limitation of this study is related to the lack of control for socioeconomic position. As we were unable to obtain the data on education in unemployed subjects, there was no adjustment for this variable in our analyses. Obviously education would modify the effect of unemployment but the complexity of specific interrelations between education, health and ability of finding a job makes the attempt to adjust for education very difficult or even not fully justified. In order to increase the validity and precision of our observations, there is a need to compare mortality indicators among unemployed individuals with an age-matched cohort of the employed population using for adjustment the occupational titles rather than education. The potential bias related to the age-matched general population as a reference group would only make the estimation of the true effect of unemployment smaller than in the case of having employed individuals as the control group. The general population at working age reflects all possible contexts in which work would occur. This includes housewives taking care of children or people not working but with sufficient material resources of the family of origin and hence not registered as unemployed. The concept of risk ratio has been introduced into this study with full awareness of the above-mentioned limitations applicable to the general population as the control group.

The interpretation of results related to deaths from neoplasms encountered several limitations, all of which were related to health selection. The process of cancer initiation and promotion can last 20 or more years before a cancer becomes clinically detectable. The exposure in this study was measured no earlier than six years before the fatal outcome. As such, factors related to cancer development potentially associated with the unemployment may have had occurred earlier than the exposure analysed in this study and lasted much longer than six years. Potential mechanisms through which job loss may accelerate the appearance of neoplastic diseases could be connected to the psychological effects of unemployment or intensification of cancer promoting risk behaviour such as smoking.34

Another weakness resulted from the method of verifying survival status. Individuals were classified as alive if their data were not present in the death registry specific for Danzig City and Danzig County. The problem of migration of unemployed people could be a source of bias but it would rather attenuate the observed discrepancy. The follow-up in this study was terminated in 2004 when Poland joined the European Union. Since then, a massive migration of young people to countries of ‘old’ Europe has been observed.

A more detailed analysis of trajectories of social determinants of health and employment should be performed to elucidate the health effects of unemployment in Poland. The differences observed between men and women underline the importance of taking gender into account in future research.


   Funding
TOP
 Introduction
 Methods
 Results
 Discussion
 Funding
References
 
This study was supported by grant no. W-75 from the Medical University of Gdansk.


   Footnotes
 
This paper has been versioned to correct the risk ratio value given in Table 2 for women dying of neoplasms.


   References
TOP
 Introduction
 Methods
 Results
 Discussion
 Funding
 References
 

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