Trends in health inequalities in 27 European countries Mackenbach, Johan P.; Valverde, José Rubio; Artnik, Barbara ...
Proceedings of the National Academy of Sciences - PNAS,
06/2018, Letnik:
115, Številka:
25
Journal Article
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Unfavorable health trends among the lowly educated have recently been reported from the United States. We analyzed health trends by education in European countries, paying particular attention to the ...possibility of recent trend interruptions, including interruptions related to the impact of the 2008 financial crisis. We collected and harmonized data on mortality from ca. 1980 to ca. 2014 for 17 countries covering 9.8 million deaths and data on self-reported morbidity from ca. 2002 to ca. 2014 for 27 countries covering 350,000 survey respondents. We used interrupted time-series analyses to study changes over time and country-fixed effects analyses to study the impact of crisis-related economic conditions on health outcomes. Recent trends were more favorable than in previous decades, particularly in Eastern Europe, where mortality started to decline among lowly educated men and where the decline in less-than-good self-assessed health accelerated, resulting in some narrowing of health inequalities. In Western Europe, mortality has continued to decline among the lowly and highly educated, and although the decline of less-than-good self-assessed health slowed in countries severely hit by the financial crisis, this affected lowly and highly educated equally. Crisis-related economic conditions were not associated with widening health inequalities. Our results show that the unfavorable trends observed in the United States are not found in Europe. There has also been no discernible short-term impact of the crisis on health inequalities at the population level. Both findings suggest that European countries have been successful in avoiding an aggravation of health inequalities.
Background Over the last decades of the 20th century, a widening of the gap in death rates between upper and lower socioeconomic groups has been reported for many European countries. For most ...countries, it is unknown whether this widening has continued into the first decade of the 21st century. Methods We collected and harmonised data on mortality by educational level among men and women aged 30–74 years in all countries with available data: Finland, Sweden, Norway, Denmark, England and Wales, Belgium, France, Switzerland, Spain, Italy, Hungary, Lithuania and Estonia. Results Relative inequalities in premature mortality increased in most populations in the North, West and East of Europe, but not in the South. This was mostly due to smaller proportional reductions in mortality among the lower than the higher educated, but in the case of Lithuania and Estonia, mortality rose among the lower and declined among the higher educated. Mortality among the lower educated rose in many countries for conditions linked to smoking (lung cancer, women only) and excessive alcohol consumption (liver cirrhosis and external causes). In absolute terms, however, reductions in premature mortality were larger among the lower educated in many countries, mainly due to larger absolute reductions in mortality from cardiovascular disease and cancer (men only). Despite rising levels of education, population-attributable fractions of lower education for mortality rose in many countries. Conclusions Relative inequalities in premature mortality have continued to rise in most European countries, and since the 1990s, the contrast between the South (with smaller inequalities) and the East (with larger inequalities) has become stronger. While the population impact of these inequalities has further increased, there are also some encouraging signs of larger absolute reductions in mortality among the lower educated in many countries. Reducing inequalities in mortality critically depends upon speeding up mortality declines among the lower educated, and countering mortality increases from conditions linked to smoking and excessive alcohol consumption such as lung cancer, liver cirrhosis and external causes.
Summary Background Studies of the effect of macroeconomic fluctuations on mortality in different socioeconomic groups are scarce and have yielded mixed findings. We analyse mortality trends in Spain ...before and during the Great Recession in different socioeconomic groups, quantifying the change within each group. Methods We did a nationwide prospective study, in which we took data from the 2001 Census. All people living in Spain on Nov 1, 2001, were followed up until Dec 31, 2011. We included 35 951 354 people alive in 2001 who were aged between 10 and 74 years in each one of the four calendar years before the economic crisis (from 2004 to 2007) and in each one of the first four calendar years of the crisis (from 2008 to 2011), and analysed all-cause and cause-specific mortality in those people. We classified individuals by socioeconomic status (low, medium, or high) using two indicators of household wealth: household floor space (<72 m2 , 72–104 m2 , and >104 m2 ) and number of cars owned by the residents of the household (none, one, and two or more). We used Poisson regression to calculate the annual percentage reduction (APR) in mortality rates during 2004–07 (pre-crisis) and 2008–11 (crisis) in each socioeconomic group, as well as the effect size, measured by the APR difference between the pre-crisis and crisis period. Findings The annual decline in all-cause mortality in the three socioeconomic groups was 1·7% (95% CI 1·2 to 2·1) for the low group, 1·7% (1·3 to 2·1) for the medium group, and 2·0% (1·4 to 2·5) for the high group in 2004–07, and 3·0% (2·5 to 3·5) for the low group, 2·8% (2·5 to 3·2) for the medium group, and 2·1% (1·6 to 2·7) for the high group in 2008–11 when individuals were classified by household floor space. The annual decline in all-cause mortality when people were classified by number of cars owned by the household was 0·3% (–0·1 to 0·8) for the low group, 1·6% (1·2 to 2·0) for the medium group, and 2·2% (1·6 to 2·8) for the high group in 2004–07, and 2·3% (1·8 to 2·8) for the low group, 2·4% (2·0 to 2·7) for the medium group and 2·5% (1·9 to 3·0) for the high group in 2008–11. The low socioeconomic group showed the largest effect size for both wealth indicators. Interpretation In Spain, probably due to the decrease in exposure to risk factors, all-cause mortality decreased more during the economic crisis than before the economic crisis, especially in low socioeconomic groups. Funding None.
Childhood obesity is a major problem in rich countries due to its high prevalence and its harmful health consequences. An exploratory analysis conducted in the PubMed database highlighted that the ...number of papers published on the relationship between socioeconomic position (SEP) and childhood-adolescent weight status had risen substantially with respect to an earlier review which had covered the period 1990-2005.
To describe the findings on the relationship between SEP and childhood-adolescent weight status in papers published in rich countries from 1990 through 2013, studies were identified in the following databases: PubMed; Web of Knowledge (WOK); PsycINFO; Global Health; and Embase. We included observational studies from the 27 richest OECD countries, which covered study populations aged 0 to 21 years, and used parental education, income and/or occupation as family SEP indicators. A total of 158 papers met the inclusion criteria and reported 134 bivariable and 90 multivariable analyses.
Examination of the results yielded by the bivariable analyses showed that 60.4% of studies found an inverse relationship, 18.7% of studies did not found relationship, and 20.9% of studies found a relationship that varied depending on another variable, such as age, sex or ethnic group; the corresponding percentages in the multivariable analyses were 51.1, 20.0 and 27.8%, respectively. Furthermore, 1.1% found a positive relationship.
The relationship between SEP and childhood-adolescent weight status in rich countries is predominantly inverse and the positive relationship almost has disappeared. The SEP indicator that yields the highest proportion of inverse relationships is parents' education. The proportion of inverse relationships is higher when the weight status is reported by parents instead using objective measurements.
Objectives: Examine trends in limitations among young (15–39), middle-aged (40–64) and older age-groups (>=65) and their socioeconomic differences. Methods: Population-based European Social Survey ...data (N = 396,853) were used, covering 30 mostly European countries and spanning the time-period 2002–2018. Limitations were measured using a global activity limitations indicator. Results: Age-differential trends in limitations were found. Activity limitations generally decreased in older adults, whereas trends varied among younger and middle-aged participants, with decreasing limitations in some countries but increasing limitations in others. These age-differential trends were replicated across limitation severity and socioeconomic groups; however, stronger limitation increases occurred regarding less-severe limitations. Discussion: Functional health has improved in older adults. Contrarily, the increasing limitations in younger and middle-aged individuals seem concerning, which were mostly observed in Western and Northern European countries. Given its public health importance, future studies should investigate the reasons for this declining functional health in the young and middle-aged.
Link and Phelan have proposed to explain the persistence of health inequalities from the fact that socioeconomic status is a “fundamental cause” which embodies an array of resources that can be used ...to avoid disease risks no matter what mechanisms are relevant at any given time. To test this theory we compared the magnitude of inequalities in mortality between more and less preventable causes of death in 19 European populations, and assessed whether inequalities in mortality from preventable causes are larger in countries with larger resource inequalities.
We collected and harmonized mortality data by educational level on 19 national and regional populations from 16 European countries in the first decade of the 21st century. We calculated age-adjusted Relative Risks of mortality among men and women aged 30–79 for 24 causes of death, which were classified into four groups: amenable to behavior change, amenable to medical intervention, amenable to injury prevention, and non-preventable.
Although an overwhelming majority of Relative Risks indicate higher mortality risks among the lower educated, the strength of the education–mortality relation is highly variable between causes of death and populations. Inequalities in mortality are generally larger for causes amenable to behavior change, medical intervention and injury prevention than for non-preventable causes. The contrast between preventable and non-preventable causes is large for causes amenable to behavior change, but absent for causes amenable to injury prevention among women. The contrast between preventable and non-preventable causes is larger in Central & Eastern Europe, where resource inequalities are substantial, than in the Nordic countries and continental Europe, where resource inequalities are relatively small, but they are absent or small in Southern Europe, where resource inequalities are also large.
In conclusion, our results provide some further support for the theory of “fundamental causes”. However, the absence of larger inequalities for preventable causes in Southern Europe and for injury mortality among women indicate that further empirical and theoretical analysis is necessary to understand when and why the additional resources that a higher socioeconomic status provides, do and do not protect against prevailing health risks.
•The theory of “fundamental causes” has only rarely been tested empirically.•Inequalities in mortality are generally larger for preventable causes of death.•This is not true for Southern Europe and for injury mortality among women.•Our results provide further support for the theory of “fundamental causes”.•However, exceptions indicate that further elaboration of the theory is needed.
The magnitude of socioeconomic inequalities in mortality differs importantly between countries, but these variations have not been satisfactorily explained. We explored the role of behavioral and ...structural determinants of these variations, by using a dataset covering 17 European countries in the period 1970–2010, and by conducting multilevel multivariate regression analyses. Our results suggest that between-country variations in inequalities in current mortality can partly be understood from variations in inequalities in smoking, excessive alcohol consumption, and poverty. Also, countries with higher national income, higher quality of government, higher social transfers, higher health care expenditure and more self-expression values have smaller inequalities in mortality. Finally, trends in behavioral risk factors, particularly smoking and excessive alcohol consumption, appear to partly explain variations in inequalities in mortality trends. This study shows that analyses of variations in health inequalities between countries can help to identify entry-points for policy.
•The magnitude of inequalities in mortality differs importantly between countries.•This is the first study of the determinants of these between-country variations.•Smoking, alcohol, and poverty partly drive these between-country variations.•Factors like national income also influence how large mortality inequalities are.•Between-country variations in health inequalities help to find policy entry-points.
Purpose
We examined changes in the burden of depressive symptoms between 2006 and 2014 in 18 European countries across different age groups.
Methods
We used population-based data drawn from the ...European Social Survey (
N
= 64.683, 54% female, age 14–90 years) covering 18 countries (Austria, Belgium, Denmark, Estonia, Finland, France, Germany, Great Britain, Hungary, Ireland, The Netherlands, Norway, Poland, Portugal, Slovenia, Spain, Sweden, Switzerland) from 2006 to 2014. Depressive symptoms were measured via the CES-D 8. Generalized additive models, multilevel regression, and linear regression analyses were conducted.
Results
We found a general decline in CES-D 8 scale scores in 2014 as compared with 2006, with only few exceptions in some countries. This decline was most strongly pronounced in older adults, less strongly in middle-aged adults, and least in young adults. Including education, health and income partially explained the decline in older but not younger or middle-aged adults.
Conclusions
Burden of depressive symptoms decreased in most European countries between 2006 and 2014. However, the decline in depressive symptoms differed across age groups and was most strongly pronounced in older adults and least in younger adults. Future studies should investigate the mechanisms that contribute to these overall and differential changes over time in depressive symptoms.
BackgroundBetween the 1990s and 2000s, relative inequalities in all-cause mortality increased, whereas absolute inequalities decreased in many European countries. Whether similar trends can be ...observed for inequalities in other health outcomes is unknown. This paper aims to provide a comprehensive overview of trends in socioeconomic inequalities in self-assessed health (SAH) in Europe between 1990 and 2010.MethodsData were obtained from nationally representative surveys from 17 European countries for the various years between 1990 and 2010. The age-standardised prevalence of less-than-good SAH was analysed by education and occupation among men and women aged 30–79 years. Socioeconomic inequalities were measured by means of absolute rate differences and relative rate ratios. Meta-analysis with random-effects models was used to examine the trends of inequalities.ResultsWe observed declining trends in the prevalence of less-than-good SAH in many countries, particularly in Southern and Eastern Europe and the Baltic states. In all countries, less-than-good SAH was more prevalent in lower educational and manual groups. For all countries together, absolute inequalities in SAH were mostly constant, whereas relative inequalities increased. Almost no country consistently experienced a significant decline in either absolute or relative inequalities.ConclusionsTrends in inequalities in SAH in Europe were generally less favourable than those found for inequalities in mortality, and there was generally no correspondence between the two when we compared the trends within countries. In order to develop policies or interventions that effectively reduce inequalities in SAH, a better understanding of the causes of these inequalities is needed.
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