Johan P. Mackenbach

Socioeconomic Inequalities in Health in 22 European Countries

BACKGROUND Comparisons among countries can help to identify opportunities for the reduction of inequalities in health. We compared the magnitude of inequalities in mortality and self-assessed health among 22 countries in all parts of Europe. METHODS We obtained data on mortality according to education level and occupational class from census-based mortality studies. Deaths were classified according to cause, including common causes, such as cardiovascular disease and cancer; causes related to smoking; causes related to alcohol use; and causes amenable to medical intervention, such as tuberculosis and hypertension. Data on self-assessed health, smoking, and obesity according to education and income were obtained from health or multipurpose surveys. For each country, the association between socioeconomic status and health outcomes was measured with the use of regression-based inequality indexes. RESULTS In almost all countries, the rates of death and poorer self-assessments of health were substantially higher in groups of lower socioeconomic status, but the magnitude of the inequalities between groups of higher and lower socioeconomic status was much larger in some countries than in others. Inequalities in mortality were small in some southern European countries and very large in most countries in the eastern and Baltic regions. These variations among countries appeared to be attributable in part to causes of death related to smoking or alcohol use or amenable to medical intervention. The magnitude of inequalities in self-assessed health also varied substantially among countries, but in a different pattern. CONCLUSIONS We observed variation across Europe in the magnitude of inequalities in health associated with socioeconomic status. These inequalities might be reduced by improving educational opportunities, income distribution, health-related behavior, or access to health care.

Income inequality and population health

Papers pp 13, 16, 20, 23 In 1992, the BMJ published a now famous paper showing a strong negative correlation between income inequality and life expectancy. Among nine Western industrialised countries those which had less income inequality seemed to have higher life expectancy.1 A few years later this was replicated in analyses looking at income inequality and mortality in states within the United States—analyses which seemed more secure because of having more and better quality data. 2 3 These findings, which suggested that income inequality is bad for the health of the whole population and not only for those with the lowest incomes, were seen to have important implications. Reducing the inequality would be in everyones interest, including those with higher incomes. A novel area of research was born, adding new perspectives to conventional studies of health inequalities. These had tended to focus on relations between socioeconomic factors and health of the individual, while the findings on income inequality suggested that contextual effects of inequality might be just as important. Considerable dissent, however, emerged on the explanation of these effects. Some favoured softer psychosocial pathways (for example through feelings of relative deprivation, or disruption of social cohesion) while others favoured harder material pathways (for example through underinvestment in public resources).4–6 Support was found for some of these mechanisms, which are also important in their own right, and the debate on income inequality versus mortality acted as a strong stimulus for further work on factors such as social cohesion and social capital.7 Although most of …

Financial crisis, austerity, and health in Europe

The financial crisis in Europe has posed major threats and opportunities to health. We trace the origins of the economic crisis in Europe and the responses of governments, examine the effect on health systems, and review the effects of previous economic downturns on health to predict the likely consequences for the present. We then compare our predictions with available evidence for the effects of the crisis on health. Whereas immediate rises in suicides and falls in road traffic deaths were anticipated, other consequences, such as HIV outbreaks, were not, and are better understood as products of state retrenchment. Greece, Spain, and Portugal adopted strict fiscal austerity; their economies continue to recede and strain on their health-care systems is growing. Suicides and outbreaks of infectious diseases are becoming more common in these countries, and budget cuts have restricted access to health care. By contrast, Iceland rejected austerity through a popular vote, and the financial crisis seems to have had few or no discernible effects on health. Although there are many potentially confounding differences between countries, our analysis suggests that, although recessions pose risks to health, the interaction of fiscal austerity with economic shocks and weak social protection is what ultimately seems to escalate health and social crises in Europe. Policy decisions about how to respond to economic crises have pronounced and unintended effects on public health, yet public health voices have remained largely silent during the economic crisis.

Educational differences in smoking: international comparison

Abstract Objective: To investigate international variations in smoking associated with educational level. Design: International comparison of national health, or similar, surveys. Subjects: Men and women aged 20 to 44 years and 45 to 74years. Setting: 12 European countries, around 1990. Main outcome measures: Relative differences (odds ratios) and absolute differences in the prevalence of ever smoking and current smoking for men and women in each age group by educational level. Results: In the 45 to 74 year age group, higher rates of current and ever smoking among lower educated subjects were found in some countries only. Among women this was found in Great Britain, Norway, and Sweden, whereas an opposite pattern, with higher educated women smoking more, was found in southern Europe. Among men a similar north-south pattern was found but it was less noticeable than among women. In the 20 to 44 year age group, educational differences in smoking were generally greater than in the older age group, and smoking rates were higher among lower educated people in most countries. Among younger women, a similar north-south pattern was found as among older women. Among younger men, large educational differences in smoking were found for northern European as well as for southern European countries, except for Portugal. Conclusions: These international variations in social gradients in smoking, which are likely to be related to differences between countries in their stage of the smoking epidemic, may have contributed to the socioeconomic differences in mortality from ischaemic heart disease being greater in northern European countries. The observed age patterns suggest that socioeconomic differences in diseases related to smoking will increase in the coming decades in many European countries.

Educational inequalities in cause-specific mortality in middle-aged and older men and women in eight western European populations

BACKGROUND Studies of socioeconomic disparities in patterns of cause of death have been limited to single countries, middle-aged people, men, or broad cause of death groups. We assessed contribution of specific causes of death to disparities in mortality between groups with different levels of education, in men and women, middle-aged and old, in eight western European populations. METHODS We analysed data from longitudinal mortality studies by cause of death, between Jan 1, 1990, and Dec 31, 1997. Data were included for more than 1 million deaths in 51 million person years of observation. FINDINGS Absolute educational inequalities in total mortality peaked at 2127 deaths per 100000 person years in men, and at 1588 deaths per 100000 person years in women aged 75 years and older. In this age-group, rate ratios were greater than 1.00 for total mortality and all specific causes of death, apart form prostate cancer in men and lung cancer in women, showing increased mortality in low versus high educational groups. In men, cardiovascular diseases accounted for 39% of the difference between low and high educational groups in total mortality, cancer for 24%, other diseases for 32%, and external causes for 5%. Among women, contributions were 60%, 11%, 30%, and 0%, respectively. The contributions of cerebrovascular disease, other cardiovascular diseases, pneumonia, and COPD strongly increased by age, whereas those of cancer and external causes declined. Although relative inequalities in total mortality were closely similar in all populations, we noted striking differences in the contribution of specific causes to these inequalities. INTERPRETATION Research needs to be broadened to include older populations, other diseases, and populations from different parts of Europe. Effective interventions should be developed and implemented to reduce exposure to cardiovascular risk factors in low-educational groups.

Occupational class and cause specific mortality in middle aged men in 11 European countries: comparison of population based studies

Abstract Objectives: To compare countries in western Europe with respect to class differences in mortality from specific causes of death and to assess the contributions these causes make to class differences in total mortality. Design: Comparison of cause of death in manual and non-manual classes, using data on mortality from national studies. Setting: Eleven western European countries in the period 1980-9. Subjects: Men aged 45–59 years at death. Results: A north-south gradient was observed: mortality from ischaemic heart disease was strongly related to occupational class in England and Wales, Ireland, Finland, Sweden, Norway, and Denmark, but not in France, Switzerland, and Mediterranean countries. In the latter countries, cancers other than lung cancer and gastrointestinal diseases made a large contribution to class differences in total mortality. Inequalities in lung cancer, cerebrovascular disease, and external causes of death also varied greatly between countries. Conclusions: These variations in cause specific mortality indicate large differences between countries in the contribution that disease specific risk factors like smoking and alcohol consumption make to socioeconomic inequalities in mortality. The mortality advantage of people in higher occupational classes is independent of the precise diseases and risk factors involved. Key messages Socioeconomic inequalities in total mortality among middle aged men are about equally large in most western European countries, with the exception of larger inequalities in France and Finland Inequalities in mortality from specific causes of death, and the contributions these causes make to inequalities in total mortality, vary between countries The contribution to inequalities in mortality of disease specific risk factors like smoking and alcohol consumption varies greatly between countries This variability imposes limits on the exchange of research findings and experiences with health policies between western European countries The similar size of inequalities in total mortality in most countries underlines the generalised ability of higher occupational classes to better avoid premature death

Migration and health in an increasingly diverse Europe.

The share of migrants in European populations is substantial and growing, despite a slowdown in immigration after the global economic crisis. This paper describes key aspects of migration and health in Europe, including the scale of international migration, available data for migrant health, barriers to accessing health services, ways of improving health service provision to migrants, and migrant health policies that have been adopted across Europe. Improvement of migrant health and provision of access for migrants to appropriate health services is not without challenges, but knowledge about what steps need to be taken to achieve these aims is increasing.

Socioeconomic inequalities in mortality among elderly people in 11 European populations

Study objective: To describe mortality inequalities related to education and housing tenure in 11 European populations and to describe the age pattern of relative and absolute socioeconomic inequalities in mortality in the elderly European population. Design and Methods: Data from mortality registries linked with population census data of 11 countries and regions of Europe were acquired for the beginning of the 1990s. Indicators of socioeconomic status were educational level and housing tenure. The study determined mortality rate ratios, relative indices of inequality (RII), and mortality rate differences. The age range was 30 to 90+ years. Analyses were performed on the pooled European data, including all populations, and on the data of populations separately. Data were included from Finland, Norway, Denmark, England and Wales, Belgium, France, Austria, Switzerland, Barcelona, Madrid, and Turin. Main results: In Europe (populations pooled) relative inequalities in mortality decreased with increasing age, but persisted. Absolute educational mortality differences increased until the ages 90+. In some of the populations, relative inequalities among older women were as large as those among middle aged women. The decline of relative educational inequalities was largest in Norway (men and women) and Austria (men). Relative educational inequalities did not decrease, or hardly decreased with age in England and Wales (men), Belgium, Switzerland, Austria, and Turin (women). Conclusions: Socioeconomic inequalities in mortality among older men and women were found to persist in each country, sometimes of similar magnitude as those among the middle aged. Mortality inequalities among older populations are an important public health problem in Europe.

Tackling socioeconomic inequalities in health: analysis of European experiences

Effective strategies must be developed to reduce socioeconomic inequalities in health. Most efforts take place in isolation, and only the UK experience has been discussed widely in international published work. We therefore analysed policy developments on health inequalities in different European countries between 1990 and 2001. We noted that countries are in widely different phases of awareness of, and willingness to take action on, inequalities in health. We identified innovative approaches in five main areas: policy steering mechanisms; labour market and working conditions; consumption and health-related behaviour; health care; and territorial approaches. National advisory committees in the UK, the Netherlands, and Sweden have proposed comprehensive strategies to reduce health inequalities. Variations between these packages suggest that policymaking in this area still is largely intuitive and would benefit from incorporation of more rigorous evidence-based approaches. Further international exchanges of experiences with development, implementation, and evaluation of policies and interventions to reduce health inequalities can help to enhance learning speed.

Socioeconomic status and ischaemic heart disease mortality in 10 western European populations during the 1990s

Objective: To assess the association between socioeconomic status and ischaemic heart disease (IHD) mortality in 10 western European populations during the 1990s. Design: Longitudinal study. Setting: 10 European populations (95 009 822 person years). Methods: Longitudinal data on IHD mortality by educational level were obtained from registries in Finland, Norway, Denmark, England/Wales, Belgium, Switzerland, Austria, Turin (Italy), Barcelona (Spain), and Madrid (Spain). Age standardised rates and rate ratios (RRs) of IHD mortality by educational level were calculated by using Poisson regression. Results: IHD mortality was higher in those with a lower socioeconomic status than in those with a higher socioeconomic status among men aged 30–59 (RR 1.55, 95% confidence interval (CI) 1.51 to 1.60) and 60 years and over (RR 1.22, 95% CI 1.21 to 1.24), and among women aged 30–59 (RR 2.13, 95% CI 1.98 to 2.29) and 60 years and over (RR 1.36, 95% CI 1.33 to 1.38). Socioeconomic disparities in IHD mortality were larger in the Scandinavian countries and England/Wales, of moderate size in Belgium, Switzerland, and Austria, and smaller in southern European populations among men and younger women (p < 0.0001). For elderly women the north–south gradient was smaller and there was less variation between populations. No socioeconomic disparities in IHD mortality existed among elderly men in southern Europe. Conclusions: Socioeconomic disparities in IHD mortality were larger in northern than in southern European populations during the 1990s. This partly reflects the pattern of socioeconomic disparities in cardiovascular risk factors in Europe. Population wide strategies to reduce risk factor prevalence combined with interventions targeted at the lower socioeconomic groups can contribute to reduce IHD mortality in Europe.