José Geurts

Income-related inequalities in health: some international comparisons

This paper presents evidence on income-related inequalities in self-assessed health in nine industrialized countries. Health interview survey data were used to construct concentration curves of self-assessed health, measured as a latent variable. Inequalities in health favoured the higher income groups and were statistically significant in all countries. Inequalities were particularly high in the United States and the United Kingdom. Amongst other European countries, Sweden, Finland and the former East Germany had the lowest inequality. Across countries, a strong association was found between inequalities in health and inequalities in income.

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.

Equity in the delivery of health care in Europe and the US

This paper presents a comparison of horizontal equity in health care utilization in 10 European countries and the US. It does not only extend previous work by using more recent data from a larger set of countries, but also uses new methods and presents disaggregated results by various types of care. In all countries, the lower-income groups are more intensive users of the health care system. But after indirect standardization for need differences, there is little or no evidence of significant inequity in the delivery of health care overall, though in half of the countries, significant pro-rich inequity emerges for physician contacts. This seems to be due mainly to a higher use of medical specialist services by higher-income groups and a higher use of GP care among lower-income groups. These findings appear to be fairly general and emerge in countries with very diverse characteristics regarding access and provider incentives.

Differences in self reported morbidity by educational level: a comparison of 11 western European countries.

STUDY OBJECTIVE: To assess whether there are variations between 11 Western European countries with respect to the size of differences in self reported morbidity between people with high and low educational levels. DESIGN AND METHODS: National representative data on morbidity by educational level were obtained from health interview surveys, level of living surveys or other similar surveys carried out between 1985 and 1993. Four morbidity indicators were included and a considerable effort was made to maximise the comparability of these indicators. A standardised scheme of educational levels was applied to each survey. The study included men and women aged 25 to 69 years. The size of morbidity differences was measured by means of the regression based Relative Index of Inequality. MAIN RESULTS: The size of inequalities in health was found to vary between countries. In general, there was a tendency for inequalities to be relatively large in Sweden, Norway, and Denmark and to be relatively small in Spain, Switzerland, and West Germany. Intermediate positions were observed for Finland, Great Britain, France, and Italy. The position of the Netherlands strongly varied according to sex: relatively large inequalities were found for men whereas relatively small inequalities were found for women. The relative position of some countries, for example, West Germany, varied according to the morbidity indicator. CONCLUSIONS: Because of a number of unresolved problems with the precision and the international comparability of the data, the margins of uncertainty for the inequality estimates are somewhat wide. However, these problems are unlikely to explain the overall pattern. It is remarkable that health inequalities are not necessarily smaller in countries with more egalitarian policies such as the Netherlands and the Scandinavian countries. Possible explanations are discussed.

Persistent variations in average height between countries and between socio-economic groups: an overview of 10 European countries.

Primary objectives: This paper aims to provide an overview of variations in average height between 10 European countries, and between socio-economic groups within these countries. Data and methods: Data on self-reported height of men and women aged 20-74 years were obtained from national health, level of living or multipurpose surveys for 1987-1994. Regression analyses were used to estimate height differences between educational groups and to evaluate whether the differences in average height between countries and between educational groups were smaller among younger than among older birth cohorts. Results: Men and women were on average tallest in Norway, Sweden, Denmark and the Netherlands and shortest in France, Italy and Spain (range for men: 170-179 cm; range for women: 160-167 cm). The differences in average height between northern and southern European countries were not smaller among younger than among older birth cohorts. In most countries average height increased linearly with increasing birth-year (≈0.7-0.8cm/5 years for men and ≈0.4cm/5 years for women). In all countries, lower educated men and women on average were shorter than higher educated men (range of differences: 1.6-3.0 cm) and women (range of differences: 1.2-2.2 cm). In most countries, education-related height differences were not smaller among younger than among older birth cohorts. Conclusions: The persistence of international differences in average height into the youngest birth cohorts indicates a high degree of continuity of differences between countries in childhood living conditions. Similarly, the persistence of education-related height differences indicates continuity of socio-economic differences in childhood living conditions, and also suggests that socio-economic differences in childhood living conditions will continue to contribute to socio-economic differences in health at adult ages.

Trends in socioeconomic health inequalities in the Netherlands, 1981–1999

Study objective: To determine changes in socioeconomic inequalities in self reported health in both the 1980s and the 1990s in the Netherlands. Design: Analysis of trends in socioeconomic health inequalities during the last decades of the 20th century were made using data from the Health Interview Survey (Nethhis) and the subsequent Permanent Survey on Living Conditions (POLS) from Statistics Netherlands. Socioeconomic inequalities in self assessed health, short-term disabilities during the past 14 days, long term health problems and chronic diseases were studied in relation to both educational level and household income. Trends from 1981 to 1999 were studied using summary indices for both the relative and absolute size of socioeconomic inequalities in health. Setting: The Netherlands. Participants: For the period 1981–1999 per year a random sample of about 7000 respondents of 18 years and older from the non-institutionalised population. Main results: Socioeconomic inequalities in self assessed health showed a fairly consistent increase over time. Socioeconomic inequalities in the other health indicators were more or less stable over time. In no case did socioeconomic inequalities in health seemed to have decreased over time. Socioeconomic inequalities in self assessed health increased both in the 1980s and the 1990s. This increase was more pronounced for income (as compared with education) and for women (as compared with men). Conclusion: There are several possible explanations for the fact that, in addition to stable health inequalities in general, income related inequalities in some health indicators increased in the Netherlands, especially in the early 1990s. Most influential were perhaps selection effects, related to changing labour market policies in the Netherlands. The fact that the health inequalities did not decrease over recent years underscores the necessity of policies that explicitly aim to tackle these inequalities.

Supplier-induced demand for physiotherapy in the Netherlands

Empirical studies of supplier-induced demand in health care have mostly concentrated on the analysis of physician behaviour. In this article, the focus is on the economic determinants of physiotherapist behaviour in The Netherlands. It is shown that relative prices work as strong incentives to alter the mix of services supplied, conform to the model of revenue maximization under a production constraint. However, the time-series analysis also gives some indication that this ability to influence the demand for their services to increase hourly income is not fully exploited. The latter finding is inconsistent with pure income maximization but rather points to a trade-off between loss of revenue and demand manipulation. The fact that the choice of therapy varies with the pressure on provider incomes does not cast some doubt on the appropriateness of the chosen patterns of treatment in terms of effectiveness.

Influence of research design on time use estimates

In 1987 the Central Bureau of Statistics (CBS) started a time use survey (TUS) in the Netherlands for the observation of informal productive activities and production within the household. A first report on the survey was published in 1989 and covered a description of the time use in different quarters of the year and in different population groups. A second publication concerns the yearly volume of informal economic production in the Netherlands. Further reports on the time use of partners within households and the yearly volume of formal economic production were published in 1990. This paper discusses the results of two methodological analyses. The first aspect concerns the effect of the sample design on the standard error of the estimates, the second describes the influence of the structure of the diary on the activity pattern over the day.