Long-term trends of inequalities in mortality in 6 European countries

Rianne De Gelder,Giuseppe Costa,Pekka Martikainen,Gwenn Menvielle,Bjørn Heine Strand,Johan P Mackenbach,Katalin Kovács

doi:10.1007/s00038-016-0922-9

Abstract

ObjectivesWe aimed to assess whether trends in inequalities in mortality during the period 1970–2010 differed between Finland, Norway, England and Wales, France, Italy (Turin) and Hungary.MethodsTotal and cause-specific mortality data by educational level and, if available, occupational class were collected and harmonized. Both relative and absolute measures of inequality in mortality were calculated.ResultsIn all countries except Hungary, all-cause mortality declined strongly over time in all socioeconomic groups. Relative inequalities in all-cause mortality generally increased, but more so in Hungary and Norway than elsewhere. Absolute inequalities often narrowed, but went up in Hungary and Norway. As a result of these trends, Hungary (where inequalities in mortality where almost absent in the 1970s) and Norway (where inequalities in the 1970s were among the smallest of the six countries in this study) now have larger inequalities in mortality than the other four countries.ConclusionsWhile some countries have experienced dramatic setbacks, others have made substantial progress in reducing inequalities in mortality.

Highlights

Widening relative and/or absolute inequalities in mortality over the past two decades have been reported from many countries (Borrell et al 2008; Fawcett et al 2005; Jemal et al 2008; Krieger et al 2008; Mackenbach et al 2003; Mackenbach et al 2014; Martikainen et al 2014; Tarkiainen et al 2012; Strand et al 2010, 2014), but studies of long-term trends stretching over three or more decades are rare, and are usually limited to a single country
While short-term trends are important for monitoring, for example because they reflect the effect of changes in exposure to determinants of mortality with a relatively immediate impact, such as improvements in medical treatment or road safety, long-term trends may provide insights into how secular changes in mortality and its determinants play out in the evolving pattern of health inequalities
Since the early 1980s, mortality gradually decreased over time in all educational groups, except in Hungary where mortality among the low and middle educated increased until the early 1980s and early 1990s and started to decline

Summary

Introduction

Widening relative and/or absolute inequalities in mortality over the past two decades have been reported from many countries (Borrell et al 2008; Fawcett et al 2005; Jemal et al 2008; Krieger et al 2008; Mackenbach et al 2003; Mackenbach et al 2014; Martikainen et al 2014; Tarkiainen et al 2012; Strand et al 2010, 2014), but studies of long-term trends stretching over three or more decades are rare, and are usually limited to a single country. High-income countries are in an advanced stage of the epidemiologic transition (Olshansky and Ault 1986; Omran 1971), with rapidly but differentially declining rates of cardiovascular disease mortality and widening inequalities in cardiovascular disease mortality as a result (Avendano et al 2006; Kunst et al 1999; Marmot and McDowall 1986). Such secular changes can only be captured on a time-scale of three or four decades. Because almost no studies have quantitatively compared these trends between countries, it is unknown whether countries differ in the timing of widening or narrowing of inequalities in mortality

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