Abstract
Socioeconomic inequalities in mortality are a challenge for public health around the world, but appear to be resistant to policy-making. We aimed to identify European countries which have been more successful than others in narrowing inequalities in mortality, and the factors associated with narrowing inequalities. We collected and harmonised mortality data by educational level in 15 European countries over the last 25 years, and quantified changes in inequalities in mortality using a range of measures capturing different perspectives on inequality (e.g., ‘relative’ and ‘absolute’ inequalities, inequalities in ‘attainment’ and ‘shortfall’). We determined which causes of death contributed to narrowing of inequalities, and conducted country- and period-fixed effects analyses to assess which country-level factors were associated with narrowing of inequalities in mortality. Mortality among the low educated has declined rapidly in all European countries, and a narrowing of absolute, but not relative inequalities was seen in many countries. Best performers were Austria, Italy (Turin) and Switzerland among men, and Spain (Barcelona), England and Wales, and Austria among women. Ischemic heart disease, smoking-related causes (men) and amenable causes often contributed to narrowing inequalities. Trends in income inequality, level of democracy and smoking were associated with widening inequalities, but rising health care expenditure was associated with narrowing inequalities. Trends in inequalities in mortality have not been as unfavourable as often claimed. Our results suggest that health care expansion has counteracted the inequalities widening effect of other influences.
Highlights
Inequalities in mortality by socioeconomic position are among the most consistently reproduced findings in public health research: rates of mortality are higher among those with a lower education, occupational class or income in all countries that have taken the trouble to collect the necessary data [1,2,3]
In Northern, Western and Southern Europe, these shortfalls in life expectancy have steadily declined over this time-period, both among the low and high educated, but in Eastern Europe recent improvements represent a reversal as compared to unfavourable trends up to around the year 2000
The Slope Index of Inequality (SII), which measures absolute differences in mortality rates between education groups taking into account their relative sizes, has mostly gone down, whereas the Relative Index of Inequality (RII) has mostly gone up
Summary
Inequalities in mortality by socioeconomic position are among the most consistently reproduced findings in public health research: rates of mortality are higher among those with a lower education, occupational class or income in all countries that have taken the trouble to collect the necessary data [1,2,3]. Relative inequalities in mortality (as indicated by, e.g., the rate ratio of mortality among lower as compared to higher socioeconomic groups) have risen strongly, whereas absolute inequalities (as indicated by, e.g., the difference between the mortality rates of lower and higher socioeconomic groups) have followed a more variable course [5]. These variations between countries and over time are important because they show that the magnitude of inequalities in mortality is far from fixed, and that there is, in principle, large scope for reducing health inequalities. We aim to identify the European countries which have been more successful than others in containing or even reducing inequalities in mortality, and we exploit variations between countries to identify the factors associated with narrowing and widening of inequalities in mortality
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