Trends in socioeconomic inequalities in self-assessed health in 17 European countries between 1990 and 2010

Trends in socioeconomic inequalities in self-rated health in Germany: a time-trend analysis of repeated cross-sectional health surveys between 2003 and 2012

OBJECTIVES

This study assessed the extent of educational and income inequalities in self-rated health (SRH) in the German adult population between 2003 and 2012 and how these inequalities changed over time.

DESIGN

Repeated cross-sectional health interview surveys conducted in 2003, 2009, 2010 and 2012.

SETTING AND PARTICIPANTS

The study population was the German adult population aged 25-69, living in private households in Germany. In total 54 197 randomly selected participants (2003: 6890; 2009: 16 418; 2010: 17 145; 2012: 13 744) were included.

MAIN OUTCOME MEASURES

SRH was assessed with one single question. Five answer categories were dichotomised into good ('very good' and 'good') versus poor ('moderate', 'poor', 'very poor') SRH. To estimate the extent of the correlation between absolute and relative inequalities in SRH on the one hand, and income and education on the other; slope indices of inequality (SII) and relative indices of inequality (RII) were estimated using linear probability and log-binomial regression models.

RESULTS

There were considerable and persisting educational and income inequalities in SRH in every survey year. Absolute educational inequalities were largely stable (2003: SII=0.25, 95% CI 0.21 to 0.30; 2012: 0.29, 95% CI 0.25 to 0.33; p trend=0.359). Similarly, absolute income inequalities were stable (2003: SII=0.22, 95% CI 0.17 to 0.27; 2012: SII=0.26, 95% CI 0.22 to 0.30; p trend=0.168). RII by education (2003: 2.53, 95% CI 2.11 to 3.03; 2012: 2.72, 95% CI 2.36 to 3.13; p trend=0.531) and income (2003: 2.09. 95% CI 1.75 to 2.49; 2012: 2.53, 95% CI 2.19 to 2.92; p trend=0.051) were equally stable over the same period.

CONCLUSIONS

We found considerable and persisting absolute and relative socioeconomic inequalities in SRH in the German adult population between 2003 and 2012, with those in lower socioeconomic position reporting poorer SRH. These findings should be a concern for both public health professionals and political decision makers.

Longer and healthier lives for all? Successes and failures of a universal consumer-driven healthcare system, Switzerland, 1990-2014

Objectives

The ability to translate increases in life expectancy into additional years in good health is a crucial challenge for public health policies. We question the success of these policies in Switzerland, a forerunner of longevity, through the evolution of healthy life expectancy (HLE) across socioeconomic groups.

Methods

Education-specific HLE conditioning on surviving to age 30 was computed for 5-year periods from the Swiss National Cohort, a mortality follow-up of the entire resident population, and the Swiss Health Interview Survey, reporting self-rated health. We compare time trends and decompose them into health, mortality and education components.

Results

Between 1990 and 2015, comparable gains in LE (males: 5.02 years; females: 3.09 years) and HLE (males: 4.52 years; females: 3.09 years) were observed. People with compulsory education, however, experienced morbidity expansion, while those with middle and high education experienced morbidity compression.

Conclusions

Divergence of morbid years by educational levels may reflect unequal access to preventive care due to high out-of-pockets contributions in the healthcare system. This growing gap and the exhaustion of the educational dividend jeopardize future increases in HLE.

Electronic supplementary material

The online version of this article (10.1007/s00038-019-01290-5) contains supplementary material, which is available to authorized users.

Exposure to second-hand smoke in the context of tobacco policy changes in Estonia, 1996-2016

BACKGROUND

Exposure to second-hand smoke (SHS) is a preventable cause of disease and disability that can effectively be tackled by tobacco legislation. The aim of the study was to analyse the trends of SHS exposure and its sociodemographic patterning during 1996-2016 in the context of tobacco policy changes in Estonia.

METHODS

Nationally representative data from biennial health surveys in 1996-2016 (n = 14 629) were used to present prevalence ratios for SHS exposure among non-smokers in Estonia. Joinpoint regression and multivariable logistic regression were used to study the sociodemographic and socio-economic differences in SHS exposure and its changes during the period.

RESULTS

Exposure to SHS among non-smoking men and women has declined 3.6 and 5 times, respectively, during 1996-2016. While the rate of change was constant among men throughout the period, the decline in SHS exposure among women became significantly faster after 2006 compared with the previous period. However, 15.6% [95% confidence interval (CI) 13.1-18.3%] of men and 8.8% (95% CI 7.1-10.6%) of women were still exposed to SHS in 2016 with higher odds found for younger age groups, non-Estonians and those with lower education and income.

CONCLUSIONS

The consistently declining prevalence of SHS exposure among non-smoking population can be at least partially attributed to implementation of tobacco legislations in 2000s. However, the existing sociodemographic and socio-economic differences in SHS exposure require further attention as those in more vulnerable positions are also more exposed to SHS-related health harms.

Educational inequalities in self-rated health and social relationships - analyses based on the European Social Survey 2002-2016

BACKGROUND

While there is evidence for educational health inequalities in Europe, studies on time trends and on the explanatory contribution of social relations are less consistent. It has been shown that the use of welfare state typologies can be helpful to examine health inequalities in a comparative perspective. Against this background, analyses are focused on three research questions: (1) How did educational inequalities in self-rated health (SRH) develop between 2002 and 2016 in different European countries? (2) In how far can structural and functional aspects of social relations help to explain these inequalities? (3) Do these explanatory contributions vary between different types of welfare states?

METHODS

Data stem from the European Social Survey. Data from 20 countries across 8 waves (2002-2016) was included in the sample (allocated to 5 types of welfare states). Structural aspects of social relations were measured by living with a partner, frequency of social contacts and social participation. Availability of emotional support was used as functional dimension. Educational level was assessed based on the International Standard Classification of Education. SRH was measured in all waves on a five-point scale by one question: "How is your health in general? Would you say it is very good, good, fair, bad or very bad?"

RESULTS

Across all countries, educational inequalities were increasing between 2002 and 2016. Explanatory contribution of emotional support, living with a partner, and social contacts was small (5% or less across the eight waves). Social participation explained 11% of the educational inequalities in SRH in the European countries. There were small variations in the explanatory contribution of social participation between welfare states.

CONCLUSIONS

Promoting social participation, especially of people with low education is a possible intervention to reduce inequalities in SRH in Europe.

Can inequalities in political participation explain health inequalities?

Inequalities in health are pervasive and durable, but they are not uniform. To date, however, the drivers of these between-country patters in health inequalities remain largely unknown. In this analysis, we draw on data from 17 European countries to explore whether inequalities in political participation, that is, inequalities in voting by educational attainment, are correlated with health inequalities. Over and above a range of relevant confounders, such as GDP, income inequality, health spending, social protection spending, poverty rates, and smoking, greater inequalities in political participation remain correlated with higher health inequalities. If 'politicians and officials are under no compulsion to pay much heed to classes and groups of citizens that do not vote' then political inequalities could indirectly affect health through its impact on policy choices that determine who has access to the resources necessary for a healthy life. Inequalities in political participation, then, may well be one of the 'causes of the causes' of ill-health.

[Intergenerational mobility and health inequalities in East and West Germany : A trend analysis from 1992 to 2012]

BACKGROUND

Social mobility processes, i. e. the movement of a person from one social position to another, are central mechanisms for explaining health inequalities. Social differences in health status or behaviour may also change with changes in social status. This article examines the importance of intergenerational mobility, i. e. the rise and fall of social status in relation to parental social position, for subjective health in East and West Germany and whether this relationship has changed over 20 years.

MATERIAL AND METHODS

The data basis is the socio-economic panel from 1992-2012. Employees aged between 25 and 59 were taken into account. Different mobility paths were determined by comparing their current occupational positions with those of their parents. For these, prevalence and logistic regression of subjective health were calculated.

RESULTS

Those in low occupational positions rated their health more often as being worse in all periods. Upwardly mobile individuals had a lower risk of poorer health (OR 0.72) compared to those who remained in their original position. Persons affected by downward mobility had a similarly worse self-rated health (OR 1.55 or OR 1.86). Significant differences in gender or region of origin (East-West Germany) could not be determined. Education and income contribute to explaining the relationship.

CONCLUSION

The results suggest that social advancement has a positive effect on health, whereas social decline is negative - regardless of gender, region of origin or time. It is therefore important to reinforce political efforts aimed at increasing the mobility opportunities of all social groups in a positive sense and thus reducing social inequalities.

Association between education and health outcomes among adults with disabilities: evidence from Shanghai, China

Background

Adults with disabilities often have worse health outcomes than do their peers without disabilities. While education is a key determinant of health, there is little research available on the health disparities across education levels among adults with disabilities in developing countries. We therefore examined the association between health outcomes and education among adults with disabilities in Shanghai, China.

Methods

We used the health examination records of 42,715 adults with disabilities in Shanghai in 2014. Five health outcomes, including two diseases (fatty liver and hemorrhoids) and three risk factors (overweight [body mass index ≥ 24]), high blood glucose, and high blood lipid), were evaluated. Descriptive statistics and Pearson’s chi-square test were used to assess differences in participants’ demographic and disability characteristics. Pearson’s chi-square test and Fisher’s exact test were conducted to compare the prevalence of each health outcome among the different education levels. Finally, logistic regression analyses were conducted to explore the association between education and health outcomes after adjusting for sociodemographic characteristics.

Results

People with an elementary school or lower degree had the highest prevalence of overweight (52.1%) and high blood glucose (20.8%), but the lowest prevalence of hemorrhoids (18.6%) and fatty liver (38.9%). We observed significant differences in the association between education and health outcomes across disability types. For example, in physically disabled adults, higher education was related to higher odds of hemorrhoids (p < 0.001); however, there were no significant disparities in hemorrhoids across the education levels among adults with intellectual disabilities.

Discussion

Compared with people without disabilities, adults with disabilities in Shanghai have relatively poor health. The association between education and health outcomes differed according to the health condition and disability type. To reduce the prevalence rate of overweight and high blood glucose among people with disabilities, tailored health promotion initiatives must be developed for people with lower education levels. In contrast, specific attention should be paid to the prevention of hemorrhoids and fatty liver among more-educated people with disabilities. Our study provides important evidence for targeting educational groups with specific disability types for health promotion and intervention.

Socioeconomic inequality in drug reimbursement during end-of-life care: a nationwide study

BACKGROUND

In Denmark, patients who are terminally ill have the right to drug reimbursement due to terminal illness (DRTI). DRTI, a proxy marker of planned end-of-life care, is intended to be equally accessible regardless of socioeconomic position. This study examined social and socioeconomic differences in DRTI among Danish patients who are terminally ill.

METHODS

This cross-sectional study based on individual-level nationwide data included all patients dying from cancer, dementia, ischaemic heart disease, chronic obstructive pulmonary disease, chronic liver disease, congestive heart failure, diabetes or stroke in 2006-2015 (n=307 188). We analysed associations between social and socioeconomic position (education, income, cohabiting status, migrant status and employment) and DRTI. Prevalence ratios (PR) and 95% CIs were estimated using log-linear models adjusted for age, gender, comorbidity, cause of death and residence.

RESULTS

Overall, 27.9% of patients received DRTI (n=85 616). A substantial difference in likelihood of receiving DRTI was observed among patients with a social and socioeconomic profile associated with the highest versus lowest probability of DRTI (adjusted PR 1.44, 95% CI 1.18 to 1.75). The probability of DRTI was higher among patients with high income compared with low income (adjusted PR 1.22, 95% CI 1.17 to 1.26). Also, living with a partner and being immigrant or descendant of such were associated with higher probability of DRTI compared with living alone and of Danish origin, whereas employment was associated with lower probability of DRTI compared with retirement.

CONCLUSION

Social and socioeconomic position was associated with the likelihood of receiving DRTI, which indicates that planned end-of-life care is not equally accessible in Denmark.

Assessing changes in social determinants of health inequalities in South Africa : a decomposition analysis

Background

Despite various policy interventions that have targeted reductions in socio-economic inequalities in health and health care in post-Apartheid South Africa, evidence suggests that not much has really changed. In particular, health inequalities, which are strongly linked to social determinants of health (SDH), persist. This study, thus, examines how changes in the SDH have impacted health inequalities over the last decade, the second since the end of Apartheid.

Methods

Data come from information collected on social determinants of health (SDH) and on health status in the 2004, 2010 and 2014 questionnaires of the South African General Household Surveys (GHSs). The health indicators considered include ill-health status and disability. Concentration indices and Oaxaca-Blinder decomposition of change in a concentration index methods were employed to unravel changes in socio-economic health inequalities and their key social drivers over the studied time period.

Results

The results show that inequalities in ill-health are consistently explained by socio-economic inequalities relating to employment status and provincial differences, which narrowed considerably over the studied periods. Relatedly, disability inequalities are largely explained by shrinking socio-economic inequalities relating to racial groups, educational attainment and provincial differences.

Conclusion

The extent of employment, location and education inequalities suggests the need for improved health care management and further delivery of education and job opportunities; greater effort in this regard is likely to be more beneficial in some way.

Depression symptoms as mediators of inequalities in self-reported health: the case of Southern European elderly

Background

Inequalities in the distribution of self-reported health (SRH) have been widely reported. Its higher expressivity among women, elderly and least educated groups has been partly attributed to differences in their health perceptions. However, this subjectivity may be masking the burden of mental illness in these groups. Thus, we sought to understand if depression symptoms mediate inequalities in SRH.

Methods

SHARE waves 4 and 6, pertaining to Spain, Italy and Portugal, were used (n2011 = 8517, n2015 = 11 046). Inequalities in SRH were calculated, comparing the risk amongst education level, gender and age groups, adjusting for chronic diseases, functional limitations and country fixed effects. We then tested depression symptoms as mediators.

Results

Depression symptoms were associated with poor SRH (odds ratio (OR)2011 = 1.379, OR2015 = 1.384, P < 0.001). Their inclusion reduced the magnitude of the association between SRH and education, annulled the statistical significance for age, and reversed the gender effect. As expected, chronic diseases and functional limitations remained significant predictors of poor SRH.

Conclusions

Depression symptoms, together with chronic diseases and functional limitations, explain the poorer SRH of the least educated, female and older groups in the Southern European population. Therefore, tackling inequalities in SRH must require focusing on mental health issues, which disproportionately affect the most vulnerable groups.

Widening health inequalities between the employed and the unemployed: A decomposition of trends in Canada (2000-2014)

Recent developments in the social epidemiological literature indicate that health inequalities between the employed and the unemployed are widening in many advanced capitalist countries. At present, we know relatively little about why these inequalities are worsening. Drawing on nationally-representative data from the largest health survey in Canada, we explored this question by analyzing changes in self-rated health inequalities between employed and unemployed Canadians from 2000 to 2014. Using a regression-based method that decomposes a given inequality into its component sources, we investigated the extent to which risk factors that account for unemployment-related health inequalities at a single point in time can also explain the extent and direction of change in these unemployment-related health inequalities over time. Our results indicate that relative and absolute health inequalities between employed and unemployed Canadians widened over the study period. Between 2000 and 2014, the prevalence of poor self-rated health among unemployed Canadians increased from 10.8% to 14.6%, while rates among employed Canadians were stable at around 6%. Our findings suggest that the demographic, socioeconomic, and proximal risk factors that are routinely used to explain unemployment-related health inequalities may not be as powerful for explaining how and why these inequalities change over time. In the case of unemployment-related health inequalities in Canada, these risk factors explain neither the increasing prevalence of poor self-rated health among the unemployed nor the growing gap between the unemployed and their employed counterparts. We provide several possible explanations for these puzzling findings. We conclude by suggesting that widening health inequalities may be driven by macrosocial trends (e.g. widening income inequality and declining social safety nets) which have changed the meaning and context of unemployment, as well as its associated risk factors, in ways that are not easy to capture using routinely available survey data.

[Healthy life expectancy of older migrants and non-migrants in three European countries over time]

We analysed differences in healthy life expectancy at age 50 (HLE₅₀) between migrants and non-migrants in Belgium, the Netherlands, and England and Wales, and their trends over time between 2001 and 2011 in the latter two countries. Population, mortality and health data were derived from registers, census or surveys. HLE₅₀ was calculated for non-migrants, western and non-western migrants by sex. We applied decomposition techniques to determine whether differences in HLE₅₀ between origin groups and changes in HLE₅₀ over time were attributable to either differences in mortality or health. The results show that in all three countries and among both sexes, older migrants, in particular those from non-western origin, could expect to live fewer years in good health than older non-migrants, mainly because of differences in self-rated health. Differences in HLE₅₀ between migrants and non-migrants diminished over time in the Netherlands, but they increased in England and Wales. Improvements in HLE₅₀ over time were mainly attributable to mortality decline. Interventions aimed at reducing the health and mortality inequalities between older migrants and non-migrants should focus on prevention, and target especially non-western migrants.

An evaluation of health systems equity in Indonesia: study protocol

BACKGROUND

Many low and middle income countries are implementing reforms to support Universal Health Coverage (UHC). Perhaps one of the most ambitious examples of this is Indonesia's national health scheme known as the JKN which is designed to make health care available to its entire population of 255 million by end of 2019. If successful, the JKN will be the biggest single payer system in the world. While Indonesia has made steady progress, around a third of its population remains without cover and out of pocket payments for health are widespread even among JKN members. To help close these gaps, especially among the poor, the Indonesian government is currently implementing a set of UHC policy reforms that include the integration of remaining government insurance schemes into the JKN, expansion of provider networks, restructuring of provider payments systems, accreditation of all contracted health facilities and a range of demand side initiatives to increase insurance uptake, especially in the informal sector. This study evaluates the equity impact of this latest set of UHC reforms.

METHODS

Using a before and after design, we will evaluate the combined effects of the national UHC reforms at baseline (early 2018) and target of JKN full implementation (end 2019) on: progressivity of the health care financing system; pro-poorness of the health care delivery system; levels of catastrophic and impoverishing health expenditure; and self-reported health outcomes. In-depth interviews with stakeholders to document the context and the process of implementing these reforms, will also be undertaken.

DISCUSSION

As countries like Indonesia focus on increasing coverage, it is critically important to ensure that the poor and vulnerable - who are often the most difficult to reach - are not excluded. The results of this study will not only help track Indonesia's progress to universalism but also reveal what the UHC-reforms mean to the poor.

Trends in health inequalities in 27 European countries

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.

Educational inequalities in subjective health in Germany from 1994 to 2014: a trend analysis using the German Socio-Economic Panel study (GSOEP)

INTRODUCTION

As trend studies have shown, health inequalities by income and occupation have widened or remained stable. However, research on time trends in educational inequalities in health in Germany is scarce. The aim of this study is to analyse how educational inequalities in health evolved over a period of 21 years in the middle-aged population in Germany, and whether the trends differ by gender.

METHODS

Data were obtained from the German Socio-Economic Panel covering the period from 1994 to 2014. In total, n=16 339 participants (106 221 person years) aged 30-49 years were included in the study sample. Educational level was measured based on the 'Comparative Analysis of Social Mobility in Industrial Nations' (CASMIN) classification. Health outcomes were self-rated health (SRH) as well as (mental and physical) health-related quality of life (HRQOL, SF-12v2). Absolute Index of Inequality (Slope Index of Inequality (SII)) and Relative Index of Inequality (RII) were calculated using linear and logarithmic regression analyses with robust SEs.

RESULTS

Significant educational inequalities in SRH and physical HRQOL were found for almost every survey year from 1994 to 2014. Relative inequalities in SRH ranged from 1.50 to 2.10 in men and 1.25 to 1.87 in women (RII). Regarding physical HRQOL, the lowest educational group yielded 4.5 to 6.6 points (men) and 3.3 to 6.1 points (women) lower scores (SII). Although educational level increased over time, absolute and relative health inequalities remained largely stable over the last 21 years. For mental HRQOL, only few educational inequalities were found.

DISCUSSION

This study found persistent educational inequalities in SRH and physical HRQOL among adults in Germany from 1994 to 2014. Our findings highlight the need to intensify efforts in social and health policies to tackle these persistent inequalities.

Socioeconomic Inequalities in the Oral Health of People Aged 15-40 Years in Kurdistan, Iran in 2015: A Cross-sectional Study

Objectives

The aim of this study was to evaluate socioeconomic inequalities in the prevalence of dental caries among an urban population.

Methods

This study was conducted among 2000 people 15-40 years of age living in Kurdistan, Iran in 2015. Using a questionnaire, data were collected by 4 trained dental students. The dependent variable was the decayed, missing, and filled teeth (DMF) index. Using principal component analysis, the socioeconomic status (SES) of families was determined based on their household assets. Inequality was measured using the concentration index; in addition, the Oaxaca analytical method was used to determine the contribution of various determinants to the observed inequality.

Results

The concentration index for poor scores on the DMF index was -0.32 (95% confidence interval [CI], -0.40 to -0.36); thus, poor DMF indices had a greater concentration in groups with a low SES (p<0.001). Decomposition analysis showed that the mean prevalence of a poor DMF index was 43.7% (95% CI, 40.4 to 46.9%) in the least privileged group and 14.4% (95% CI, 9.5 to 9.2%) in the most privileged group. It was found that 85.8% of the gap observed between these groups was due to differences in sex, parents' education, and the district of residence. A poor DMF index was less prevalent among people with higher SES than among those with lower SES (odds ratio, 0.31; 95% CI, 0.19 to 0.52).

Conclusions

An alarming degree of SES inequality in oral health status was found in the studied community. Hence, it is suggested that inequalities in oral health status be reduced via adopting appropriate policies such as the delivery of oral health services to poorer groups and covering such services in insurance programs.

Educational differences in psychological distress? Results from a population-based sample of men and women in Sweden in 2012

BACKGROUND

Mental health problems are more frequent in socially disadvantaged groups, but the results vary between different studies, different populations and different measures of mental health. This paper investigated the association between educational level, economic difficulties and psychological distress in men and women in Sweden.

METHODS

The study population included 24 510 respondents aged 25-74 years who responded to a survey questionnaire in Mid-Sweden in 2012 (response rate 53%). Psychological distress was measured with the 12-item version of the General Health Questionnaire, and multivariate logistic regression models were used in statistical analyses, adjusting for age, employment status and social support.

RESULTS

The prevalence of psychological distress was higher in women (16.4%) than in men (11.3%; p<0.001). Persons with low and medium educational level had a lower risk of psychological distress than persons with high educational level after adjustment for confounders. Economic difficulties had a strong association with psychological distress (OR 2.80 (95% CI 2.39 to 3.27) and OR 2.40 (95% CI 2.12 to 3.71) in men and women, respectively) after adjustment for confounders.

CONCLUSION

We found a strong association between economic difficulties and psychological distress in this study, but no inverse association between educational level and psychological distress. On the contrary, persons with high education had more psychological distress than persons with low and medium education when age, employment status and social support were taken into account. The findings were similar in men and women.

Indicators for evaluating European population health: a Delphi selection process

Background

Indicators are essential instruments for monitoring and evaluating population health. The selection of a multidimensional set of indicators should not only reflect the scientific evidence on health outcomes and health determinants, but also the views of health experts and stakeholders. The aim of this study is to describe the Delphi selection process designed to promote agreement on indicators considered relevant to evaluate population health at the European regional level.

Methods

Indicators were selected in a Delphi survey conducted using a web-platform designed to implement and monitor participatory processes. It involved a panel of 51 experts and 30 stakeholders from different areas of knowledge and geographies. In three consecutive rounds the panel indicated their level of agreement or disagreement with indicator’s relevance for evaluating population health in Europe. Inferential statistics were applied to draw conclusions on observed level of agreement (Scott’s Pi interrater reliability coefficient) and opinion change (McNemar Chi-square test). Multivariate analysis of variance was conducted to check if the field of expertise influenced the panellist responses (Wilk’s Lambda test).

Results

The panel participated extensively in the study (overall response rate: 80%). Eighty indicators reached group agreement for selection in the areas of: economic and social environment (12); demographic change (5); lifestyle and health behaviours (8); physical environment (6); built environment (12); healthcare services (11) and health outcomes (26). Higher convergence of group opinion towards agreement on the relevance of indicators was seen for lifestyle and health behaviours, healthcare services, and health outcomes. The panellists’ field of expertise influenced responses: statistically significant differences were found for economic and social environment (p < 0.05 in round 1 and 2), physical environment (p < 0.01 in round 1) and health outcomes (p < 0.01 in round 3).

Conclusions

The high levels of participation observed in this study, by involving experts and stakeholders and ascertaining their views, underpinned the added value of using a transparent Web-Delphi process to promote agreement on what indicators are relevant to appraise population health.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5463-0) contains supplementary material, which is available to authorized users.

Cohort profile: the Italian Network of Longitudinal Metropolitan Studies (IN-LiMeS), a multicentre cohort for socioeconomic inequalities in health monitoring

PURPOSE

The Italian Network of Longitudinal Metropolitan Studies (IN-LiMeS) is a system of integrated data on health outcomes, demographic and socioeconomic information, and represents a powerful tool to study health inequalities.

PARTICIPANTS

IN-LiMeS is a multicentre and multipurpose pool of metropolitan population cohorts enrolled in nine Italian cities: Turin, Venice, Reggio Emilia, Modena, Bologna, Florence, Leghorn, Prato and Rome. Data come from record linkage of municipal population registries, the 2001 population census, mortality registers and hospital discharge archives. Depending on the source of enrolment, cohorts can be closed or open. The census-based closed cohort design includes subjects resident in any of the nine cities at the 2001 census day; 4 466 655 individuals were enrolled in 2001 in the nine closed cohorts. The open cohort design includes subjects resident in 2001 or subsequently registered by birth or immigration until the latest available follow-up (currently 31 December 2013). The open cohort design is available for Turin, Venice, Reggio Emilia, Modena, Bologna, Prato and Rome. Detailed socioeconomic data are available for subjects enrolled in the census-based cohorts; information on demographic characteristics, education and citizenship is available from population registries.

FINDINGS TO DATE

The first IN-LiMeS application was the study of differentials in mortality between immigrants and Italians. Either using a closed cohort design (nine cities) or an open one (Turin and Reggio Emilia), individuals from high migration pressure countries generally showed a lower mortality risk. However, a certain heterogeneity between the nine cities was noted, especially among men, and an excess mortality risk was reported for some macroareas of origin and specific causes of death.

FUTURE PLANS

We are currently working on the linkage of the 2011 population census data, the expansion of geographical coverage and the implementation of the open design in all the participating cohorts.

Post-millennial trends of socioeconomic inequalities in chronic illness among adults in Germany

Objective

Time trends in health inequalities have scarcely been studied in Germany as only few national data have been available. In this paper, we explore trends in socioeconomic inequalities in the prevalence of chronic illness using Germany-wide data from four cross-sectional health surveys conducted between 2003 and 2012 (n = 54,197; ages 25–69 years). We thereby expand a prior analysis on post-millennial inequality trends in behavioural risk factors by turning the focus to chronic illness as the outcome measure. The regression-based slope index of inequality (SII) and relative index of inequality (RII) were calculated to estimate the extent of absolute and relative socioeconomic inequalities in chronic illness, respectively.

Results

The results for men revealed a significant increase in the extent of socioeconomic inequalities in chronic illness between 2003 and 2012 on both the absolute and relative scales (SII₂₀₀₃ = 0.06, SII₂₀₁₂ = 0.17, p-trend = 0.013; RII₂₀₀₃ = 1.18, RII₂₀₁₂ = 1.57, p-trend = 0.013). In women, similar increases in socioeconomic inequalities in chronic illness were found (SII₂₀₀₃ = 0.05, SII₂₀₁₂ = 0.14, p-trend = 0.022; RII₂₀₀₃ = 1.14, RII₂₀₁₂ = 1.40, p-trend = 0.021). Whereas in men this trend was driven by an increasing prevalence of chronic illness in the low socioeconomic group, the trend in women was predominantly the result of a declining prevalence in the high socioeconomic group.

Health inequalities in Germany and in international comparison: trends and developments over time

Social epidemiological research has consistently demonstrated that people with a low socioeconomic status are particularly at risk of diseases, health complaints and functional limitations, and die at younger ages than those with a higher socioeconomic status. Greater stresses and strains in the workplace, family and living environment are under discussion as possible explanations. Health-related behaviours, psycho-social factors and personal resources, which are important in coping with everyday demands, certainly also play a role. From a public health and health policy perspective, reducing these health inequalities is an important goal. Insights into developments and trends in health inequalities over time can contribute towards highlighting new and emerging problems, and can thus help identify possible target groups and settings for relevant interventions. At the same time, these insights provide a basis upon which the success of policies and programmes that have already been implemented can be analysed and measured. Against this background, this review examines how health inequalities in Germany have developed over the last 20 to 30 years and places its findings within the context of the latest international research in this field.

Welfare states, the Great Recession and health: Trends in educational inequalities in self-reported health in 26 European countries

BACKGROUND

Although socioeconomic inequalities in health have long been observed in Europe, few studies have analysed their recent patterning. In this paper, we examined how educational inequalities in self-reported health have evolved in different European countries and welfare state regimes over the last decade, which was troubled by the Great Recession.

METHODS

We used cross-sectional data from the EU-SILC survey for adults from 26 European countries, from 2005 to 2014 (n = 3,030,595). We first calculated education-related absolute (SII) and relative (RII) inequalities in poor self-reported health by country-year, adjusting for age, sex, and EU-SILC survey weights. We then regressed the year- and country-specific RII and SII on a yearly time trend, globally and by welfare regime, adjusting for country fixed effects. We further adjusted the analysis for the economic cycle using GDP growth, unemployment, and income inequality.

RESULTS

Overall, absolute inequalities persisted and relative inequalities slightly widened (betaRII = 0.0313, p<0.05). There were substantial differences by welfare regime: Anglo-Saxon countries experienced the largest increase in absolute inequalities (betaSII = 0.0032, p<0.05), followed by Bismarkian countries (betaSII = 0.0024, p<0.001), while they reduced in Post-Communist countries (betaSII = -0.0022, p<0.001). Post-Communist countries also experienced a widening in relative inequalities (betaRII = 0.1112, p<0.001), which were found to be stable elsewhere. Adjustment for income inequality only explained such trend in Anglo-Saxon countries.

CONCLUSIONS

Educational inequalities in health have overall persisted across European countries over the last decade. However, there is considerable variation across welfare regimes, possibly related to underpinning social safety nets and to austerity measures implemented during this 10-year period.

The social determinants of inequalities in self-reported health in Europe: findings from the European social survey (2014) special module on the social determinants of health

Background

Health inequalities persist between and within European countries. Such inequalities are usually explained by health behaviours and according to the conditions in which people work and live. However, little is known about the relative contribution of these factors to health inequalities in European countries. This paper aims to investigate the independent and joint contribution of a comprehensive set of behavioural, occupational and living conditions factors in explaining social inequalities in self-rated health (SRH).

Method

Data from 21 countries was obtained from the 2014 European Social Survey and examined for respondents aged 25-75. Adjusted rate differences (ARD) and adjusted rate risks (ARR), generated from binary logistic regression models, were used to measure health inequalities in SRH and the contribution of behavioural, occupational and living conditions factors.

Result

Absolute and relative inequalities in SRH were found in all countries and the magnitude of socio-economic inequalities varied considerably between countries. While factors were found to differentially contribute to the explanation of educational inequalities in different European countries, occupational and living conditions factors emerged as the leading causes of inequalities across most of the countries, contributing both independently and jointly with behavioural factors.

Conclusion

The observed shared effects of different factors to health inequalities points to the interdependent nature of occupational, behavioural and living conditions factors. Tackling health inequalities should be a concentred effort that goes beyond interventions focused on single factors.

Revisiting the Link Between Depression Symptoms and High School Dropout: Timing of Exposure Matters

PURPOSE

Recent reviews concluded that past depression symptoms are not independently associated with high school dropout, a conclusion that could induce schools with high dropout rates and limited resources to consider depression screening, prevention, and treatment as low-priority. Even if past symptoms are not associated with dropout, however, it is possible that recent symptoms are. The goal of this study was to examine this hypothesis.

METHODS

In 12 disadvantaged high schools in Montreal (Canada), all students at least 14 years of age were first screened between 2012 and 2015 (N_screened = 6,773). Students who dropped out of school afterward (according to school records) were then invited for interviews about their mental health in the past year. Also interviewed were matched controls with similar risk profiles but who remained in school, along with average not at-risk schoolmates (N_interviewed = 545). Interviews were conducted by trained graduate students.

RESULTS

Almost one dropout out of four had clinically significant depressive symptoms in the 3 months before leaving school. Adolescents with recent symptoms had an odd of dropping out more than twice as high as their peers without such symptoms (adjusted odds ratio = 2.17; 95% confidence interval = 1.14-4.12). In line with previous findings, adolescents who had recovered from earlier symptoms were not particularly at risk.

CONCLUSIONS

These findings suggest that to improve disadvantaged youths' educational outcomes, investments in comprehensive mental health services are needed in schools struggling with high dropout rates, the very places where adolescents with unmet mental health needs tend to concentrate.

Educational inequalities in late-life depression across Europe: results from the generations and gender survey

This study explores country- and gender-stratified educational differences in depression among older adults from 10 European countries. We examine inequalities in both absolute (prevalence differences) and relative (odds ratios) terms and in bivariate and multivariate models. We use cross-sectional, nationally representative data from the generations and gender survey. The analysis comprises 27,331 Europeans aged 60-80. Depression is measured with a seven-item version of the Center for Epidemiologic Studies Depression scale. Findings show considerable between-country heterogeneity in late-life depression. An East-West gradient is evident, with rates of depression up to three times higher in Eastern European than in Scandinavian countries. Rates are about twice as high among women than men in all countries. Findings reveal marked absolute educational gaps in depression in all countries, yet the gaps are larger in weaker welfare states. This pattern is less pronounced for the relative inequalities, especially for women. Some countries observe similar relative inequalities but vastly different absolute inequalities. We argue that the absolute differences are more important for social policy development and evaluation. Educational gradients in depression are strongly mediated by individual-level health and financial variables. Socioeconomic variation in late-life depression is greater in countries with poorer economic development and welfare programs.

Occupational class differences in diagnostic-specific sickness absence: a register-based study in the Finnish population, 2005-2014

BACKGROUND

Musculoskeletal diseases and mental disorders are major causes of long-term sickness absence in Western countries. Although sickness absence is generally more common in lower occupational classes, little is known about class differences in diagnostic-specific absence over time. Focusing on Finland during 2005-2014, we therefore set out to examine the magnitude of and changes in absolute and relative occupational class differences in long-term sickness absence due to major diagnostic causes.

METHODS

A 70-per-cent random sample of Finns aged 25-64 linked to register data on medically certified sickness absence (of over 10 working days) in 2005-2014 was retrieved from the Social Insurance Institution of Finland. Information on occupational class was obtained from Statistics Finland and linked to the data. The study focused on female (n = 658,148-694,142) and male (n = 604,715-642,922) upper and lower non-manual employees and manual workers. The age-standardised prevalence, the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII) were calculated for each study year to facilitate examination of the class differences.

RESULTS

The prevalence of each diagnostic cause of sickness absence declined during the study period, the most common causes being musculoskeletal diseases, mental disorders and injuries. The prevalence of other causes under scrutiny was less than 1 % annually. By far the largest absolute and relative differences were in musculoskeletal diseases among both women and men. Moreover, the absolute differences in both genders (p < 0.0001) and the relative differences in men (p < 0.0001) narrowed over time as the prevalence declined most among manual workers. Both genders showed modest and stable occupational class differences in mental disorders. In the case of injuries, no major changes occurred in absolute differences but relative differences narrowed over time in men (p < 0.0001) due to a strong decline in prevalence among manual workers. Class differences in the other studied diagnostic causes under scrutiny appeared negligible.

CONCLUSIONS

By far the largest occupational class differences in long-term sickness absence concerned musculoskeletal diseases, followed by injuries. The results highlight potential targets for preventive measures aimed at reducing sickness absence and narrowing class differences in the future.

"Evolution and financial cost of socioeconomic inequalities in ambulatory care sensitive conditions: an ecological study for Portugal, 2000-2014"

BACKGROUND

Hospitalizations for Ambulatory Care Sensitive Conditions (ACSC) are specific conditions for which hospitalization is thought to be avoidable through patient education, health promotion initiatives, early diagnosis and by appropriate chronic disease management, and have been shown to be greatly influenced by socioeconomic (SE) characteristics. We examined the SE inequalities in hospitalization rates for ACSC in Portugal, their evolution over time (2000-2014), and their associated financial burden.

METHODS

We modeled municipality-level ACSC hospitalization rates per 1000 inhabitants and ACSC hospitalization-related costs per inhabitant, for the 2000-2014 period (n = 4170), as a function of SE indicators (illiteracy and purchasing power, in quintiles), controlling for the proportion of elderly, sex, disease specific mortality rate, population density, PC supply, and time trend. The evolution of inequalities was measured interacting SE indicators with a time trend. Costs attributable to ACSC related hospitalization inequalities were measured by the predicted values for each quintile of the SE indicators.

RESULTS

Hospitalization rate for ACSC was significantly higher in the 4th quintile of illiteracy compared with the 1st quintile (beta = 1.97; p < 0.01), and significantly lower in the 5th quintile of purchasing power, compared with the 1st quintile (beta = - 1.19; p < 0.05). ACSC hospitalization-related costs were also significantly higher in the 4th quintile of illiteracy compared with the 1st quintile (beta = 4.04€; p < 0.05), and significantly lower in the 5th quintile of purchasing power, compared with the 1st quintile (beta = - 4,69€; p < 0.01). The SE gradient significantly increased over the 2000-2014 period, and the annual cost of inequalities were estimated at more than 15 million euros for the Portuguese NHS.

CONCLUSION

There was an increasing SE patterning in ACSC related hospitalizations, possibly reflecting increasing SE inequalities in early and preventive high-quality care, imposing a substantial financial burden to the Portuguese NHS.

Temporal changes in health within 5 years before and after disability pension-the HUNT Study

Background

Health status has been reported to change before, during and after disability pension receipt. These associations might be subject to temporal changes according to changes in policy, incidence of disability pensions and other contextual factors. We compared the perceived health around time of disability retirement among persons receiving disability pension in the 1990 s and 2000 s in Norway.

Methods

We linked data from two consecutive cross-sectional population based Norwegian health surveys, HUNT2 (1995-97) and HUNT3 (2006-08), to national registries, identifying those who received disability pension within 5 years before or after participation in the survey (HUNT2: n = 5362, HUNT3: n = 4649). We used logistic regression to assess associations of time from receiving a disability pension with self-rated health, insomnia, depression and anxiety symptoms and subsequently estimated adjusted prevalence over time.

Results

Prevalence of poor self-rated health peaked around time of receiving disability pension in both decades. For those aged 50+, prevalence the year before disability pension was slightly lower in 2006-08 (74%, 95% CI 70-79%) than in 1995-97 (83%, 95% CI 79-87%), whereas peak prevalence was similar between surveys for those younger than 50. Depression symptoms peaked more pronouncedly in 1995-97 than in 2006-08, whereas prevalence of anxiety symptoms was similar at time of receiving disability pension between surveys.

Conclusions

We found no strong evidence of differences in health selection to disability pension in the 2000 s compared to the 1990 s. However, we found indication of less depression symptoms around time of disability pension in the 2000 s compared to the 1990 s.

Trends in educational inequalities in obesity in 15 European countries between 1990 and 2010

BACKGROUND

The prevalence of obesity increased dramatically in many European countries in the past decades. Whether the increase occurred to the same extent in all socioeconomic groups is less known. We systematically assessed and compared the trends in educational inequalities in obesity in 15 different European countries between 1990 and 2010.

METHODS

Nationally representative survey data from 15 European countries were harmonized and used in a meta-regression of trends in prevalence and educational inequalities in obesity between 1990 and 2010. Educational inequalities were estimated by means of absolute rate differences and relative rate ratios in men and women aged 30-64 years.

RESULTS

A statistically significant increase in the prevalence of obesity was found for all countries, except for Ireland (among men) and for France, Hungary, Italy and Poland (among women). Meta-regressions showed a statistically significant overall increase in absolute inequalities of 0.11% points [95% CI 0.03, 0.20] per year among men and 0.12% points [95% CI 0.04, 0.20] per year among women. Relative inequalities did not significantly change over time in most countries. A significant reduction of relative inequalities was found among Austrian and Italian women.

CONCLUSION

The increase in the overall prevalence aligned with a widening of absolute but not of relative inequalities in obesity in many European countries over the past two decades. Our findings urge for a further understanding of the drivers of the increase in obesity in lower education groups particularly, and an equity perspective in population-based obesity prevention strategies.

Impact of marital status and comorbid disorders on health-related quality of life after cardiac surgery

PURPOSE

To explore associations between HRQL, marital status, and comorbid disorders in men and women following cardiac surgery.

METHOD

A secondary analysis was completed using data from a randomized controlled trial in which 416 individuals (23% women) scheduled for elective coronary artery bypass graft and/or valve surgery were recruited between March 2012 and September 2013. HRQL was assessed using the Health State Descriptive System (15D) preoperatively, then at 2 weeks, and at 3, 6, and 12 months following cardiac surgery. Linear mixed model analyses were performed to explore associations between HRQL, social support, and comorbid disorders.

RESULTS

The overall 15D scores for the total sample improved significantly from 2 weeks to 3 months post surgery, with only a gradual change observed from 3 to 12 months. Thirty percent (n = 92) of the total sample reported a lower 15D total score at 12 months compared to preoperative status, of whom 78% (n = 71) had a negative minimum important differences (MID), indicating a worse HRQL status. When adjusted for age and marital status, women had statistically significant lower 15D total scores compared to men at 3, 6, and 12 months post surgery. Compared to pre-surgery, improvement was demonstrated in 4 out of 15 dimensions of HRQL for women, and in 6 out of 15 dimensions for men at 12 months post surgery. Both men and women associated back/neck problems, depression, and persistent pain intensity with lower HRQL; for women, not living with a partner/spouse was associated with lower HRQL up to 12 months.

CONCLUSION

Women experienced decreased HRQL and a slower first-year recovery following cardiac surgery compared to men. This study demonstrates a need for follow-up and support to help women manage their symptoms and improve their function within the first year after cardiac surgery. This was particularly pronounced for those women living alone.

Social inequalities in self-rated health in Ukraine in 2007: the role of psychosocial, material and behavioural factors

Background

Despite Ukraine's large population, few studies have examined social inequalities in health. This study describes Ukrainian educational inequalities in self-rated health and assesses how far psychosocial, material and behavioural factors account for the education gradient in health.

Methods

Data were analyzed from the 2007 wave of the Ukrainian Longitudinal Monitoring Survey. Education was categorized as: lower secondary or less, upper secondary and tertiary. In logistic regressions of 5451 complete cases, stratified by gender, declaring less than average health was regressed on education, before and after adjusting for psychosocial, material and behavioural factors.

Results

In analyses adjusted for socio-demographic characteristics, compared with those educated up to lower secondary level, tertiary education was associated with lower risk of less than average health for both men and women. Including material factors (income quintiles, housing assets, labour market status) reduced the association between education and health by 55-64% in men and 35-47% in women. Inclusion of health behaviours (physical activity, smoking, alcohol consumption and body mass index) reduced the associations by 27-30% in men and 19-27% in women; in most cases including psychosocial factors (marital status, living alone, trust in family and friends) did not reduce the size of the associations. Including all potential explanatory factors reduced the associations by 68-84% in men and 43-60% in women.

Conclusions

The education gradient in self-rated health in Ukraine was partly accounted for by material and behavioural factors. In addition to health behaviours, policymakers should consider upstream determinants of health inequalities, such as joblessness and poverty.

Differences in healthy life expectancy between older migrants and non-migrants in three European countries over time

OBJECTIVES

We analysed differences in healthy life expectancy at age 50 (HLE₅₀) between migrants and non-migrants in Belgium , the Netherlands, and England and Wales, and their trends over time between 2001 and 2011 in the latter two countries.

METHODS

Population, mortality and health data were derived from registers, census or surveys. HLE₅₀ and the share of remaining healthy life years were calculated for non-migrants, western and non-western migrants by sex. We applied decomposition techniques to answer whether differences in HLE₅₀ between origin groups and changes in HLE₅₀ over time were attributable to either differences in mortality or health.

RESULTS

In all three countries, older (non-western) migrants could expect to live less years in good health than older non-migrants. Differences in HLE₅₀ between migrants and non-migrants diminished over time in the Netherlands, but they increased in England and Wales. General health, rather than mortality, mainly explained (trends in) inequalities in healthy life expectancy between migrants and non-migrants.

CONCLUSIONS

Interventions aimed at reducing the health and mortality inequalities between older migrants and non-migrants should focus on prevention, and target especially non-western migrants.

Univariate predictors of maternal concentrations of environmental chemicals: The MIREC study

BACKGROUND

The developing fetus and pregnant woman can be exposed to a variety of environmental chemicals that may adversely affect their health. Moreover, environmental exposure and risk disparities are associated with different social determinants, including socioeconomic status (SES) and demographic indicators. Our aim was to investigate whether and how maternal concentrations of a large panel of persistent and non-persistent environmental chemicals vary according to sociodemographic and lifestyle characteristics in a large pregnancy and birth cohort.

METHODS

Data were analyzed from the Maternal-Infant Research on Environmental Chemicals (MIREC) Study, a cohort of pregnant women (N=2001) recruited over four years (2008-2011) in 10 cities across Canada. In all, 1890 urine and 1938 blood samples from the first trimester (1st and 3rd trimester for metals) were analysed and six sociodemographic and lifestyle indicators were assessed: maternal age, household income, parity, smoking status, country of birth and pre-pregnancy body mass index (BMI).

RESULTS

We found these indicators to be significantly associated with many of the chemicals measured in maternal blood and urine. Women born outside Canada had significantly higher concentrations of di-2-ethylhexyl and diethyl phthalate metabolites, higher levels of all metals except cadmium (Cd), as well as higher levels of polychlorinated biphenyls (PCBs) and legacy organochlorine pesticides (OCPs). Nulliparity was associated with higher concentrations of dialkyl phosphates (DAPs), arsenic, dimethylarsinic acid (DMAA), perfluoroalkyl substances (PFASs) and many of the persistent organic pollutants. Smokers had higher levels of bisphenol A, Cd and perfluorohexane sulfonate, while those women who had never smoked had higher levels of triclosan, DMAA, manganese and some OCPs.

CONCLUSION

Our results demonstrated that inequitable distribution of exposure to chemicals among populations within a country can occur. Sociodemographic and lifestyle factors are an important component of a thorough risk assessment as they can impact the degree of exposure and may modify the individual's susceptibility to potential health effects due to differences in lifestyle, cultural diets, and aging.

Trends in self-rated health and association with socioeconomic position in Estonia: data from cross-sectional studies in 1996-2014

Background

Self-rated health (SRH) and socioeconomic position (SEP) as important determinants of health differences are associated with health and economic changes in society.

The objectives of this paper were (1) to describe trends in SRH and (2) to analyze associations between SRH and SEP among adults in Estonia in 1996–2014.

Methods

The study was based on a 25–64-year-old subsample (n = 18757) of postal cross-sectional surveys conducted every second year in Estonia during 1990–2014. SRH was measured using five-point scale and was dichotomized to good and less-than-good. Standardized prevalence of SRH was calculated for each study year. Poisson regression with likelihood ratio test was performed for testing trends of SRH over study years. Age, nationality, marital status, education, work status and income were used to determine SEP. Logistic regression analysis was used to assess association between SRH and SEP.

Results

The prevalence of dichotomized good self-rated health increased significantly over the whole study period with slight decrease in 2008–2010. Until 2002, good SRH was slightly more prevalent among men, but after that, among women. Good SRH was significantly associated with younger age, higher education and income and also with employment status among both, men and women. Good SRH was more prevalent among Estonian women and less prevalent among single men.

Conclusions

There was a definite increase of good SRH over two decades in Estonia following economic downturn between 2008 and 2010. Good SRH was associated with higher SEP over the study period. Further research is required to study the possible reasons behind increase of good SRH, and it’s association with SEP among adults in Estonia.

Did the English strategy reduce inequalities in health? A difference-in-difference analysis comparing England with three other European countries

BACKGROUND

Between 1997 and 2010, the English government pursued an ambitious programme to reduce health inequalities, the explicit and sustained commitment of which was historically and internationally unique. Previous evaluations have produced mixed results. None of these evaluations have, however, compared the trends in health inequalities within England with those in other European countries. We carried out an innovative analysis to assess whether changes in trends in health inequalities observed in England after the implementation of its programme, have been more favourable than those in other countries without such a programme.

METHODS

Data were obtained from nationally representative surveys carried out in England, Finland, the Netherlands and Italy for years around 1990, 2000 and 2010. A modified difference-in-difference approach was used to assess whether trends in health inequalities in 2000-2010 were more favourable as compared to the period 1990-2000 in England, and the changes in trends in inequalities after 2000 in England were then compared to those in the three comparison countries. Health outcomes were self-assessed health, long-standing health problems, smoking status and obesity. Education was used as indicator of socioeconomic position.

RESULTS

After the implementation of the English strategy, more favourable trends in some health indicators were observed among low-educated people, but trends in health inequalities in 2000-2010 in England were not more favourable than those observed in the period 1990-2000. For most health indicators, changes in trends of health inequalities after 2000 in England were also not significantly different from those seen in the other countries.

CONCLUSIONS

In this rigorous analysis comparing trends in health inequalities in England both over time and between countries, we could not detect a favourable effect of the English strategy. Our analysis illustrates the usefulness of a modified difference-in-difference approach for assessing the impact of policies on population-level health inequalities.

Socioeconomic gradient in health in Canada: Is the gap widening or narrowing?

BACKGROUND

Notwithstanding a general improvement in health status, the socioeconomic gradient in health remains a public health challenge worldwide.

OBJECTIVE

Using longitudinal data from the National Population Health Survey (NPHS, n=17,276), we examined trends in socioeconomic gradients in two health indicators, viz. the Health Utility Index (HUI) and the Frailty Index (FI), among Canadian adults (25 years and older) between 1998/9-2010/11.

METHODS

The relative and slope indices of inequality (RII and SII, respectively) were employed to summarize income- and education-based inequality in the FI and the HUI in Canada as whole, and in five regions: the Atlantic provinces, Quebec, Ontario, the Prairies and British Columbia.

RESULTS

We found that education- and income-related inequalities in health were present in all five regions of Canada. The estimated RIIs and SIIs suggested that education-related inequalities in the FI and the HUI increased among women. The results also revealed that relative and absolute income-related inequalities in the HUI increased in Canada, especially among women. Both absolute and relative inequalities indicated that income-related inequalities in the HUI increased in Quebec and in the Prairies over time.

CONCLUSION

Persistent and growing socioeconomic inequalities in health in Canada over the past one and half decades should warrant more attention. The mechanisms underlying socioeconomic-related inequalities in Canada are less clear. Therefore, further studies are required to identify effective polices to reduce the socioeconomic gradient in health in Canada.