Have regional inequalities in life expectancy widened within the European Union between 1991 and 2008?

Life expectancy and geographic variation in mortality: an observational comparison study of six high-income Anglophone countries

OBJECTIVE

To compare life expectancy levels and within-country geographic variation in life expectancy across six high-income Anglophone countries between 1990 and 2018.

DESIGN

Demographic analysis using aggregated mortality data.

SETTING

Six high-income Anglophone countries (USA, UK, Canada, Australia, Ireland and New Zealand), by sex, including an analysis of subnational geographic inequality in mortality within each country.

POPULATION

Data come from the Human Mortality Database, the WHO Mortality Database and the vital statistics agencies of six high-income Anglophone countries.

MAIN OUTCOME MEASURES

Life expectancy at birth and age 65; age and cause of death contributions to life expectancy differences between countries; index of dissimilarity for within-country geographic variation in mortality.

RESULTS

Among six high-income Anglophone countries, Australia is the clear best performer in life expectancy at birth, leading its peer countries by 1.26-3.95 years for women and by 0.97-4.88 years for men in 2018. While Australians experience lower mortality across the age range, most of their life expectancy advantage accrues between ages 45 and 84. Australia performs particularly well in terms of mortality from external causes (including drug- and alcohol-related deaths), screenable/treatable cancers, cardiovascular disease and influenza/pneumonia and other respiratory diseases compared with other countries. Considering life expectancy differences across geographic regions within each country, Australia tends to experience the lowest levels of inequality, while Ireland, New Zealand and the USA tend to experience the highest levels.

CONCLUSIONS

Australia has achieved the highest life expectancy among Anglophone countries and tends to rank well in international comparisons of life expectancy overall. It serves as a potential model for lower-performing countries to follow to reduce premature mortality and inequalities in life expectancy.

Epidemiology and demographic patterns of cardiovascular diseases and neoplasms deaths in Western Europe: a 1990-2019 analysis

OBJECTIVES

Cardiovascular diseases (CVDs) and neoplasms have been considered as public health concerns worldwide. This study aimed to estimate the epidemiological patterns of death burden on CVDs and neoplasms and its attributable risk factors in Western Europe from 1990 to 2019 to discuss the potential causes of the disparities.

STUDY DESIGN AND METHODS

We collected data on CVDs and neoplasms deaths in 24 Western European countries from the Global Burden of Disease Study. We analyzed patterns by age, sex, country, and associated risk factors. The results include percentages of total deaths, age-standardized death rates per 100,000 population, and uncertainty intervals (UIs). Time trends were assessed using annual percent change.

RESULTS

In 2019, CVDs and neoplasms accounted for 33.54% and 30.15% of Western Europe's total deaths, with age-standardized death rates of 128.05 (95% UI: 135.37, 113.02) and 137.51 (95% UI: 142.54, 128.01) per 100,000. Over 1990-2019, CVDs rates decreased by 54.97%, and neoplasms rates decreased by 19.54%. Top CVDs subtypes were ischemic heart disease and stroke; top cancers for neoplasms were lung and colorectal. Highest CVD death burdens were in Finland, Greece, Austria; neoplasm burdens in Monaco, San Marino, Andorra. The major risk factors were metabolic (CVDs) and behavioral (neoplasms). Gender differences revealed higher CVDs death burden in males, while neoplasms burden varied by risk factors and age groups.

CONCLUSION

In 2019, CVDs and neoplasms posed significant health risks in Western Europe, with variations in death burdens and risk factors across genders, age groups, and countries. Future interventions should target vulnerable groups to lessen the impact of CVDs and neoplasms in the region.

Population health differences in cross-border regions within the European Union and Schengen area: a protocol for a scoping review

INTRODUCTION

Along with European integration and the harmonisation of living conditions, improvements in health have been observed over the past decades. However, sociospatial inequalities within and across member states still exist today. While drivers of these health inequalities have been widely researched on a national and regional scale, cross-border regions remain understudied. The removal of border controls within the European Union (EU) member states has facilitated economic convergence and created new opportunities, including cross-border cooperation in the healthcare systems. However, whether and how these developments have influenced the population health in the respective cross-border regions is unclear. Hence, this scoping review aims to examine the empirical literature on the changes in health outcomes over time at the population level in EU cross-border areas. Additionally, we aim to identify the type of evidence and available data sources in those studies. Finally, we will determine the research gaps in the literature.

METHODS AND ANALYSIS

We will follow the Joanna Briggs Institute methodology for this scoping review. The 'Population-Concept-Context' framework will be used to identify the eligibility criteria. A three-step search strategy will be conducted to find relevant studies in the databases of PubMed, Web of Science, Scopus and EBSCOhost (SocIndex). Additionally, we will search on websites of international governmental institutions for further reports and articles. The finalisation of the search is planned for August 2023. The extracted data from the scoping review will be presented in a tabular form. A narrative summary of the selected studies will accompany the tabulated results and describe how they answer the research questions.

ETHICS AND DISSEMINATION

We will exclusively use secondary data from available studies for our analysis. Therefore, this review does not require ethical approval. We aim to publish our findings at (inter-)national conferences and as an open-access, peer-reviewed journal article.

Inequalities in the burden of non-communicable diseases across European countries: a systematic analysis of the Global Burden of Disease 2019 study

BACKGROUND

Although overall health status in the last decades improved, health inequalities due to non-communicable diseases (NCDs) persist between and within European countries. There is a lack of studies giving insights into health inequalities related to NCDs in the European Economic Area (EEA) countries. Therefore, the aim of the present study was to quantify health inequalities in age-standardized disability adjusted life years (DALY) rates for NCDs overall and 12 specific NCDs across 30 EEA countries between 1990 and 2019. Also, this study aimed to determine trends in health inequalities and to identify those NCDs where the inequalities were the highest.

METHODS

DALY rate ratios were calculated to determine and compare inequalities between the 30 EEA countries, by sex, and across time. Annual rate of change was used to determine the differences in DALY rate between 1990 and 2019 for males and females. The Gini Coefficient (GC) was used to measure the DALY rate inequalities across countries, and the Slope Index of Inequality (SII) to estimate the average absolute difference in DALY rate across countries.

RESULTS

Between 1990 and 2019, there was an overall declining trend in DALY rate, with larger declines among females compared to males. Among EEA countries, in 2019 the highest NCD DALY rate for both sexes were observed for Bulgaria. For the whole period, the highest DALY rate ratios were identified for digestive diseases, diabetes and kidney diseases, substance use disorders, cardiovascular diseases (CVD), and chronic respiratory diseases - representing the highest inequality between countries. In 2019, the highest DALY rate ratio was found between Bulgaria and Iceland for males. GC and SII indicated that the highest inequalities were due to CVD for most of the study period - however, overall levels of inequality were low.

CONCLUSIONS

The inequality in level 1 NCDs DALYs rate is relatively low among all the countries. CVDs, digestive diseases, diabetes and kidney diseases, substance use disorders, and chronic respiratory diseases are the NCDs that exhibit higher levels of inequality across countries in the EEA. This might be mitigated by applying tailored preventive measures and enabling healthcare access.

Disparities in premature mortality: Evidence for the OECD countries

This paper studies the existence of international health outcome disparities. We focus on the use of the potential years of life lost for a database that includes information from 33 OECD countries and covers the period 1990-2017. The methodology proposed by Phillips and Sul (2007) allows us to reject the existence of a single pattern of behaviour between countries for both males and females, suggesting the existence of severe health outcome inequalities. This methodology estimates the existence of four convergence clubs whose composition slightly varies when comparing the male and female cases. Some socioeconomic factors are found to be very important in explaining the forces that may drive the creation of these convergence clubs. In particular, the evolution of the economy and health policies are pivotal to understanding the creation of these estimated convergence clubs. Additionally, our results offer evidence in favor of the importance of environmental policies to explain these health outcome differences.

Emergence of a mortality disparity between a marginal rural area and the rest of Denmark, 1968-2017

BACKGROUND

Lolland-Falster is a rural area of Denmark, where the life expectancy is presently almost six years lower than in the rich capital suburbs. To determine the origin of this disparity, we analysed changes in mortality during 50 years in Lolland-Falster.

METHODS

Annual population number and number of deaths at municipality level were retrieved from StatBank Denmark and from Statistics Denmark publications, 1968-2017. For 1974-2017, life expectancy at birth by sex and 5-year calendar period was calculated. From 1968 to 2017, standardised mortality ratio (SMR) for all-cause mortality was calculated by sex, 5-year calendar period and municipality, with Denmark as standard and including 95% confidence intervals (CI).

RESULTS

In 1968-2017, life expectancy in Lolland-Falster increased, but less so than in the rest of Denmark. Fifty years ago, Lolland-Falster had a mortality similar to the rest of Denmark. The increasing mortality disparity developed gradually starting in the late 1980s, earlier in Lolland municipality (western part) than in Guldborgsund municipality (eastern part), and earlier for men than for women. By 2013-2017, the SMR had reached 1.25 (95% CI 1.19-1.31) for men in the western part, and 1.11 (95% CI 1.08-1.16) for women in the eastern part. Increasing mortality disparity was particularly seen in people aged 20-69 years.

CONCLUSIONS

This study is the first to report on increasing geographical segregation in all-cause mortality in a Nordic welfare state. Development of the mortality disparity between Lolland-Falster and the rest of Denmark followed changes in agriculture, industrial company closure, a shipyard close-down, administrative centralisation, and a decreasing population size.

Mortality convergence in the enlarged European Union: a systematic literature review

Background

The high mortality rates in the European Union (EU) Member States that acceded in 2004 sparked political interest in mortality convergence. Whether mortality is converging in the EU remains unclear. We reviewed the literature on mortality convergence in the post-2004 EU territory as a whole. We also explored whether the study designs influenced the results and whether any determinants of mortality convergence had been empirically examined.

Methods

A systematic literature review was performed. Our search included scientific databases and the websites of international governmental institutions and European demographic research institutes.

Results

We uncovered 94 unique records and included seven studies that reported on 36 analyses. There was marked methodological heterogeneity, including in the convergence measures (beta and sigma convergence). All of the beta convergence analyses found narrowing mortality differentials, whereas most of the sigma convergence analyses found widening mortality differentials. The results are robust to the units of analysis and mortality and dispersion measures. Our results also suggest that there is a lack of evidence on the determinants of mortality convergence in the EU.

Conclusions

There is general agreement that the EU regions and the Member States with high initial mortality rates improved the fastest, but this trend did not lead to overall mortality convergence in the EU. The harmonization of mortality convergence measures and research into determinants of mortality convergence are needed to support future EU cohesion policy. Policy-makers should consider supporting areas that have moderate but stagnant mortality rates, in addition to those with high mortality rates.

Reducing socioeconomic inequalities in life expectancy among municipalities: the Brazilian experience

OBJECTIVES

This study analyzed the evolution of regional and socioeconomic inequality in life expectancy (LE) at birth and the probability of living up to 40 (LU40) and up to 60 years of age (LU60) in Brazilian municipalities between 1991 and 2010.

METHODS

We analyzed data from the last three national census (1991, 2000 and 2010) computed for the 5565 Brazilian municipalities. They were divided into centiles according to the average per capita income. Poisson regression was performed to calculate the ratios between the poorest and the richest centiles.

RESULTS

The average LE (+ 8.8 years), LU40 [6.7 percentage points (pp)] and LU60 increased (12.2 pp) between 1991 and 2010. The ratio of LE between the 1% of richest counties and the 1% of poorest counties decreased from 1.20 in 1991 to 1.09 in 2010. While in the poorest municipalities there was a gain of around 12 years of life, among the richest this increase was around 7 years.

CONCLUSIONS

There was a remarkable decrease in regional and socioeconomic inequality in LE, LU40 and LU60 in Brazil between 1991 and 2010.

Deprivation-specific life tables using multivariable flexible modelling - trends from 2000-2002 to 2010-2012, Portugal

BACKGROUND

Completing mortality data by information on possible socioeconomic inequalities in mortality is crucial for policy planning. The aim of this study was to build deprivation-specific life tables using the Portuguese version of the European Deprivation Index (EDI) as a measure of area-level socioeconomic deprivation, and to evaluate mortality trends between the periods 2000-2002 and 2010-2012.

METHODS

Statistics Portugal provided the counts of deaths and population by sex, age group, calendar year and area of residence (parish). A socioeconomic deprivation level was assigned to each parish according to the quintile of their national EDI distribution. Death counts were modelled within the generalised linear model framework as a function of age, deprivation level and calendar period. Mortality Rate Ratios (MRR) were estimated to evaluate variations in mortality between deprivation groups and periods.

RESULTS

Life expectancy at birth increased from 74.0 and 80.9 years in 2000-2002, for men and women, respectively, and to 77.6 and 83.8 years in 2010-2012. Yet, life expectancy at birth differed by deprivation, with, compared to least deprived population, a deficit of about 2 (men) and 1 (women) years among most deprived in the whole study period. The higher mortality experienced by most deprived groups at birth (in 2010-2012, mortality rate ratios of 1.74 and 1.29 in men and women, respectively) progressively disappeared with increasing age.

CONCLUSIONS

Persistent differences in mortality and life expectancy were observed according to ecological socioeconomic deprivation. These differences were larger among men and mostly marked at birth for both sexes.

The Portuguese version of the European Deprivation Index: Development and association with all-cause mortality

Socioeconomic inequalities are major health determinants. To monitor and understand them at local level, ecological indexes of socioeconomic deprivation constitute essential tools. In this study, we describe the development of the updated version of the European Deprivation Index for Portuguese small-areas (EDI-PT), describe its spatial distribution and evaluate its association with a general health indicator–all-cause mortality in the period 2009–2012. Using data from the 2011 European Union–Statistics on Income and Living Conditions Survey (EU-SILC), we obtained an indicator of individual deprivation. After identifying variables that were common to both the EU-SILC and the census, we used the indicator of individual deprivation to test if these variables were associated with individual-level deprivation, and to compute weights. Accordingly, eight variables were included. The EDI-PT was produced for the smallest area unit possible (n = 18084 census block groups, mean/area = 584 inhabitants) and resulted from the weighted sum of the eight selected variables. It was then categorized into quintiles (Q1-least deprived to Q5-most deprived). To estimate the association with mortality we fitted Bayesian spatial models. The EDI-PT was unevenly distributed across Portugal–most deprived areas concentrated in the South and in the inner North and Centre of the country, and the least deprived in the coastal North and Centre. The EDI-PT was positively and significantly associated with overall mortality, and this relation followed a rather clear dose-response relation of increasing mortality as deprivation increases (Relative Risk Q2 = 1.012, 95% Credible Interval 0.991–1.033; Q3 = 1.026, 1.004–1.048; Q4 = 1.053, 1.029–1.077; Q5 = 1.068, 1.042–1.095). Summing up, we updated the index of socioeconomic deprivation for Portuguese small-areas, and we showed that the EDI-PT constitutes a sensitive measure to capture health inequalities, since it was consistently associated with a key measure of population health/development, all-cause mortality. We strongly believe this updated version will be widely employed by social and medical researchers and regional planners.

Geographic health inequalities in Norway: a Gini analysis of cross-county differences in mortality from 1980 to 2014

Background

This study aims at quantifying the level and changes over time of inequality in age-specific mortality and life expectancy between the 19 Norwegian counties from 1980 to 2014.

Methods

Data on population and mortality by county was obtained from Statistics Norway for 1980–2014. Life expectancy and age-specific mortality rates (0–4, 5–49 and 50–69 age groups) were estimated by year and county. Geographic inequality was described by the absolute Gini index annually.

Results

Life expectancy in Norway has increased from 75.6 to 82.0 years, and the risk of death before the age of 70 has decreased from 26 to 14% from 1980 to 2014. The absolute Gini index decreased over the period 1980 to 2014 from 0.43 to 0.32 for life expectancy, from 0.012 to 0.0057 for the age group 50–69 years, from 0.0038 to 0.0022 for the age group 5–49 years, and from 0.0009 to 0.0006 for the age group 0–4 years. It will take between 2 and 32 years (national average 7 years) until the counties catch up with the life expectancy in the best performing county if their annual rates of increase remain unchanged.

Conclusion

Using the absolute Gini index as a metric for monitoring changes in geographic inequality over time may be a valuable tool for informing public health policies. The absolute inequality in mortality and life expectancy between Norwegian counties has decreased from 1980 to 2014.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0771-7) contains supplementary material, which is available to authorized users.

Does community deprivation determine longevity after the age of 75? A cross-national analysis

OBJECTIVES

Analyze the association between socioeconomic deprivation and old-age survival in Europe, and investigate whether it varies by country and gender.

METHODS

Our study incorporated five countries (Portugal, Spain, France, Italy, and England). A 10-year survival rate expressing the proportion of population aged 75-84 years who reached 85-94 years old was calculated at area-level for 2001-11. To estimate associations, we used Bayesian spatial models and a transnational measure of deprivation. Attributable/prevention fractions were calculated.

RESULTS

Overall, there was a significant association between deprivation and survival in both genders. In England that association was stronger, following a dose-response relation. Although lesser in magnitude, significant associations were observed in Spain and Italy, whereas in France and Portugal these were even weaker. The elimination of socioeconomic differences between areas would increase survival by 7.1%, and even a small reduction in socioeconomic differences would lead to a 1.6% increase.

CONCLUSIONS

Socioeconomic deprivation was associated with survival among older adults at ecological-level, although with varying magnitude across countries. Reasons for such cross-country differences should be sought. Our results emphasize the importance of reducing socioeconomic differences between areas.

Regional inequalities in self-reported conditions and non-communicable diseases in European countries: Findings from the European Social Survey (2014) special module on the social determinants of health

Background

Within the European Union (EU), substantial efforts are being made to achieve economic and social cohesion, and the reduction of health inequalities between EU regions is integral to this process. This paper is the first to examine how self-reported conditions and non-communicable diseases (NCDs) vary spatially between and within countries.

Methods

Using 2014 European Social Survey (ESS) data from 20 countries, this paper examines how regional inequalities in self-reported conditions and NCDs vary for men and women in 174 regions (levels 1 and 2 Nomenclature of Statistical Territorial Units, ‘NUTS’). We document absolute and relative inequalities across Europe in the prevalence of eight conditions: general health, overweight/obesity, mental health, heart or circulation problems, high blood pressure, back, neck, muscular or joint pain, diabetes and cancer.

Results

There is considerable inequality in self-reported conditions and NCDs between the regions of Europe, with rates highest in the regions of continental Europe, some Scandinavian regions and parts of the UK and lowest around regions bordering the Alps, in Ireland and France. However, for mental health and cancer, rates are highest in regions of Eastern European and lowest in some Nordic regions, Ireland and isolated regions in continental Europe. There are also widespread and consistent absolute and relative regional inequalities in all conditions within countries. These are largest in France, Germany and the UK, and smallest in Denmark, Sweden and Norway. There were higher inequalities amongst women.

Conclusion

Using newly available harmonized morbidity data from across Europe, this paper shows that there are considerable regional inequalities within and between European countries in the distribution of self-reported conditions and NCDs.

Residents' Dissatisfaction and All-Cause Mortality. Evidence from 74 European Cities

Background: About 2/3 of the Europeans reside in cities. Thus, we must expand our knowledge on how city characteristics affect health and well-being. Perceptions about cities' resources and functioning might be related with health, as they capture subjective experiences of the residents. We characterized the health status of 74 European cities, using all-cause mortality as indicator, and investigated the association of mortality with residents' dissatisfaction with key domains of urban living.

Methods: We considered 74 European cities from 29 countries. Aggregated data on residents' dissatisfaction was obtained from the Flash Eurobarometer, Quality of life in European cities (2004–2015). For each city a global dissatisfaction score and a dissatisfaction score by domain (environment, social, economic, healthcare, and infrastructures/services) were calculated. Data on mortality and population was obtained from the Eurostat. Standardized Mortality Ratios, SMR, and 95% Confidence Intervals (95% CI) were calculated. The association between dissatisfaction scores and SMR was estimated using Generalized Linear Models.

Results: SMR varied markedly (range: 73.2–146.5), being highest in Eastern Europe and lowest in the South and Western European cities. Residents' dissatisfaction levels also varied greatly. We found a significant association between city SMR and residents' dissatisfaction with healthcare (β = 0.334; IC 95% 0.030–0.639) and social environment (β = 0.239; IC 95% 0.015–0.464). No significant association was found with the dissatisfaction scores related with the physical and economic environment and the infrastructures/services.

Conclusions: We found a significant association between city levels of mortality and residents' dissatisfaction with certain urban features, suggesting subjective assessments can be also used to comprehend urban health.

Decomposition of regional convergence in population aging across Europe

In the face of rapidly aging population, decreasing regional inequalities in population composition is one of the regional cohesion goals of the European Union. To our knowledge, no explicit quantification of the changes in regional population aging differentiation exist. We investigate how regional differences in population aging developed over the last decade and how they are likely to evolve in the coming three decades, and we examine how demographic components of population growth contribute to the process. We use the beta-convergence approach to test whether regions are moving towards a common level of population aging. The change in population composition is decomposed into the separate effects of changes in the size of the non-working-age population and of the working-age population. The latter changes are further decomposed into the effects of cohort turnover, migration at working ages, and mortality at working ages. European Nomenclature of Territorial Units for Statistics (NUTS)-2 regions experienced notable convergence in population aging during the period 2003-2012 and are expected to experience further convergence in the coming three decades. Convergence in aging mainly depends on changes in the population structure of East-European regions. Cohort turnover plays the major role in promoting convergence. Differences in mortality at working ages, though quite moderate themselves, have a significant cumulative effect. The projections show that when it is assumed that net migration flows at working ages are converging across European regions, this will not contribute to convergence of population aging. The beta-convergence approach proves useful to examine regional variations in population aging across Europe.

Multi-scalar influences on mortality change over time in 274 European cities

Understanding determinants of urban health is of growing importance. Factors at multiple scales intertwine to influence health in cities but, with the growing autonomy of some cities from their countries, city population health may be becoming more a matter for city-level rather than national-level policy and action. We assess the importance of city, country, and macroregional (Western and East-Central Europe) scales to mortality change over time for 274 cities (population 80 million) from 27 European countries. We then investigate whether mortality changes over time are related to changes in city-level affluence. Using Urban Audit data, all-age all-cause standardised mortality ratios (SMRs) for males and females were calculated at three time points (wave one 1999-2002, wave two 2003-2006, and wave three 2007-2009) for each city. Multilevel regression was used to model the SMRs as a function of survey wave and city region gross domestic product (GDP) per 1000 capita. SMRs declined over time and the substantial East-West gap narrowed slightly. Variation at macroregion and country scales characterised SMRs for women in Western and East-Central European cities, and SMRs for men in East-Central European cities. Between-city variation was evident for male SMRs in Western Europe. Changes in city-region GDP per capita were not associated with changes in mortality over the study period. Our results show how geographical scales differentially impact urban mortality. We conclude that changes in urban health should be seen in both city and wider national and macroregional contexts.

Patterns of life expectancy before and during economic recession, 2003-12: a European regions panel approach

BACKGROUND

Previous research has reported a decrease in all-cause mortality during times of economic recession. Our objective was to identify the short-term effects of the current Great Recession on life expectancy at birth in Europe, and the role of social protection typology, income and gender.

METHODS

We used a pooled time series cross-sectional design, with 232 European regions (level 2 of the Nomenclature of Territorial Units for Statistics) as the unit of analysis over 10 years (2003-12). The dependent variable was life expectancy at birth, and the independent variable was unemployment rate. We fit a model in first differences for the periods before and during the Great Recession (2003-07 and 2008-12, respectively), and stratified by sex, social protection typology (Eastern, Mediterranean and Northern) and regional income per capita RESULTS: We observed a negative association during the Great Recession between life expectancy (in years) and in unit change in unemployment among men and women in low-income Mediterranean regions [-0.048(95%CI: -0.081,-0.014) and -0.050(95%CI:-0.091,-0.007), respectively] but no change in trend, and a change in trend to a non-significant negative association among men in high-income Mediterranean and Northern regions (P = 0.005 and P = 0.002, respectively). We also observed a positive association among men in middle-income Mediterranean regions [0.044 (95%CI:0.004,0.084)], with change in trend (P = 0.047), and Eastern regions [0.042 (95%CI:0.001,0.072)] without change in trend.

CONCLUSION

Overall, our data do not support the notion that increased life expectancy is associated with unemployment during the Great Recession.

Johan Mackenbach, awarded an honorary doctorate for his work on health inequalities, in a discussion of burning issues in tackling health inequalities

On 20 March 2015, Professor Johan Mackenbach of the Erasmus University Medical Centre was awarded a doctorate honoris causa by the Catholic University (Université Catholique) of Louvain, Belgium, for his outstanding contribution to the analysis of health inequalities in Europe and to the development of policies intended to address them. In this context, a debate took place between Professor Mackenbach, Professor Maniquet, a well-being economist, and a representative of the Federal Health Ministry (Mr. Brieuc Vandamme). They were asked to debate on three topics. (1) socio-economic inequalities in health are not smaller in countries with universal welfare policies; (2) Policies needs to target either absolute inequalities or relative inequalities; (3) The focus of policies should either address the social determinants of health or concentrate on access to health care. The results of the debate by the three speakers highlighted the fact that welfare systems have not been able to tackle diseases of affluence. Targets for health policies should be set according to opportunity cost: health care is increasingly costly and a focus on health inequalities above all other inequalities runs the risk of taking a dogmatic approach to well-being. Health is only one dimension of well-being and policies to address inequality need to balance preferences between several dimensions of well-being. Finally, policymakers may not have that much choice when it comes to reducing inequality: all effective policies should be implemented. For example, Belgium and other European countries should not leave aside health protection policies that are evidence-based, in particular taxes on tobacco and alcohol. In his final contribution, Professor Mackenbach reminded the audience that politics is medicine on a larger scale and stated that policymakers should make more use of research into public health.

Development of a measure of multiple physical environmental deprivation. After United Kingdom and New Zealand, Portugal

BACKGROUND

Spatial inequalities in health have been identified, but the contribution of physical environment has been largely ignored. In Portugal, strong spatial differences in morbidity and mortality remain unexplained. Based on previous United Kingdom (UK) and New Zealand (NZ) research, we aimed to develop a Portuguese measure of multiple environmental deprivation (PT-MEDIx) to assist in understanding spatial inequalities in health.

METHODS

PT-MEDIx was built at municipality level in four stages: (i) identify health-relevant environmental factors; (ii) acquire datasets about selected environmental factors and calculate municipality-level measures using Geographical Information Systems; (iii) test associations between selected environmental factors and mortality using negative binomial models, adjusting for age, sex, socioeconomic deprivation and interactions and (iv) construct a summary measure and assess its association with mortality.

RESULTS

We included five dimensions of the physical environment: air pollution, climate, drinking water quality, green space availability and industry proximity. PT-MEDIx score ranged from -1 (least environmental deprivation) to +4 (most) and depicted a clear spatial pattern: least deprived municipalities in the depopulated rural areas and most deprived in urban and industrial settings. Comparing with those in the intermediate category of environment deprivation, less deprived municipalities showed lower mortality rate ratios (MRRs) and vice versa: MRRs for all-cause mortality were 0.962 (95% confidence interval: 0.934-0.991) and 1.209 (1.086-1.344), in the least and most deprived municipalities, respectively, and for cancer, 0.957 (0.911-1.006) and 1.345 (1.123-1.598).

CONCLUSIONS

The methods used to create UK and NZ indexes have good transferability to Portugal. MEDIx might contribute to untangle the complex pathways that link health, socioeconomic and physical environment.

The impact of NHS resource allocation policy on health inequalities in England 2001-11: longitudinal ecological study

OBJECTIVE

To investigate whether the policy of increasing National Health Service funding to a greater extent in deprived areas in England compared with more affluent areas led to a reduction in geographical inequalities in mortality amenable to healthcare.

DESIGN

Longitudinal ecological study.

SETTING

324 lower tier local authorities in England, classified by their baseline level of deprivation.

INTERVENTION

Differential trends in NHS funds allocated to local areas resulting from the NHS resource allocation policy in England between 2001 and 2011.

MAIN OUTCOME MEASURE

Trends in mortality from causes considered amenable to healthcare in local authority areas in England. Using multivariate regression, we estimated the reduction in mortality that was associated with the allocation of additional NHS resources in these areas.

RESULTS

Between 2001 and 2011 the increase in NHS resources to deprived areas accounted for a reduction in the gap between deprived and affluent areas in male mortality amenable to healthcare of 35 deaths per 100,000 population (95% confidence interval 27 to 42) and female mortality of 16 deaths per 100,000 (10 to 21). This explained 85% of the total reduction of absolute inequality in mortality amenable to healthcare during this time. Each additional £10 m of resources allocated to deprived areas was associated with a reduction in 4 deaths in males per 100,000 (3.1 to 4.9) and 1.8 deaths in females per 100,000 (1.1 to 2.4). The association between absolute increases in NHS resources and improvements in mortality amenable to healthcare in more affluent areas was not significant.

CONCLUSION

Between 2001 and 2011, the NHS health inequalities policy of increasing the proportion of resources allocated to deprived areas compared with more affluent areas was associated with a reduction in absolute health inequalities from causes amenable to healthcare. Dropping this policy may widen inequalities.

Particulate air pollution and health inequalities: a Europe-wide ecological analysis

Background

Environmental disparities may underlie the unequal distribution of health across socioeconomic groups. However, this assertion has not been tested across a range of countries: an important knowledge gap for a transboundary health issue such as air pollution. We consider whether populations of low-income European regions were a) exposed to disproportionately high levels of particulate air pollution (PM₁₀) and/or b) disproportionately susceptible to pollution-related mortality effects.

Methods

Europe-wide gridded PM₁₀ and population distribution data were used to calculate population-weighted average PM₁₀ concentrations for 268 sub-national regions (NUTS level 2 regions) for the period 2004–2008. The data were mapped, and patterning by mean household income was assessed statistically. Ordinary least squares regression was used to model the association between PM₁₀ and cause-specific mortality, after adjusting for regional-level household income and smoking rates.

Results

Air quality improved for most regions between 2004 and 2008, although large differences between Eastern and Western regions persisted. Across Europe, PM₁₀ was correlated with low household income but this association primarily reflected East–West inequalities and was not found when Eastern or Western Europe regions were considered separately. Notably, some of the most polluted regions in Western Europe were also among the richest. PM₁₀ was more strongly associated with plausibly-related mortality outcomes in Eastern than Western Europe, presumably because of higher ambient concentrations. Populations of lower-income regions appeared more susceptible to the effects of PM₁₀, but only for circulatory disease mortality in Eastern Europe and male respiratory mortality in Western Europe.

Conclusions

Income-related inequalities in exposure to ambient PM₁₀ may contribute to Europe-wide mortality inequalities, and to those in Eastern but not Western European regions. We found some evidence that lower-income regions were more susceptible to the health effects of PM₁₀.