Is austerity responsible for the recent change in mortality trends across high-income nations? A protocol for an observational study

The health gap and HRQoL inequalities in Greece before and during the economic crisis

Objective

The aim of this study was twofold: (i) to assess the health gap among young socio-economic groups generated by the economic crisis in Greece and (ii) to investigate HRQoL (Health Related Quality of Life) inequalities using the Theil index.

Methods

The EQ-5D-5L instrument was administered to a sample of 4,177 young individuals in Greece, mean age 22.3 (±SD 4.8) and 53.8% males, and 46.2% females. The Greek version of the EQ-5D-5L instrument was used in a web-based questionnaire to collect data. Subjects were asked to assess their subjective health status during the economic crisis of 2016 using the EQ-5D-5L instrument, and to recall their health before the crisis of 2009. The health gap was assessed on a Visual Analogue Scale (EQ-VAS), the EQ-5D-5L Index, and the five dimensions of the EQ-5D-5L instrument. Regression analysis was employed to measure the effects of the economic crisis on age, sex, education, and income on the EQ-VAS and EQ-5D-5L. Theil index was used to assess HRQoL inequalities.

Results

The economic crisis brought a significant deterioration in the HRQoL of young Greeks. The EQ-VAS was reduced during the crisis by -10.05% (p < 0.001) and the EQ-5D-5L index declined by -19.61% (p < 0.001). The prevalence of the health gap in each dimension of the EQ-5D-5L was also significant in terms of deterioration of Mobility [change by 66.8% (p < 0.001)], Self-care [change by 61.0% (p < 0.001)], Usual activities [change by 97.1% (p < 0.001)], Pain/discomfort [change by 65.0% (p < 0.001)], and Anxiety/depression [change by 70.5% (p < 0.001)]. Significant reductions in EQ-5D-5L indices were also associated with greater inequalities in the distribution of health among age, gender, income, and educational groups. The EQ-5D-5L health gap among the poor was much greater (0.198), in comparison to richer (0.128) classes. Similar gaps were also found in terms of educational inequalities. The EQ-5D-5L health gap among those with primary education was 0.211, whereas for those with tertiary education it was 0.16. The Theil index indicated an increase in income-related HRQoL inequalities by 222.3% for the EQ-5D-5L index and by 124.2% for the EQ-VAS. The effects of demographic and socioeconomic variables on the EQ-VAS were found statistically significant: sex (p < 0.05), age (p < 0.001), education (p < 0.001), and income (p < 0.001).

Conclusion

The EQ-5D-5L instrument appears to be a powerful tool in assessing the health gap and the HRQoL inequalities among young people in Greece. The findings indicate the importance of developing effective health policies to combat inequalities and mitigate the impact of austerity measures on the quality of life of the young.

When experts disagree: interviews with public health experts on health outcomes in the UK 2010-2020

OBJECTIVES

To ascertain the views of public health experts on adverse trends in life expectancy across England and Wales over the past decade, causal factors, possible solutions, and their opinions about how the prepandemic situation influenced the UK's COVID-19 response.

STUDY DESIGN

Semistructured, in-depth interviews.

METHODS

Nineteen public health experts were identified by purposeful sampling and invited to take part via e-mail. Sixty-three percent responded and participated (n = 12), six females and six males. Interviews took place via Microsoft Teams between November 2021 and January 2022. Interviews were transcribed and analysed using thematic content analysis.

RESULTS

There was no consensus on the significance of the stalling and, at some ages, reversal of previous improvements in life expectancy between 2010 and 2020. Explanations offered included data misinterpretation, widening health inequalities, and disinvestment in public services, as well as some disease-specific causes. Those accepting that the decline was concerning linked it to social factors and suggested solutions based on increased investment and implementing existing evidence on how to reduce health inequalities. These interviewees also pointed to the same factors playing a role in the UK's poor COVID-19 response, highlighting the need to understand and address these underlying issues as part of pandemic preparedness.

CONCLUSIONS

There was no consensus among a group of influential public health experts in the UK on the scale, nature, and explanations of recent trends in life expectancy. A majority called for implementation of existing evidence on reducing inequalities, especially in the wake of COVID-19. However, without agreement on what the problem is, action is likely to remain elusive.

Slowing down or returning to normal? Life expectancy improvements in Britain compared to five large European countries before the COVID-19 pandemic

INTRODUCTION OR BACKGROUND

Life expectancy is an important summary measure of population health. In the absence of a significant event like war or disease outbreak, trends should, and historically have, increase over time, albeit with some fluctuations.

SOURCES OF DATA

Data were extracted from the human mortality database for life expectancy at birth and age 65 years from 1980 to the latest available year for England & Wales, Scotland (Great Britain), France, Spain, Italy, the Netherlands and Germany.

AREAS OF AGREEMENT

It is well established that life expectancy improvements in Great Britain have stalled in recent years, and that a similar stalling was seen in other high-income countries during the mid-2010s.

AREAS OF CONTROVERSY

The significance and causes of the slowdown in improvement in life expectancy in Britain are disputed. First, was Britain's slowdown in progress in life expectancy in the 2010s a deviation 'from' earlier sustained improvements or simply returning to normal (slower) improvement rates following faster gains in the 2000s? Second, did other European countries have slowdowns comparable to that in Britain?

GROWING POINTS

Life expectancy, as a summary measure, conceals inequalities. Other measures, such as lifespan disparity, complement it in understanding changing trends. While annual fluctuations in life expectancy are expected, continued stalls should raise concern. The three British nations examined were the only ones among these European countries to experience stalling of life expectancy gains in both sexes.

AREAS TIMELY FOR DEVELOPING RESEARCH

While it is clear that Britain is making less progress in health than similar countries, more research is needed to explain why.

Is austerity a cause of slower improvements in mortality in high-income countries? A panel analysis

BACKGROUND

The rate of improvement in mortality slowed across many high-income countries after 2010. Following the 2007-08 financial crisis, macroeconomic policy was dominated by austerity as countries attempted to address perceived problems of growing state debt and government budget deficits. This study estimates the impact of austerity on mortality trends for 37 high-income countries between 2000 and 2019.

METHODS

We fitted a suite of fixed-effects panel regression models to mortality data (period life expectancy, age-standardised mortality rates (ASMRs), age-stratified mortality rates and lifespan variation). Austerity was measured using the Alesina-Ardagna Fiscal Index (AAFI), Cyclically-Adjusted Primary Balance (CAPB), real indexed Government Expenditure, and Public Social Spending as a % of GDP. Sensitivity analyses varied the lag times, and confined the panel to economic downturns and to non-oil-dominated economies.

RESULTS

Slower improvements, or deteriorations, in life expectancy and mortality trends were seen in the majority of countries, with the worst trends in England & Wales, Estonia, Iceland, Scotland, Slovenia, and the USA, with generally worse trends for females than males. Austerity was implemented across all countries for at least some time when measured by AAFI and CAPB, and for many countries across all four measures (and particularly after 2010). Austerity adversely impacted life expectancy, ASMR, age-specific mortality and lifespan variation trends when measured with Government Expenditure, Public Social Spending and CAPB, but not with AAFI. However, when the dataset was restricted to periods of economic downturn and in economies not dominated hydrocarbon production, all measures of austerity were found to reduce the rate of mortality improvement.

INTERPRETATION

Stalled mortality trends and austerity are widespread phenomena across high-income countries. Austerity is likely to be a cause of stalled mortality trends. Governments should consider alternative economic policy approaches if these harmful population health impacts are to be avoided.

Glossary: economics and health

As we emerge from the COVID-19 pandemic, there is an increasing focus on how the economy is rebuilt and the impact this will have on population health. Many of the economic policy proposals being discussed have their own vocabulary, which is not always understood in the same way within or between disciplines. This glossary seeks to provide a common language and concise summary of the key economic terminology relevant for policymakers and public health at this time.

Trends in infant mortality and stillbirth rates in Scotland by socio-economic position, 2000-2018: a longitudinal ecological study

BACKGROUND

As Scotland strives to become a country where children flourish in their early years, it is faced with the challenge of socio-economic health inequalities, which are at risk of widening amidst austerity policies. The aim of this study was to explore trends in infant mortality rates (IMR) and stillbirth rates by socio-economic position (SEP) in Scotland, between 2000 and 2018, inclusive.

METHODS

Data for live births, infant deaths, and stillbirths between 2000 and 2018 were obtained from National Records of Scotland. Annual IMR and stillbirth rates were calculated and visualised for all of Scotland and when stratified by SEP. Negative binomial regression models were used to estimate the association between SEP and infant mortality and stillbirth events, and to assess for break points in trends over time. The slope (SII) and relative (RII) index of inequality compared absolute and relative socio-economic inequalities in IMR and stillbirth rates before and after 2010.

RESULTS

IMR fell from 5.7 to 3.2 deaths per 1000 live births between 2000 and 2018, with no change in trend identified. Stillbirth rates were relatively static between 2000 and 2008 but experienced accelerated reduction from 2009 onwards. When stratified by SEP, inequalities in IMR and stillbirth rates persisted throughout the study and were greatest amongst the sub-group of post-neonates. Although comparison of the SII and RII in IMR and stillbirths before and after 2010 suggested that inequalities remained stable, descriptive trends in mortality rates displayed a 3-year rise in the most deprived quintiles from 2016 onwards.

CONCLUSION

Whilst Scotland has experienced downward trends in IMR and stillbirth rates between 2000 and 2018, the persistence of socio-economic inequalities and suggestion that mortality rates amongst the most deprived groups may be worsening warrants further action to improve maternal health and strengthen support for families with young children.

Scaling COVID-19 against inequalities: should the policy response consistently match the mortality challenge?

BACKGROUND

The mortality impact of COVID-19 has thus far been described in terms of crude death counts. We aimed to calibrate the scale of the modelled mortality impact of COVID-19 using age-standardised mortality rates and life expectancy contribution against other, socially determined, causes of death in order to inform governments and the public.

METHODS

We compared mortality attributable to suicide, drug poisoning and socioeconomic inequality with estimates of mortality from an infectious disease model of COVID-19. We calculated age-standardised mortality rates and life expectancy contributions for the UK and its constituent nations.

RESULTS

Mortality from a fully unmitigated COVID-19 pandemic is estimated to be responsible for a negative life expectancy contribution of -5.96 years for the UK. This is reduced to -0.33 years in the fully mitigated scenario. The equivalent annual life expectancy contributions of suicide, drug poisoning and socioeconomic inequality-related deaths are -0.25, -0.20 and -3.51 years, respectively. The negative impact of fully unmitigated COVID-19 on life expectancy is therefore equivalent to 24 years of suicide deaths, 30 years of drug poisoning deaths and 1.7 years of inequality-related deaths for the UK.

CONCLUSION

Fully mitigating COVID-19 is estimated to prevent a loss of 5.63 years of life expectancy for the UK. Over 10 years, there is a greater negative life expectancy contribution from inequality than around six unmitigated COVID-19 pandemics. To achieve long-term population health improvements it is therefore important to take this opportunity to introduce post-pandemic economic policies to 'build back better'.

Scaling COVID-19 against inequalities: should the policy response consistently match the mortality challenge?

BACKGROUND

The mortality impact of COVID-19 has thus far been described in terms of crude death counts. We aimed to calibrate the scale of the modelled mortality impact of COVID-19 using age-standardised mortality rates and life expectancy contribution against other, socially determined, causes of death in order to inform governments and the public.

METHODS

We compared mortality attributable to suicide, drug poisoning and socioeconomic inequality with estimates of mortality from an infectious disease model of COVID-19. We calculated age-standardised mortality rates and life expectancy contributions for the UK and its constituent nations.

RESULTS

Mortality from a fully unmitigated COVID-19 pandemic is estimated to be responsible for a negative life expectancy contribution of -5.96 years for the UK. This is reduced to -0.33 years in the fully mitigated scenario. The equivalent annual life expectancy contributions of suicide, drug poisoning and socioeconomic inequality-related deaths are -0.25, -0.20 and -3.51 years, respectively. The negative impact of fully unmitigated COVID-19 on life expectancy is therefore equivalent to 24 years of suicide deaths, 30 years of drug poisoning deaths and 1.7 years of inequality-related deaths for the UK.

CONCLUSION

Fully mitigating COVID-19 is estimated to prevent a loss of 5.63 years of life expectancy for the UK. Over 10 years, there is a greater negative life expectancy contribution from inequality than around six unmitigated COVID-19 pandemics. To achieve long-term population health improvements it is therefore important to take this opportunity to introduce post-pandemic economic policies to 'build back better'.

The contribution of changes to tax and social security to stalled life expectancy trends in Scotland: a modelling study

BACKGROUND

Life expectancy (LE) improvements have stalled, and UK tax and welfare 'reforms' have been proposed as a cause. We estimated the effects of tax and welfare reforms from 2010/2011 to 2021/2022 on LE and inequalities in LE in Scotland.

METHODS

We applied a published estimate of the cumulative income impact of the reforms to the households within Scottish Index of Multiple Deprivation (SIMD) quintiles. We estimated the impact on LE by applying a rate ratio for the impact of income on mortality rates (by age group, sex and SIMD quintile) and calculating the difference between inflation-only changes in benefits and the reforms.

RESULTS

We estimated that changes to household income resulting from the reforms would result in an additional 1041 (+3.7%) female deaths and 1013 (+3.8%) male deaths. These deaths represent an estimated reduction of female LE from 81.6 years to 81.2 years (-20 weeks), and male LE from 77.6 years to 77.2 years (-23 weeks). Cuts to benefits and tax credits were modelled to have the most detrimental impact on LE, and these were estimated to be most severe in the most deprived areas. The modelled impact on inequalities in LE was widening of the gap between the most and least deprived 20% of areas by a further 21 weeks for females and 23 weeks for males.

INTERPRETATION

This study provides further evidence that austerity, in the form of cuts to social security benefits, is likely to be an important cause of stalled LE across the UK.