Trends in Health Inequalities in 27 European Countries
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Trends in health inequalities in 27 European countries Johan P. Mackenbacha,1, José Rubio Valverdea, Barbara Artnikb, Matthias Boppc, Henrik Brønnum-Hansend, Patrick Debooseree, Ramune Kaledienef, Katalin Kovácsg, Mall Leinsaluh,i, Pekka Martikainenj, Gwenn Menviellek, Enrique Regidorl, Jitka Rychtaríkovám, Maica Rodriguez-Sanzn, Paolo Vineiso, Chris Whitep, Bogdan Wojtyniakq, Yannan Hua, and Wilma J. Nusseldera aDepartment of Public Health, Erasmus University Medical Center, 3015 CE Rotterdam, The Netherlands; bDepartment of Public Health, Faculty of Medicine, 1000 Ljubljana, Slovenia; cEpidemiology, Biostatistics and Prevention Institute, University of Zürich, 8006 Zurich, Switzerland; dInstitute of Public Health, Copenhagen University, 1165 Copenhagen, Denmark; eDepartment of Sociology, Vrije Universiteit Brussel, 1050 Ixelles, Belgium; fLithuanian University of Health Sciences, Kaunas 44307, Lithuania; gDemographic Research Institute, 1525 Budapest, Hungary; hStockholm Centre for Health and Social Change, Södertörn University, 89 Huddinge, Sweden; iDepartment of Epidemiology and Biostatistics, National Institute for Health Development, 11619 Tallinn, Estonia; jDepartment of Sociology, University of Helsinki, 00100 Helsinki, Finland; kINSERM, Sorbonne Universités, Institut Pierre Louis d’Epidémiologie et de Santé Publique (IPLESP UMRS 1136), 75646 Paris, France; lDepartment of Preventive Medicine and Public Health, Universidad Complutense de Madrid, 28040 Madrid, Spain; mDepartment of Demography, Charles University, 128 43 Prague 2, Czech Republic; nAgència de Salut Pública de Barcelona, 08023 Barcelona, Spain; oMedical Research Council-Public Health England Centre for Environment and Health, School of Public Health, Imperial College, London W2 1PG, United Kingdom; pOffice of National Statistics, Newport NP10 8XG, United Kingdom; and qDepartment of Monitoring and Analyses of Population Health, National Institute of Public Health-National Institute of Hygiene, 00-791 Warsaw, Poland Edited by Teresa Seeman, University of California, Los Angeles, CA, and accepted by Editorial Board Member Mary C. Waters April 17, 2018 (received for review January 2, 2018) Unfavorable health trends among the lowly educated have re- crisis led to an economic recession with rising unemployment cently been reported from the United States. We analyzed health and fiscal austerity in most European countries, particularly in trends by education in European countries, paying particular countries that had to be bailed out by the international com- attention to the possibility of recent trend interruptions, including munity such as Greece, Cyprus, and Ireland (8). Because there interruptions related to the impact of the 2008 financial crisis. We were important differences among countries (SI Appendix, Fig. collected and harmonized data on mortality from ca. 1980 to ca. S1), there is ample scope for assessing the impact of the crisis. 2014 for 17 countries covering 9.8 million deaths and data on self- Previous recessions usually have had limited effects on pop- reported morbidity from ca. 2002 to ca. 2014 for 27 countries cov- ulation health, with increases in suicide and alcohol-related MEDICAL SCIENCES ering 350,000 survey respondents. We used interrupted time- deaths and decreases in road-traffic fatalities (9). So far, the series analyses to study changes over time and country-fixed evidence for the latest recession is mixed: All-cause mortality has effects analyses to study the impact of crisis-related economic con- continued to decline, but suicide rates have risen, as have some ditions on health outcomes. Recent trends were more favorable other health problems in some of the countries that were se- than in previous decades, particularly in Eastern Europe, where verely hit, such as Greece, Spain, and Portugal (10). However, mortality started to decline among lowly educated men and because the negative consequences of economic crises are likely where the decline in less-than-good self-assessed health accelera- to be borne primarily by the most disadvantaged, it is important ted, resulting in some narrowing of health inequalities. In Western to assess the health effects by socioeconomic group. Here again, SOCIAL SCIENCES Europe, mortality has continued to decline among the lowly and the available evidence is scarce (11, 12). highly educated, and although the decline of less-than-good self- assessed health slowed in countries severely hit by the financial Significance crisis, this affected lowly and highly educated equally. Crisis- related economic conditions were not associated with widening Inequalities in mortality and morbidity among socioeconomic health inequalities. Our results show that the unfavorable trends groups are a highly persistent phenomenon despite having observed in the United States are not found in Europe. There has been the focus of public health policy in many countries. The also been no discernible short-term impact of the crisis on health United States has recently witnessed a widening of health in- inequalities at the population level. Both findings suggest that equalities due to rising mortality and morbidity among the European countries have been successful in avoiding an aggrava- lowly educated. Our study shows that, despite the financial tion of health inequalities. crisis, most European countries have experienced an improve- ment in the health of the lowly educated in recent years. In mortality | morbidity | health inequalities | Europe | financial crisis Eastern Europe, this even represents a reversal as compared with previous decades. The 2008 financial crisis has had mixed lthough reducing inequalities in health among socioeco- effects without widening health inequalities. Our results sug- Anomic groups has become a priority for policy-makers in gest that European countries have been successful in avoiding many European countries, health inequalities have generally an aggravation of health inequalities. widened over the period from 1980 to the late 2000s (1–4). An update of these findings for the 2010s is urgently needed, for two Author contributions: J.P.M. and P.V. designed research; J.P.M., J.R.V., B.A., M.B., H.B.-H., reasons. The first is that unfavorable trends in mortality among P.D., R.K., K.K., M.L., P.M., G.M., E.R., J.R., M.R.-S., C.W., B.W., Y.H., and W.J.N. performed the lowly educated have recently been reported from the United research; J.P.M., J.R.V., Y.H., and W.J.N. analyzed data; and J.P.M. wrote the paper. States (5). Since the early 2000s total mortality and self-reported The authors declare no conflict of interest. morbidity have risen among middle-aged white Americans as a This article is a PNAS Direct Submission. T.S. is a guest editor invited by the Editorial Board. result of rising rates of suicide and poisonings, partly due to an Published under the PNAS license. epidemic of misuse of opioid painkiller drugs (6). These deaths “ ” Data deposition: The aggregate data reported in this paper have been deposited in the have been labeled deaths of despair, because the increases in institutional repository of Erasmus University Rotterdam (http://hdl.handle.net/1765/ mortality were concentrated among the lowly educated who in 106273). the United States have experienced increasing economic and 1To whom correspondence should be addressed. Email: [email protected]. social disadvantage (7). This article contains supporting information online at www.pnas.org/lookup/suppl/doi:10. The second reason is that the impact of the 2008 financial 1073/pnas.1800028115/-/DCSupplemental. crisis and its aftermath on health inequalities is unknown. The www.pnas.org/cgi/doi/10.1073/pnas.1800028115 PNAS Latest Articles | 1of6 Downloaded by guest on October 1, 2021 The study reported in this paper therefore aimed to assess all-cause mortality trend in recent years among either the lowly recent trends in health inequalities in a large number of Euro- educated or highly educated in Western Europe but that a pean countries, paying particular attention to the possible impact favorable change did occur among lowly educated men in of the 2008 financial crisis. Health inequalities are quantified Eastern Europe (Fig. 2 and SI Appendix,TableS5). These favor- both on a relative scale (using ratio measures such as the Rela- able changes were strongest among the middle-aged and for mor- tive Index of Inequality, RII) and on an absolute scale (using tality from cancer, alcohol-related causes, and suicide, as previously difference measures such as the Slope Index of Inequality, SII) rising trends slowed. (13). Both perspectives are important. Because relative in- Trends were generally unchanged, but not altogether favor- equalities depend only on the distribution of health problems in able, in Western Europe. There was no mortality decline among the population, they are often more easily understood. However, younger lowly educated women, as mortality from smoking-and because a 50% higher rate of a rare health problem is less im- alcohol-related causes went up. However, mortality from most portant for the public’s health than a 10% higher rate of a much causes of death declined among lowly educated men and women. more frequent health problem, absolute inequalities, which also After 2008 this decline accelerated for road injuries, whereas the depend on the average rate of health problems in the population, increase of alcohol-related mortality slowed. There was no are important too (14). change in trend for suicide and causes