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      Long-term trends of inequalities in mortality in 6 European countries

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          Abstract

          Objectives

          We aimed to assess whether trends in inequalities in mortality during the period 1970–2010 differed between Finland, Norway, England and Wales, France, Italy (Turin) and Hungary.

          Methods

          Total and cause-specific mortality data by educational level and, if available, occupational class were collected and harmonized. Both relative and absolute measures of inequality in mortality were calculated.

          Results

          In all countries except Hungary, all-cause mortality declined strongly over time in all socioeconomic groups. Relative inequalities in all-cause mortality generally increased, but more so in Hungary and Norway than elsewhere. Absolute inequalities often narrowed, but went up in Hungary and Norway. As a result of these trends, Hungary (where inequalities in mortality where almost absent in the 1970s) and Norway (where inequalities in the 1970s were among the smallest of the six countries in this study) now have larger inequalities in mortality than the other four countries.

          Conclusions

          While some countries have experienced dramatic setbacks, others have made substantial progress in reducing inequalities in mortality.

          Electronic supplementary material

          The online version of this article (doi:10.1007/s00038-016-0922-9) contains supplementary material, which is available to authorized users.

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          Most cited references29

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          Explaining the decline in coronary heart disease mortality in England and Wales between 1981 and 2000.

          Belgin Unal, Julia Alison Critchley, Simon Capewell (2004)
          Coronary heart disease mortality rates have been decreasing in the United Kingdom since the 1970s. Our study aimed to examine how much of the decrease in England and Wales between 1981 and 2000 could be attributed to medical and surgical treatments and how much to changes in cardiovascular risk factors. The IMPACT mortality model was used to combine and analyze data on uptake and effectiveness of cardiological treatments and risk factor trends in England and Wales. The main data sources were published trials and meta-analyses, official statistics, clinical audits, and national surveys. Between 1981 and 2000, coronary heart disease mortality rates in England and Wales decreased by 62% in men and 45% in women 25 to 84 years old. This resulted in 68 230 fewer deaths in 2000. Some 42% of this decrease was attributed to treatments in individuals (including 11% to secondary prevention, 13% to heart failure treatments, 8% to initial treatments of acute myocardial infarction, and 3% to hypertension treatments) and 58% to population risk factor reductions (principally smoking, 48%; blood pressure, 9.5%; and cholesterol, 9.5%). Adverse trends were seen for physical activity, obesity and diabetes. More than half the coronary heart disease mortality decrease in Britain between 1981 and 2000 was attributable to reductions in major risk factors, principally smoking. This emphasizes the importance of a comprehensive strategy that promotes primary prevention, particularly for tobacco and diet, and that maximizes population coverage of effective treatments, especially for secondary prevention and heart failure. These findings may be cautiously generalizable to the United States and other developed countries.
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            Widening socioeconomic inequalities in mortality in six Western European countries.

            Ryan Andersen, Mario Cardano, Giuseppe Costa … (2003)
            During the past decades a widening of the relative gap in death rates between upper and lower socioeconomic groups has been reported for several European countries. Although differential mortality decline for cardiovascular diseases has been suggested as an important contributory factor, it is not known what its quantitative contribution was, and to what extent other causes of death have contributed to the widening gap in total mortality. We collected data on mortality by educational level and occupational class among men and women from national longitudinal studies in Finland, Sweden, Norway, Denmark, England/Wales, and Italy (Turin), and analysed age-standardized death rates in two recent time periods (1981-1985 and 1991-1995), both total mortality and by cause of death. For simplicity, we report on inequalities in mortality between two broad socioeconomic groups (high and low educational level, non-manual and manual occupations). Relative inequalities in total mortality have increased in all six countries, but absolute differences in total mortality were fairly stable, with the exception of Finland where an increase occurred. In most countries, mortality from cardiovascular diseases declined proportionally faster in the upper socioeconomic groups. The exception is Italy (Turin) where the reverse occurred. In all countries with the exception of Italy (Turin), changes in cardiovascular disease mortality contributed about half of the widening relative gap for total mortality. Other causes also made important contributions to the widening gap in total mortality. For these causes, widening inequalities were sometimes due to increasing mortality rates in the lower socioeconomic groups. We found rising rates of mortality from lung cancer, breast cancer, respiratory disease, gastrointestinal disease, and injuries among men and/or women in lower socioeconomic groups in several countries. Reducing socioeconomic inequalities in mortality in Western Europe critically depends upon speeding up mortality declines from cardiovascular diseases in lower socioeconomic groups, and countering mortality increases from several other causes of death in lower socioeconomic groups.
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              Implicit value judgments in the measurement of health inequalities.

              John Lynch, Marsha Reichman, Nancy Breen … (2010)
              Quantitative estimates of the magnitude, direction, and rate of change of health inequalities play a crucial role in creating and assessing policies aimed at eliminating the disproportionate burden of disease in disadvantaged populations. It is generally assumed that the measurement of health inequalities is a value-neutral process, providing objective data that are then interpreted using normative judgments about whether a particular distribution of health is just, fair, or socially acceptable. We discuss five examples in which normative judgments play a role in the measurement process itself, through either the selection of one measurement strategy to the exclusion of others or the selection of the type, significance, or weight assigned to the variables being measured. Overall, we find that many commonly used measures of inequality are value laden and that the normative judgments implicit in these measures have important consequences for interpreting and responding to health inequalities. Because values implicit in the generation of health inequality measures may lead to radically different interpretations of the same underlying data, we urge researchers to explicitly consider and transparently discuss the normative judgments underlying their measures. We also urge policymakers and other consumers of health inequalities data to pay close attention to the measures on which they base their assessments of current and future health policies.
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                Author and article information

                Contributors
                Johan P. Mackenbach: j.mackenbach@erasmusmc.nl
                Journal
                Journal ID (nlm-ta): Int J Public Health
                Journal ID (iso-abbrev): Int J Public Health
                Title: International Journal of Public Health
                Publisher: Springer International Publishing (Cham )
                ISSN (Print): 1661-8556
                ISSN (Electronic): 1661-8564
                Publication date (Electronic): 9 December 2016
                Publication date PMC-release: 9 December 2016
                Publication date (Print): 2017
                Volume: 62
                Issue: 1
                Pages: 127-141
                Affiliations
                [1 ]ISNI 000000040459992X, GRID grid.5645.2, Department of Public Health, , Erasmus MC, ; Rotterdam, The Netherlands
                [2 ]ISNI 0000 0001 2308 1657, GRID grid.462844.8, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique (IPLESP UMRS 1136), , Sorbonne Universités, ; Paris, France
                [3 ]ISNI 0000 0001 2336 6580, GRID grid.7605.4, Department of Clinical Medicine and Biology, , University of Turin, ; Turin, Italy
                [4 ]Demographic Research Institute, Budapest, Hungary
                [5 ]ISNI 0000 0004 0410 2071, GRID grid.7737.4, Department of Sociology, , University of Helsinki, ; Helsinki, Finland
                [6 ]ISNI 0000 0001 1541 4204, GRID grid.418193.6, Division of Epidemiology, , Norwegian Institute of Public Health, ; Oslo, Norway
                Article
                Publisher ID: 922
                DOI: 10.1007/s00038-016-0922-9
                PMC ID: 5288439
                PubMed ID: 27942745
                SO-VID: 18b20163-db96-4818-b692-f3f7867634c7
                Copyright © © The Author(s) 2016
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                Date received : 29 April 2016
                Date revision received : 1 November 2016
                Date accepted : 10 November 2016
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100004963, Seventh Framework Programme;
                Award ID: FP7-CP-FP grant no. 278511
                Award Recipient :
                Categories
                Subject: Original Article
                Custom metadata
                issue-copyright-statement © Swiss School of Public Health (SSPH+) 2017

                ScienceOpen disciplines: Public health
                Keywords: mortality,socioeconomic inequalities,trends,europe
                Data availability:
                ScienceOpen disciplines: Public health
                Keywords: mortality, socioeconomic inequalities, trends, europe

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