Objective To determine whether government efforts in reducing inequalities in health in European countries have actually made a difference to mortality inequalities by socioeconomic group.Design Register based study.Data source Mortality data by level of education and occupational class in the period 1990-2010, usually collected in a census linked longitudinal study design. We compared changes in mortality between the lowest and highest socioeconomic groups, and calculated their effect on absolute and relative inequalities in mortality (measured as rate differences and rate ratios, respectively).Setting All European countries for which data on socioeconomic inequalities in mortality were available for the approximate period between years 1990 and 2010. These included Finland, Norway, Sweden, Scotland, England and Wales (data applied to both together), France, Switzerland, Spain (Barcelona), Italy (Turin), Slovenia, and Lithuania.Results Substantial mortality declines occurred in lower socioeconomic groups in most European countries covered by this study. Relative inequalities in mortality widened almost universally, because percentage declines were usually smaller in lower socioeconomic groups. However, as absolute declines were often smaller in higher socioeconomic groups, absolute inequalities narrowed by up to 35%, particularly among men. Narrowing was partly driven by ischaemic heart disease, smoking related causes, and causes amenable to medical intervention. Progress in reducing absolute inequalities was greatest in Spain (Barcelona), Scotland, England and Wales, and Italy (Turin), and absent in Finland and Norway. More detailed studies preferably using individual level data are necessary to identify the causes of these variations.Conclusions Over the past two decades, trends in inequalities in mortality have been more favourable in most European countries than is commonly assumed. Absolute inequalities have decreased in several countries, probably more as a side effect of population wide behavioural changes and improvements in prevention and treatment, than as an effect of policies explicitly aimed at reducing health inequalities.

BackgroundRheumatic heart disease (RHD) remains a major health concern for Aboriginal Australians. A key component of RHD control is prevention of recurrent acute rheumatic fever (ARF) using long-term secondary prophylaxis with intramuscular benzathine penicillin (BPG). This is the most important and cost-effective step in RHD control. However, there are significant challenges to effective implementation of secondary prophylaxis programs. This project aimed to increase understanding and improve quality of RHD care through development and implementation of a continuous quality improvement (CQI) strategy.MethodsWe used a CQI strategy to promote implementation of national best-practice ARF/RHD management guidelines at primary health care level in Indigenous communities of the Northern Territory (NT), Australia, 2008–2010. Participatory action research methods were employed to identify system barriers to delivery of high quality care. This entailed facilitated discussion with primary care staff aided by a system assessment tool (SAT). Participants were encouraged to develop and implement strategies to overcome identified barriers, including better record-keeping, triage systems and strategies for patient follow-up. To assess performance, clinical records were audited at baseline, then annually for two years. Key performance indicators included proportion of people receiving adequate secondary prophylaxis (≥80% of scheduled 4-weekly penicillin injections) and quality of documentation.ResultsSix health centres participated, servicing approximately 154 people with ARF/RHD. Improvements occurred in indicators of service delivery including proportion of people receiving ≥40% of their scheduled BPG (increasing from 81/116 [70%] at baseline to 84/103 [82%] in year three, p = 0.04), proportion of people reviewed by a doctor within the past two years (112/154 [73%] and 134/156 [86%], p = 0.003), and proportion of people who received influenza vaccination (57/154 [37%] to 86/156 [55%], p = 0.001). However, the proportion receiving ≥80% of scheduled BPG did not change. Documentation in medical files improved: ARF episode documentation increased from 31/55 (56%) to 50/62 (81%) (p = 0.004), and RHD risk category documentation from 87/154 (56%) to 103/145 (76%) (p < 0.001). Large differences in performance were noted between health centres, reflected to some extent in SAT scores.ConclusionsA CQI process using a systems approach and participatory action research methodology can significantly improve delivery of ARF/RHD care.

ObjectivesA relationship between ambient air pollution and adverse birth outcomes has been found in a large number of studies that have mainly used a nearest monitor methodology. Recent research has suggested that the effect size may have been underestimated in these studies. This paper examines associations between birth outcomes and ambient levels of residential and workplace sulphur dioxide, particulates and Nitrogen Dioxide estimated using an alternative method – pollution climate mapping.MethodsRisk of low birthweight and mean birthweight (for n=21,843 term births) and risk of preterm birth (for n=23,086 births) were modelled against small area annual mean ambient air pollution concentrations at work and residence location adjusting for potential confounding factors for singleton live births (1994–2008) across Scotland.ResultsOdds ratios of low birthweight of 1.02 (95% CI, 1.01–1.03) and 1.07 (95% CI, 1.01–1.12) with concentration increases of 1 µg/m3 for NO2 and PM10 respectively. Raised but insignificant risks of very preterm birth were found with PM10 (relative risk ratio=1.08; 95% CI, 1.00 to 1.17 per 1 µg/m3) and NO2 (relative risk ratio=1.01; 95% CI, 1.00 to 1.03 per 1 µg/m3). An inverse association between mean birthweight and mean annual NO2(−1.24 g; 95% CI, −2.02 to −0.46 per 1 µg/m3) and PM10 (−5.67 g; 95% CI, −9.47 to −1.87 per 1 µg/m3). SO2 showed no significant associations.ConclusionsThis study highlights the association between air pollution exposure and reduced newborn size at birth. Together with other recent work it also suggests that exposure estimation based on the nearest monitor method may have led to an under-estimation of the effect size of pollutants on birth outcomes.

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