Progress against inequalities in mortality: register-based study of 15 European countries between 1990 and 2015

Abstract

Socioeconomic inequalities in mortality are a challenge for public health around the world, but appear to be resistant to policy-making. We aimed to identify European countries which have been more successful than others in narrowing inequalities in mortality, and the factors associated with narrowing inequalities. We collected and harmonised mortality data by educational level in 15 European countries over the last 25 years, and quantified changes in inequalities in mortality using a range of measures capturing different perspectives on inequality (e.g., 'relative' and 'absolute' inequalities, inequalities in 'attainment' and 'shortfall'). We determined which causes of death contributed to narrowing of inequalities, and conducted country-and period-fixed effects analyses to assess which country-level factors were associated with narrowing of inequalities in mortality. Mortality among the low educated has declined rapidly in all European countries, and a narrowing of absolute, but not relative inequalities was seen in many countries. Best performers were Austria, Italy (Turin) and Switzerland among men, and Spain (Barcelona), England and Wales, and Austria among women. Ischemic heart disease, smoking-related causes (men) and amenable causes often contributed to narrowing inequalities. Trends in income inequality, level of democracy and smoking were associated with widening inequalities, but rising health care expenditure was associated with narrowing inequalities. Trends in inequalities in mortality have not been as unfavourable as often claimed. Our results suggest that health care expansion has counteracted the inequalities widening effect of other influences.

Social inequalities in tobacco-attributable mortality in Spain. The intersection between age, sex and educational level

“…Tobacco is also a leading contributor to health inequalities [3][4][5][6][7][8][9][10][11][12]. The unequal distribution of tobacco consumption is influenced by the social, economic, and environmental circumstances in which people are born, live, learn, work, and age (i.e., the social determinants of health) [13].…”

“…Moreover, it may influence access to and quality of health care services, environmental exposure to other contaminants, and the presence of other health risks, including chronic biological stress, alcohol consumption, sedentary behavior, unhealthy diet, and morbidities [13,17]. Overall, there is a social gradient and low socioeconomic status tends to have more of a negative impact than high status [3][4][5][6][7][8][9][10][11][12].…”

“…Some European studies that have examined social inequalities in mortality and survival attribute a substantial part of these inequalities to unequal tobacco consumption [3][4][5][6][7][8][9][10][11][12]. Gregoraci et al estimated that the contribution of smoking to socioeconomic inequalities in mortality varied between 19% and 55% in men and -1% and 56% in women [4].…”

“…Thus, the potential for reducing the relative inequalities in premature mortality depends largely on lowering the prevalence of tobacco consumption in the groups with the lowest level of education [9]. At the regional level, absolute inequalities in TAM and the contribution of smoking to inequalities in total mortality in most countries have decreased among men, while increasing among women [4,10]. Southern European countries, including Spain, are between the third and fourth stage of the tobacco epidemic.…”

Economic Fluctuations and Urban-rural Differences in Educational Inequalities in Mortality in Three Baltic Countries and Finland in 2000–2015: A Register-based Study

“…Educational inequalities in mortality persist in Europe although in most countries mortality rates have also declined rapidly among the low educated [1].…”