Socioeconomic Inequalities in Health in 22 European Countries
05 Jun 2008-The New England Journal of Medicine (Massachusetts Medical Society)-Vol. 358, Iss: 23, pp 2468-2481
TL;DR: In this article, the authors compared the magnitude of inequalities in mortality and self-assessed health among 22 countries in all parts of Europe and found that in almost all countries, the rates of death and poorer selfassessments of health were substantially higher in groups of lower socioeconomic status.
Abstract: A b s t r ac t Background Comparisons among countries can help to identify opportunities for the reduction of inequalities in health. We compared the magnitude of inequalities in mortality and self-assessed health among 22 countries in all parts of Europe. Methods We obtained data on mortality according to education level and occupational class from census-based mortality studies. Deaths were classified according to cause, including common causes, such as cardiovascular disease and cancer; causes related to smoking; causes related to alcohol use; and causes amenable to medical intervention, such as tuberculosis and hypertension. Data on self-assessed health, smoking, and obesity according to education and income were obtained from health or multipurpose surveys. For each country, the association between socioeconomic status and health outcomes was measured with the use of regression-based inequality indexes. Results In almost all countries, the rates of death and poorer self-assessments of health were substantially higher in groups of lower socioeconomic status, but the magnitude of the inequalities between groups of higher and lower socioeconomic status was much larger in some countries than in others. Inequalities in mortality were small in some southern European countries and very large in most countries in the eastern and Baltic regions. These variations among countries appeared to be attributable in part to causes of death related to smoking or alcohol use or amenable to medical intervention. The magnitude of inequalities in self-assessed health also varied substantially among countries, but in a different pattern. Conclusions We observed variation across Europe in the magnitude of inequalities in health associated with socioeconomic status. These inequalities might be reduced by improving educational opportunities, income distribution, health-related behavior, or access to health care.
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TL;DR: A scientific consensus is emerging that the origins of adult disease are often found among developmental and biological disruptions occurring during the early years of life as mentioned in this paper, and that these early experiences can affect adult health in 2 ways: cumulative damage over time or by the biological embedding of adversities during sensitive developmental periods.
Abstract: A scientific consensus is emerging that the origins of adult disease are often found among developmental and biological disruptions occurring during the early years of life. These early experiences can affect adult health in 2 ways—either by cumulative damage over time or by the biological embedding of adversities during sensitive developmental periods. In both cases, there can be a lag of many years, even decades, before early adverse experiences are expressed in the form of disease. From both basic research and policy perspectives, confronting the origins of disparities in physical and mental health early in life may produce greater effects than attempting to modify health-related behaviors or improve access to health care in adulthood.
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TL;DR: Evidence has accumulated pointing to socioeconomic factors such as income, wealth, and education as the fundamental causes of a wide range of health outcomes, and plausible pathways and biological mechanisms that may explain their effects are reviewed.
Abstract: During the past two decades, the public health community’s attention has been drawn increasingly to the social determinants of health (SDH)—the factors apart from medical care that can be influenced by social policies and shape health in powerful ways. We use “medical care” rather than “health care” to refer to clinical services, to avoid potential confusion between “health” and “health care.” The World Health Organization’s Commission on the Social Determinants of Health has defined SDH as “the conditions in which people are born, grow, live, work and age” and “the fundamental drivers of these conditions.” The term “social determinants” often evokes factors such as health-related features of neighborhoods (e.g., walkability, recreational areas, and accessibility of healthful foods), which can influence health-related behaviors. Evidence has accumulated, however, pointing to socioeconomic factors such as income, wealth, and education as the fundamental causes of a wide range of health outcomes. This article broadly reviews some of the knowledge accumulated to date that highlights the importance of social—and particularly socioeconomic— factors in shaping health, and plausible pathways and biological mechanisms that may explain their effects. We also discuss challenges to advancing this knowledge and how they might be overcome.
1,856 citations
TL;DR: In the United States between 2001 and 2014, higher income was associated with greater longevity, and differences in life expectancy across income groups increased over time, however, the association between life expectancy and income varied substantially across areas; differences in longevity acrossincome groups decreased in some areas and increased in others.
Abstract: Importance The relationship between income and life expectancy is well established but remains poorly understood. Objectives To measure the level, time trend, and geographic variability in the association between income and life expectancy and to identify factors related to small area variation. Design and Setting Income data for the US population were obtained from 1.4 billion deidentified tax records between 1999 and 2014. Mortality data were obtained from Social Security Administration death records. These data were used to estimate race- and ethnicity-adjusted life expectancy at 40 years of age by household income percentile, sex, and geographic area, and to evaluate factors associated with differences in life expectancy. Exposure Pretax household earnings as a measure of income. Main Outcomes and Measures Relationship between income and life expectancy; trends in life expectancy by income group; geographic variation in life expectancy levels and trends by income group; and factors associated with differences in life expectancy across areas. Results The sample consisted of 1 408 287 218 person-year observations for individuals aged 40 to 76 years (mean age, 53.0 years; median household earnings among working individuals, $61 175 per year). There were 4 114 380 deaths among men (mortality rate, 596.3 per 100 000) and 2 694 808 deaths among women (mortality rate, 375.1 per 100 000). The analysis yielded 4 results. First, higher income was associated with greater longevity throughout the income distribution. The gap in life expectancy between the richest 1% and poorest 1% of individuals was 14.6 years (95% CI, 14.4 to 14.8 years) for men and 10.1 years (95% CI, 9.9 to 10.3 years) for women. Second, inequality in life expectancy increased over time. Between 2001 and 2014, life expectancy increased by 2.34 years for men and 2.91 years for women in the top 5% of the income distribution, but by only 0.32 years for men and 0.04 years for women in the bottom 5% ( P r = −0.69, P r = 0.72, P r = 0.42, P r = 0.57, P Conclusions and Relevance In the United States between 2001 and 2014, higher income was associated with greater longevity, and differences in life expectancy across income groups increased over time. However, the association between life expectancy and income varied substantially across areas; differences in longevity across income groups decreased in some areas and increased in others. The differences in life expectancy were correlated with health behaviors and local area characteristics.
1,663 citations
TL;DR: Improving adolescent health worldwide requires improving young people's daily life with families and peers and in schools, addressing risk and protective factors in the social environment at a population level, and focusing on factors that are protective across various health outcomes.
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TL;DR: A 5-tier pyramid best describes the impact of different types of public health interventions and provides a framework to improve health and implements interventions at each of the levels to achieve the maximum possible sustained public health benefit.
Abstract: A 5-tier pyramid best describes the impact of different types of public health interventions and provides a framework to improve health. At the base of this pyramid, indicating interventions with the greatest potential impact, are efforts to address socioeconomic determinants of health. In ascending order are interventions that change the context to make individuals' default decisions healthy, clinical interventions that require limited contact but confer long-term protection, ongoing direct clinical care, and health education and counseling.Interventions focusing on lower levels of the pyramid tend to be more effective because they reach broader segments of society and require less individual effort. Implementing interventions at each of the levels can achieve the maximum possible sustained public health benefit.
1,230 citations
References
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01 Jan 1990
TL;DR: In this paper, Esping-Andersen distinguishes three major types of welfare state, connecting these with variations in the historical development of different Western countries, and argues that current economic processes such as those moving toward a post-industrial order are shaped not by autonomous market forces but by the nature of states and state differences.
Abstract: Few discussions in modern social science have occupied as much attention as the changing nature of welfare states in Western societies. Gosta Esping-Andersen, one of the foremost contributors to current debates on this issue, here provides a new analysis of the character and role of welfare states in the functioning of contemporary advanced Western societies. Esping-Andersen distinguishes three major types of welfare state, connecting these with variations in the historical development of different Western countries. He argues that current economic processes, such as those moving toward a postindustrial order, are shaped not by autonomous market forces but by the nature of states and state differences. Fully informed by comparative materials, this book will have great appeal to all those working on issues of economic development and postindustrialism. Its audience will include students of sociology, economics, and politics."
16,883 citations
TL;DR: A Commission on Social Determinants of Health is launching, which will review the evidence, raise societal debate, and recommend policies with the goal of improving health of the world's most vulnerable people.
3,670 citations
TL;DR: In this paper, the authors identify some common traits of the welfare states of Italy, Spain, Por tugal and Greece, with special attention to in stitutional and political aspects, and propose a model to compare them.
Abstract: This article tries to identify some common traits of the welfare states of Italy, Spain, Por tugal and Greece, with special attention to in stitutional and political aspects.
2,588 citations
TL;DR: Among individuals aged 70 to 90 years, adherence to a Mediterranean diet and healthful lifestyle is associated with a more than 50% lower rate of all-causes and cause-specific mortality.
Abstract: ContextDietary patterns and lifestyle factors are associated with mortality
from all causes, coronary heart disease, cardiovascular diseases, and cancer,
but few studies have investigated these factors in combination.ObjectiveTo investigate the single and combined effect of Mediterranean diet,
being physically active, moderate alcohol use, and nonsmoking on all-cause
and cause-specific mortality in European elderly individuals.Design, Setting, and ParticipantsThe Healthy Ageing: a Longitudinal study in Europe (HALE) population,
comprising individuals enrolled in the Survey in Europe on Nutrition and the
Elderly: a Concerned Action (SENECA) and the Finland, Italy, the Netherlands,
Elderly (FINE) studies, includes 1507 apparently healthy men and 832 women,
aged 70 to 90 years in 11 European countries. This cohort study was conducted
between 1988 and 2000.Main Outcome MeasuresTen-year mortality from all causes, coronary heart disease, cardiovascular
diseases, and cancer.ResultsDuring follow-up, 935 participants died: 371 from cardiovascular diseases,
233 from cancer, and 145 from other causes; for 186, the cause of death was
unknown. Adhering to a Mediterranean diet (hazard ratio [HR], 0.77; 95% confidence
interval [CI], 0.68-0.88), moderate alcohol use (HR, 0.78; 95% CI, 0.67-0.91),
physical activity (HR, 0.63; 95% CI, 0.55-0.72), and nonsmoking (HR, 0.65;
95% CI, 0.57-0.75) were associated with a lower risk of all-cause mortality
(HRs controlled for age, sex, years of education, body mass index, study,
and other factors). Similar results were observed for mortality from coronary
heart disease, cardiovascular diseases, and cancer. The combination of 4 low
risk factors lowered the all-cause mortality rate to 0.35 (95% CI, 0.28-0.44).
In total, lack of adherence to this low-risk pattern was associated with a
population attributable risk of 60% of all deaths, 64% of deaths from coronary
heart disease, 61% from cardiovascular diseases, and 60% from cancer.ConclusionAmong individuals aged 70 to 90 years, adherence to a Mediterranean
diet and healthful lifestyle is associated with a more than 50% lower rate
of all-causes and cause-specific mortality.
1,545 citations
TL;DR: Eight different classes of summary measures can be distinguished, and measures of "total impact" can be further subdivided on the basis of their underlying assumptions, to arrive at 12 types of summary measure.
1,219 citations