Health Inequalities

Definition and explanations of socioeconomic inequalities in health

Socioeconomic inequalities in health (higher morbidity and mortality among people with a low level of education, occupation or income) have been reported for many countries and are an important challenge for public health in Europe.

Socioeconomic inequalities in health may be reduced by aiming policies and interventions at:

• inequalities in education, income, occupation
• the negative effects of health problems on the educational level, occupational level and income of people
• exposure to unhealthy living and working conditions and to an unhealthy life style in the lower socioeconomic groups
• access to health care facilities and quality of health care for people with a low socioeconomic status.

Eurothine project important data source

In this EUphocus we mainly present findings of the Eurothine project, the most recent (1990s and early 2000s) European project on the magnitude of socioeconomic inequalities in health in a large number of countries of both Western and Eastern Europe (Mackenbach et al., 2007a). The sections on ‘inequalities in mortality and morbidity’, 'inequalities in cancer mortality', ‘inequalities in diabetes mellitus’ and ‘inequalities in lifestyle’ are mainly based on results from this project.

Inequalities in mortality and morbidity and in cancer mortality

The most important findings are that in all countries included in the study:

• all cause mortality is higher in the lower as compared to higher educated men and women
• self-assessed health is worse in lower as compared to higher educated men and women
• alcohol related mortality is higher among the lower educated men and women
• avoidable mortality is higher among lower educated men and women; this was found for all cause avoidable mortality and for mortality from infectious diseases, cardio-respiratory conditions and all avoidable acute conditions, but to a much lesser extent for mortality from all avoidable malignant conditions.
• both total cancer mortality rates and lung cancer mortality are higher among lower educated men than among higher educated men, while among women, the gradient is much smaller or even absent in some countries
• inequalities in morbidity and mortality vary substantially between countries for each of the studied causes

Inequalities in diabetes mellitus

Low educated people have a higher prevalence of diabetes than the higher educated. Inequalities in the prevalence of diabetes are larger among women than among men. Among men, the majority of countries show weak associations between educational level and diabetes prevalence, while in women these associations are clearer.

Inequalities in life style

The association between socioeconomic status and a number of lifestyle factors is presented in this EUphocus, as lifestyle factors are important determinants of socioeconomic inequalities in health.

Inequalities in obesity

The prevalence of obesity is higher among lower socioeconomic groups almost anywhere in Europe. Exceptions are men in all Baltic and most Eastern European countries, where obesity was (slightly) more common among higher educated men. Among women, the inequalities were largest in Southern Europe. In countries with a high general welfare level obesity is more common among lower educated men than among higher educated men. This association between general welfare level and inequalities in obesity was not found among women.

Inequalities in physical activity

The prevalence of a sedentary lifestyle was lowest in the highest educational group in most countries. Northern countries (Finland, Norway, Denmark) have a distinct profile. Although the overall prevalence of a sedentary lifestyle is relatively low, relatively small differences between the highest and lowest educated groups can be observed. In Southern countries a stronger association between educational level and a sedentary life style is found than in Central European countries.

Inequalities in smoking

In Europe as a whole, smoking is more common in lower educational groups, with inequalities in smoking being larger among men. In the North, West and Continental regions large inequalities in smoking can be identified. Small inequalities, even ‘reverse’ inequalities, among women in smoking are observed in the southern regions. In the East and Baltic regions the pattern is inconsistent. Inequalities in the quitting smoking are also observed. Among both men and women, higher educated ever-smokers are more likely to have quitted than lower educated ever-smokers.

Inequalities in health service access

Access to good quality health services is an important determinant of socioeconomic inequalities in health. The most commonly used definition of ‘equitable access to health services’ is described as equal access to treatment for those in equal medical need, irrespective of other characteristics, such as income.

EU Member States have identified the need to ensure equal access for all as a priority. Accessible healthcare is included in the common objectives of the ‘Open method of coordination’ on social protection and social inclusion.

Some barriers to access health services may have relatively more impact on disadvantaged groups than others. Examples of such barriers are costs and distance on the supply-side, as well as demand-side factors such as communication skills and health beliefs. These barriers should be translated into clear policy measures when aiming to tackle inequalities in access.

Access to health services is mostly measured by the proxy measure ‘service utilisation’ or by indicators of access hurdles such as user charges of waiting times. Need for services is often measured by levels of (self-reported) ill-health, which is generally worse among the lower socioeconomic groups. Within EU-related frameworks, indicators of access barriers and indicators of service utilisation are used.

In all current EU member states inequalities in access to health services exist. In general, people with a higher socioeconomic status have better access to the medical specialist and dentist, while they use less emergency services than those with a lower socioeconomic status. The access to GP services seems fairly equally distributed across socioeconomic groups. However, once people go to see their GP the people with lower incomes are more likely to consult them more often.

Costs of health services seem to be the most important barrier in health service access, compared to organisational distance and availability of transport, in the vast majority of Member States. The extent and characteristics of financial hurdles are shaped by national health system characteristics and vary from country to country. Private health insurance and especially costs sharing seem to impact equity of access most negatively.

Policies to reduce health inequalities

Both the World Health Organisation (WHO) and the European Union (EU) provide policy frameworks which supports individual countries in emphasizing the need to tackle inequalities in health.

WHO policy

The WHO set a health equity target for its European region in 1998 (WHO, 1998a): ‘By the year 2020, the health gap between socioeconomic groups should be reduced by at least one fourth in all member states, by substantially improving the level of health of disadvantaged groups’. Furthermore WHO has undertaken two important initiatives which help to prioritise health inequalities: the WHO-Europe Programme 'Socioeconomic Determinants of Health’ and ‘the Commission on Social Determinants of Health’.

EU policy

EU policy in the area of inequalities in health involves:

• the inclusion of a specific health equity objective within both its new Health Strategy (‘the reduction of inequities in health, both between and within member states’) and its Public Health Programme (‘greater equality in health’). Both programmes cover the period 2008 to 2013.
• supporting the reduction of inequalities by promoting the integration of health equity considerations into non-health policies and legislation (‘cross-sectoral policies’.
• promoting social inclusion within its member states (via the ‘Community Action Programme to Combat Social Exclusion’ and the ‘PROGRESS programme’);
• funding a number of initiatives through its Public Health Programmes that promote the sharing of good practice and knowledge on health inequalities and policy advice (these include: ‘Closing the Gap’, ‘Eurothine’ and ‘DETERMINE’). [link all three: see document on policies)

National policies and strategies

Socioeconomic inequalities in health are the result of a broad range of determinants and therefore a comprehensive national policy approach is needed to tackle these inequalities. Country specific analyses of the contribution of these determinants to inequalities in health should guide a national policy and this policy should be supported by specific, measurable, achievable, realistic and time-based equity targets. These targets enable the progress towards greater health equity to be monitored at a national level and the effectiveness of the chosen policy approach to be evaluated on a regular basis.

Currently, EU member states are at different stages in establishing policies and strategies to reduce these inequalities. Some countries have adopted a cross-government strategy to tackle health inequalities, such as Norway, Sweden and England. The policy approach in England serves as an example for other countries: the cross-government strategy is backed by all government departments, is based on strong local, regional and national partnerships and is supported by clear targets which are being monitored.

Definition of ‘socioeconomic inequalities in health’

Socioeconomic inequalities in health can be defined as systematic differences in the prevalence or incidence of health problems between people of higher and lower socioeconomic status (distinguished by level of education, occupational class, or income) (Kunst & Mackenbach, 1994). For most health problems, a higher prevalence or incidence is observed in the lower socioeconomic groups.

Explanations of socioeconomic inequalities in health

Several explanations of socioeconomic inequalities in health are entry-points for policies and interventions to reduce these inequalities. A reduction of socioeconomic inequalities in health may be achieved by (a combination of) the following entry-points:

• a reduction of inequalities in education, income, occupation
• to diminish the negative effects of health problems on the educational level, occupational level and income of people
• to diminish the negative health effects of exposure to unhealthy living and working conditions and of an unhealthy life style; the prevalence of these unhealthy factors is often higher in the lower socioeconomic groups (see: Inequalities in smoking and lung cancer)
• to improve access to health care facilities and the quality of health care for people with a low socioeconomic status.

Inequalities in health are strongly connected to inequalities in other areas of society, such as inequalities in socioeconomic status and living and working conditions. It is a problem with many causes, that cannot be tackled by the health care sector alone. An integrated approach based on integrated policy is needed (Wilkinson & Marmot, 2003; De Hollander et al., 2006).

Introduction

Socioeconomic inequalities in health are an important challenge for public health in Europe. Such inequalities are substantial in all countries for which data exist and they concern inequalities in mortality, life expectancy and morbidity.

In the 1980s, socioeconomic inequalities in mortality and morbidity were found in many Western European countries. In countries in Northern Europe, such as Norway, Sweden and Finland, health inequalities were not smaller than in other Western European countries, despite long-term political commitment to reduce socioeconomic inequalities in these Northern countries (Mackenbach et al., 1997).

Here we present the findings of the Eurothine project, the most recent (1990s and early 2000s) European project on the magnitude of socioeconomic inequalities in mortality and morbidity in a large number of countries of both Western and Eastern Europe (Mackenbach et al., 2007a).

Inequalities in all cause mortality

In 16 European countries, all cause mortality was higher in the lower as compared to the higher socioeconomic groups. See Relative inequalities in total mortality by level of education. However, the magnitude of inequalities in total mortality by educational level varies substantially between countries. For both men and women, inequalities are smallest in the Basque Country and the largest in the Czech Republic (for men) and Lithuania (for women). In the Southern European populations, educational inequalities in mortality were smaller than average, while most countries in the East and Baltic regions have larger-than-average educational inequalities in mortality (Mackenbach et al., 2007b).

Inequalities in morbidity

Throughout the European continent, the same pattern is observed: worse self-assessed health is lower as compared to higher socioeconomic groups. In Italy and Spain, educational inequalities in self-assessed health are smaller than the European average. In the Baltic region, educational inequalities in self-assessed health are larger than average (see Relative inequalities in self-assessed health by level of education).

The association between alcohol consumption and mortality is complex: there are potential benefical effects of moderate alcohol consumption, while excessive use may cause substantial health problems and mortality.

Alcohol related mortality includes deaths from a great number of underlying causes, which can be divided into two large groups:

• mortality from alcohol related disease (natural causes);
• mortality from alcohol related injuries or adverse effects (external causes).

It is important to note that only part of the specific causes of death related to alcohol, such as alcoholic cirrhosis, can be wholly attributed to alcohol. For many other diseases, alcohol is only one of the potential causes.

A few earlier studies reported on higher alcohol-related mortality among lower socioeconomic groups within some European populations (Harrison & Gardiner, 1999; Mäkelä et al., 1997; Mäkelä et al., 2003). From the Eurothine study it appears that alcohol related mortality is higher among lower educated men and women in all countries. Educational differences in alcohol related mortality are especially large in some countries; for example in Hungary and the Czech Republic for men and in the East and Baltic region for women (Van Oyen et al., 2007).

See Relative indices of inequality for all cause mortality and alcohol related mortality in men in selected countries by age, and Relative indices of inequality for all cause mortality and alcohol related mortality in women in selected countries by age.

See also EUphact details Alcohol use.

Socioeconomic inequalities in health may partly be caused by inequalities in access to and quality of health services. Avoidable mortality stands for mortality from conditions amenable to medical interventions.

Some studies revealed higher levels of avoidable mortality among people with a low socioeconomic status or among people from disadvantaged ethnic groups (Tobias & Jackson, 2001; Poikolainen & Eskola, 1995; Wood et al., 1999; Stirbu et al., 2006; Westerling et al., 1996; Schwarz, 2007.

In the Eurothine study, avoidable mortality refers to mortality from conditions that are amenable to treatment, including those subject to early detection programs (Stirbu et al., 2007).

Inequalities in all avoidable mortality

Inequalities in all avoidable mortality are present in all included European populations. Smaller inequalities in all avoidable mortality are observed in Southern European populations and larger inequalities are found in Central-Eastern European countries and Baltic countries (Stirbu et al., 2007).

See Relative index of inequality (RII) for all avoidable mortality in selected countries.

Inequalities in mortality from infectious diseases

Large inequalities are observed in the group infectious diseases. For all infectious diseases combined, inequalities are larger in CEE and Baltic countries, while among western European countries large inequalities are found in Denmark and the Basque region (Stirbu et al., 2007).

See Relative index of inequality (RII) for diseases of infectious origin in selected countries.

Inequalities in mortality from all avoidable malignant conditions

Small or no inequalities are found in mortality from all avoidable malignant conditions in Northern and Western European countries. In CEE and Baltic countries, inequalities in mortality from these causes are clearly larger, in favour of the higher educated (Stirbu et al., 2007).

See Relative index of inequality (RII) for avoidable mortility of all malignant diseases in selected countries.

Inequalities in mortality from cardio-respiratory conditions

For all countries, inequalities by education are observed for mortality from all cardio-respiratory conditions, favouring the higher educated. Inequalities are especially large in CEE and Baltic countries (Stirbu et al., 2007).

See Relative index of inequality (RII) for all cardio-respiratory conditions in selected countries.

Inequalities in mortality from all avoidable acute conditions

Relatively large inequalities, with higher mortality in the lower educated, are found in all European countries for all avoidable acute conditions. The level of inequalities varies substantially between countries however (Stirbu et al., 2007).

See Relative index of inequality (RII) for all avoidable acute conditions in selected countries.

Inequalities in total cancer mortality

Total cancer mortality rates are higher among lower educated men than among higher educated men (Faggiano et al., 1997; Borrell et al., 2003; Mackenbach et al., 1999; Doornbos & Kromhout, 1990; Faggiano et al., 1995; Menvielle et al., 2005; Davey Smith et al., 1991; Menvielle et al., 2007).

Among women, the educational gradient in cancer mortality is much smaller than among men and even absent in Spanish regions and Slovenia.

See Relative indices of inequality related to education and mortality rates for total cancer mortality.

Most earlier studies were conduced in Southern Europe and did not find any variation in total cancer mortality by socioeconomic status among women (Faggiano et al., 1997; Borrell et al., 2003; Menvielle et al., 2005; Michelozzi, 1999).

Inequalities in lung cancer mortality

Lung cancer is the most common death from cancer (almost 20% from total cancer mortality) (Ferlay et al., 2007).

Socioeconomic differences in lung cancer mortality are present in many countries. Although there is quite some variation in the size of inequalities in lung cancer mortality, lung cancer mortality is higher among men with a lower socioeconomic status in all countries (Mackenbach et al., 2004; van der Van der Heyden et al., 2007). See Relative indices of inequality for lung cancer mortality in men in selected countries by age.

Among women, more variation in the pattern of lung cancer mortality by education is observed than among men. In the Northern European and Continental populations, lung cancer mortality is higher among women with a low education. In Southern European populations and Slovenia, a low socioeconomic status is associated with a lower lung cancer mortality. See Relative indices of inequality for lung cancer mortality in women in selected countries by age.

Inequalities in smoking and lung cancer

Patterns of educational differences in lung cancer mortality differ according to population and gender. The differences in lung cancer mortality found between populations reflect differences in the smoking epidemic between countries.

‘Smoking epidemic’ is a concept used to describe the diffusion of the smoking habit in a population. The general pattern is that first, higher smoking rates are observed among people with a high socioeconomic position, but later smoking rates are higher among people with a low socioeconomic position.

• in Slovenia and Spain, smoking occurs more often among highly educated women (but among men the reverse pattern is observed).
• in Nordic countries, Belgium and Switzerland, smoking is more common among women with a low education.
• France and Northern Italy (Turin) show an intermediate situation.

Also see Inequalities in life style, and the EUphacts on Smoking, and Lung cancer.

Inequalities in the prevalence of diabetes

In earlier studies on the association between socioeconomic position and diabetes prevalence, a disadvantaged socioeconomic position was related to a higher prevalence of diabetes (Dalstra et al., 2005; Larranaga et al., 2005; Abu et al., 1997; Connolly et al., 2000; Brown et al., 2004; Kumari et al., 2004; Wray et al., 2006).

This association was confirmed in a more recent study on socioeconomic inequalities in the prevalence of diabetes in different areas of Europe (Espelt et al., 2007). In the majority of the studied countries, people with a higher socioeconomic position have a prevalence of diabetes of around 3%. People with a lower socioeconomic position have a higher prevalence of diabetes, which is around 5%. Inequalities in the prevalence of diabetes are larger in women than in men. In men, the majority of countries show weak associations between socioeconomic position and diabetes, while in women these associations are clearer. These differences are more accentuated in Western countries, both in women as in men.

See Age-standardised prevalence ratio of diabetes by educational level in men and women, 30-64 years of age in selected countries.

Obesity and diabetes

Diabetes and obesity are strongly linked but the prevalence of both diabetes and obesity varies throughout populations. In Western countries, the risk of developing diabetes and/or risk factors associated with diabetes is linked to a low socioeconomic position (Connolly & Kesson, 1996; Connolly et al., 2000; Evans et al., 2000; Hjelm et al., 1996).

In most countries, a lower educational level was associated with a relatively high prevalence of diabetes. Among people with a lower education diabetes was 1.5 and 2.7 times more common for men and women, respectively. Obesity was 1.6 and 1.9 times more common for men and women with lower education. Inequalities in both diabetes and obesity were generally larger among women, especially among those from southern European countries. Combating inequalities in obesity prevalence is very likely to also impact inequalities in diabetes (Roskam & Kunst, 2007).

Also see EUphacts Overweight and Diabetes..

Obesity is, just like smoking, strongly socially patterned in many countries, and therefore potentially relevant for explaining international variations in health inequalities. Over the past decades, obesity has become more prevalent in the lower socioeconomic groups in many countries, sometimes with transitions from ‘reverse’ inequalities (higher rates of obesity in higher socioeconomic groups) to ‘regular’ inequalities (higher rates of obesity in lower socioeconomic groups) (Van Oort et al., 2005; Lopez et al., 1994; Huisman et al., 2005a; Ezzati et al., 2005; Sobal & Stunkard, 1989).

It is found that in Europe obesity is more common in lower educational groups, with larger inequalities among women than among men. Large inequalities in obesity are observed in the Southern region of Europe, particularly among women. In the East and Baltic regions inequalities in obesity tend to be smaller than the European average (Mackenbach et al., 2007).

Also see EUphact Overweight.

Among men, the overall prevalence of obesity was 11%, and ranged from 6.0% in France to 21.6% in England. Considerable variations in inequalities in obesity in men could be observed between different countries. Sweden, Czech Republic and the Netherlands showed the largest ‘negative’ educational inequalities in obesity and Ireland, Latvia and Lithuania the smallest. Among women, the overall prevalence of obesity was also 11%, and ranged from 5.0% in Italy to 23.3% in England. The educational inequalities in obesity were smallest in Latvia, Finland and Norway and largest in Portugal.

It can be concluded that the phenomenon of inverse gradients of obesity (prevalence is higher among lower socioeconomic groups) is present almost anywhere in Europe. Exceptions were men in all Baltic and most Eastern European countries, where obesity was (slightly) more common among men with a higher education. The inequalities were largest among women of Southern Europe. When general welfare levels increased obesity became increasingly more common among men of lower education, while the opposite was true for men of higher education. Women did not show a clear effect of general welfare level on inequalities in obesity.

See Relative inequalities by level of education in obesity in men and women in selected countries.

Evidence for socioeconomic inequalities in physical activity is scarce and inconclusive. Earlier studies show that, for total physical activity among males, the higher socioeconomic groups have lower levels of physical activity, while females display fewer differences between the socioeconomic groups (DoH, 2004; NCSR, 2003, 2004). When the focus is on sports activities, the relation shows the opposite; higher socioeconomic groups have higher levels of participation in sports (NCSR, 2003, 2004). Furthermore it was found that participants with primary level education were more sedentary than those with higher levels of education, with greater differences among females (Varo et al., 2003).

Also see EUphact Physical activity

A more recent study shows that the levels of physical activity during leisure time are low in general throughout Europe (Demarest et al., 2007). Overall, 36% of males and 42% of females in the age group 16 to 64 years describe their leisure time activity as predominantly of a sedentary nature. The prevalence of a sedentary lifestyle was lowest in the highest educational group. Northern countries (Finland, Norway, Denmark) have a distinct profile. Although the overall prevalence of a sedentary lifestyle is relatively low, relatively small differences between the highest and lowest educated groups can be observed. In both Southern and Eastern European countries, large parts of the population do indicate not to perform any leisure time activity. In Southern countries, this phenomenon is more explicitly socioeconomical determined than in Central European countries.

See Percentage age-adjusted prevalence of a sedentary lifestyle by educational level in men and women in selected countries.

Socio-economic inequalities in smoking have widened and persisted in the last decades (Giskes et al., 2005). Due to higher initiation rates and lower cessation rates, smoking prevalence is higher among lower socioeconomic groups compared to higher socioeconomic groups in most European countries. On average, lower socioeconomic groups smoke more cigarettes per day and are more susceptible to nicotine addiction compared to higher socioeconomic groups. The inequalities in smoking are somewhat more pronounced in northern Europe than in southern Europe. This is a consequence of a more advanced evolvement of the smoking epidemic in northern European countries (Schaap et al., 2007a; Huisman et al., 2005b; Cavelaars et al., 2000).

Countries in the South region are in an earlier stage of the smoking epidemic than countries in the North, West and Continental regions (Van Oort et al., 2005; Lopez et al., 1994). For women a reverse association between educational level and smoking was found (higher educated women smoke more often than lower educated women), while inequalities in smoking were small among men (Mackenbach et al., 2007b).

The history of the smoking epidemic is not extensively documented for the East and Baltic regions, contrary to other European regions. For decades smoking has been highly prevalent among men, and although smoking rates have traditionally been low among women, they have increased strongly in the 1990s (Kubik et al., 1995; Pudule et al., 1999). Although proper historical data on the social pattern in smoking is lacking in these countries, it can be assumed that smoking rates are higher in the lower socioeconomic groups. This is consistent with the larger inequalities in mortality from smoking related conditions (Mackenbach et al., 2007b).

In Europe as a whole, smoking is more common in lower educational groups, with inequalities in smoking being larger among men. In the North, West and Continental regions large inequalities in smoking can be identified. Small inequalities, even ‘reverse’ inequalities, among women in smoking are observed in the southern regions. In the East and Baltic regions the pattern is inconsistent (Mackenbach et al., 2007b).

See Relative inequalities by level of education in current smoking in men and women in selected countries

Inequalities in smoking quit ratios

Among both men and women, higher educated ever-smokers are more likely to have quitted than lower educated ever-smokers. Absolute differences in quit ratios between high and low educated are generally larger in the age group 25-39 years than in the age group 40-59 years. Quit ratios are especially high in Sweden, England, The Netherlands, Belgium and France, and relatively low in Lithuania and Latvia (Schaap et al., 2007b).

Men

For men in the age of 25-39 years, the largest inequalities in quit ratios are found in the Czech Republic and Latvia. Inequalities in quit ratios are smallest in Ireland and Sweden. For men in the age of 40-59 years, largest inequalities in quit ratios are found in Latvia, Lithuania and Estonia. In Portugal and Germany the inequalities in quit ratios are smallest in this subgroup (Schaap et al., 2007b).

See National levels and educational inequalities in quit ratios in men in selected countries

Women

For women in the age of 25-39 years, the largest inequalities in quit ratios are found in Latvia and Hungary, while Portugal had small inequalities in this subgroup. For women in the age of 40-59 years, the largest inequalities in quit ratios are observed in Denmark and Slovakia, while small inequalities are observed in Latvia and Portugal (Schaap et al., 2007b).

See National levels and educational inequalities in quit ratios in women in selected countries

Also see EUphacts Smoking and Smoking policies.

Equitable access to health care may alleviate health inequalities

Access to good quality health services is an important health determinant. Over the years, improved access to health care services for the lower socio-economic groups helped reduce inequities in health, notably differences in mortality (Dahlgren & Whitehead, 2006). Health systems are still widely recognized as an important means to improve population health and improving health systems can play a role in tackling health inequalities (WHO, 2000c; Mackenbach, 2005). Socio-economic differences in health services access across may exacerbate existing health inequalities. Thus, understanding the extent of inequalities in access is essential in understanding the broader goal of health equity (Allin et al., 2005).

Principles of universal and equitable access widely acknowledged

Equitable distribution of health care is a principle subscribed to in many EU countries, as are universal rights to health care access. This is reflected in the Charter of Fundamental Rights of the European Union: article 35 states that “Everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices” (Official Journal of the European Communities, 2000).

The EU Council endorsed universality, access to good quality care, equity, and solidarity as common values and principles underpinning the health systems in the EU Member States. It also confirmed that health systems should aim to reduce the gap in health inequalities (CEU, 2006).

EU Member States have identified the need to ensure equal access for all as a priority. At EU-level, work on safeguarding equity of access to good-quality care is predominantly channeled via the Open Method of Coordination (OMC) on social protection and social inclusion. Accessible healthcare is included in the common objectives of in this process.

Defining equity of access not clear-cut

There is no one clear-cut definition of equitable access to health services (Allin et al., 2007). Most commonly, it is described as equal access to treatment for those in equal medical need, irrespective of other characteristics, such as income. This principle is also known as ‘horizontal equity’ of health care delivery (Wagstaff & Van Doorslaer, 2000). In contrast, the concept of ‘vertical equity’ refers to the extent to which individuals on unequal incomes are treated unequally to achieve equity (‘fairness’) in health care finance (Tamsma & Berman, 2004). WHO defines accessibility as ‘a measure of the proportion of the population that reaches appropriate health services’ (WHO, 1998b).

Potential of universal access may be hindered by access barriers

Even where universal access to health services is formally in place, individuals can face a range of barriers hindering the actual utilisation of that service. If persisting inequities in access are to be addressed it is necessary to look beyond the assumption of universal coverage (Busse et al., 2006).

Barriers to access may stem from factors within the health system itself (i.e. at the supply side) or be due to patient-related (demand side) aspects. Supply-side barriers may be due to:

• gaps in population coverage of health insurance;
• scope of the public health benefit package (‘health basket’);
• financial factors such as cost-sharing;
• geographical factors such as distance;
• organisational factors, including waiting lists and opening hours;
• lack/appropriateness of information

Inequality of access at the demand side is related to the characteristics of the potential service users, such as income, age, gender, cultural background, health literacy, or health beliefs.

Some access hurdles have relatively more impact on disadvantaged groups than others (Tamsma & Berman, 2004). Examples of these are costs and distance, as well as demand-side factors such as communication skills and health beliefs (Dixon et al., 2003). This points towards the relevance of targeted measures when aiming to tackle inequalities in access.

Measuring inequity of access often indirect

Access as such can rarely be observed and measured. Instead, a range of indicators can be used to measure its dimensions, and the various barriers to access. Service utilisation is most commonly used as a proxy measure for access (Allin, 2006), as are indicators of access hurdles such a user charges or waiting times.

Typically, lower socio-economic status is associated with poorer health status. In order to measure inequity, inequality in utilization of health care must therefore be standardized for differences in need (O’Donnell et al., 2007). More qualitative aspects of access that may help understand inequalities tend to receive less attention. Need for services is often measured by levels of –self-reported- ill-health (Allin et al., 2007).

This approach is also reflected in the way access is measured within EU-related frameworks. While the ECHI shortlist does not include one specific indicator for equity of access, it does include indicators of access barriers:

• Population coverage by public insurance
• Waiting times elective surgeries

Indicators of service utilisation are also included, albeit not specified for differences by socio-economic status as regards uptake:

• Vaccination coverage children
• Breast cancer screening
• Cervical cancer screening
• GP utilisation

Within the EU’s social protection and social inclusion process, the following common indicators are especially relevant:

• Unmet need for medical care
• Unmet need for dental care
• Population coverage by public insurance
• Infant mortality
• Life expectancy
• Self-perceived health

Socio-economic inequalities in access exist across Europe

Evidence based on the 2003 European Quality of Life Survey suggests income-related inequalities in access existed in all current EU Member States as regards distance, delay, waiting and cost factors. Differences are most pronounced as regards the proportion of people who indicated that their most recent visit to the doctor was made very difficult by cost factors (Anderson, 2004).

The overall picture emerging from research is that richer, better educated people find their way to medical specialists and dentist more easily and more frequent, while people in the lower income brackets tend to use more emergency services. The access to GP services seems fairly equally distributed across income. However, once people go to see their GP the poor are more likely to consult them more often. In contrast, the level of pro-rich inequality as regards access to medical specialist increases with the total number of specialist visits. Education appears to be a more important cause of inequality in specialist care than in other health care services (Van Doorslaer et al., 2004; Allin et al., 2005).

Financial hurdles of relatively great importance

EU-SILC data from 2005 indicate a social gradient for total self-reported unmet need exists across the EU. The organisation of health systems are somewhat reflected in the absolute and relative importance of the various access hurdles. Compared to organisational –waiting- and geographical – distance and availability of transport- hurdles, costs appear to be the most important hurdle in the vast majority of Member States. See Self reported unmet need for medical examination by income quintile in 2005 in EU-25 Norway and Iceland.

Nevertheless, out-of-pocket payments have consistently increased across EU countries. This is due to the exclusion of certain types of care from the public benefits package, and to rises in co-payments. See Private expenditure on medical service. To compensate more vulnerable groups for the effects, Member States have introduced exemptions, pre-payments and expenditure ceilings (CEU, 2007).

Extent and characteristics of financial hurdles are shaped by national health system characteristics and vary from country to country. Health services may be funded through taxation, social health insurance, private health insurance and/or private costs sharing. The latter includes direct user charges, or ‘out-of-pocket payments’. Evidence suggests that private health insurance and especially costs sharing most negatively impact equity of access (Mossialos & Dixon, 2002; Tamsma & Berman, 2004).

WHO draws Europe’s attention to the need for policies to reduce health inequalities

European member states are increasingly implementing policy measures aimed at reducing health inequalities (Judge et al., 2006). The World Health Organisation laid much of the foundation for this growing interest in September 1998 by approving a new health policy framework for the WHO European region entitled Health 21. This policy document identified equity in health as a basic human right, set a clear quantitative equity target for the European region and offered the WHO European region practical policy advice on how to achieve this target (WHO, 1998a). It built on the earlier established WHO Health for All Policy, in which the WHO defined the main social target for its member states as the attainment of a level of health that would allow all people to lead a socially and economically productive life by the Year 2000- the so-called Health for All Policy (WHA, 1977).

WHO prioritises health equity through two initiatives

The WHO has also helped prioritise health equity in its member states by undertaking the following two initiatives:

• the WHO-Europe Programme Socioeconomic Determinants of Health, led by the European Office of Investment for Health and Development, which is supporting countries in the WHO European Region to integrate social and economic determinants of health into their development strategies; and
• the Commission on Social Determinants of Health, a global WHO initiative, which aims to assist countries and global health partners to address socio-economic and environmental factors that can lead to health inequalities, such as unemployment, unsafe workplaces, urban slums, globalization and lack of access to health systems.

The WHO Commission on Social Determinants has also commissioned various useful publications on health inequalities, including, for example:

• Challenging Inequity through Health Systems (Gilson et al., 2007)
• Social determinants of health. The solid facts (Wilkinson & Marmot, 2003)

EU Health Strategy and Public Health Programme support reduction of health inequalities

The EU has shown a growing interest in health inequalities, which has recently led to it including specific health equity objectives within both its new Health Strategy and Public Health Programme. The Together For Health Strategy (2008-2013) identifies the reduction of inequities in health, both between and within member states as an important objective to be achieved within the framework of the stategy's first principle of 'shared health values' (EC, 2007). In the current Public Health Programme for 2008 to 2013 the EU identifies 'the attainment of a high level of physical and mental health and well-being and greater equality in health matters throughout the Community' as its overarching aim (EC, 2007a).

Much of this growing interest at an EU level can be attributed to the engagement of the UK Presidency of the EU, who in 2005 made the reduction of health inequalities a major focal point for the EU, by hosting a special Tackling Health Inequalities Summit in London. This summit was attended by representatives from all 25 member states, the European Commission, the World Health Organization and experts in public health from across the world. As part of its Presidency, the UK also commissioned two important health inequalities publications:

• Health Inequalities: Europe in Profile (Mackenbach, 2006); and
• Health Inequalities: A Challenge for Europe (Judge et al., 2006).

EU encourages integration of health equity considerations into non-health policies and legislation

The EU has also supported the reduction of inequalities by promoting the integration of health equity considerations into non-health policies and legislation. In 2006 the Council of the European Union adopted the Health in All Policies conclusion, in which it urges both EU institutions (such as the EU Commission and the EU Parliament) and EU member states to integrate health equity considerations into the development of their policies and legislation and to promote cross-sectoral engagement to achieve greater health equity (EU, 2006).

EU social inclusion policy supports reduction of health inequalities

The EU has also contributed to the reduction of health inequalities through the promotion of social inclusion within its member states, via the Community Action Programme to Combat Social Exclusion (2002 to 2006) and the current PROGRESS programme. These Programmes have encouraged EU member states to adopt national strategies to prevent and combat poverty and social exclusion and to learn from each other through the sharing of good practices and knowledge. Recent progress reports have shown that this engagement at an EU level has fostered greater recognition of the problem of social exclusion within EU member states and first steps toward the development of plans to tackle the problem. As social exclusion and poverty are key contributors to health inequalities, the EU’s engagement at this level has the potential to help reduce the health gap between different socio-economic groups within the EU (BZgA, 2008).

EU Public Health Programme initiatives promote sharing of good practice and knowledge

In recent years the EU has funded a number of initiatives through its Public Health Programmes that promote the sharing of good practice and knowledge on health inequalities and offer the EU member states practical policy advice. These include:

• Closing the Gap: Strategies for Action to Tackle Health Inequalities in the EU (2004-2007), which led to the establishment of a health inequalities knowledge portal offering practical (policy) information and guidance to the EU and its Member States on tackling health inequalities;
• Eurothine, which has developed and collected health inequality indicators, assessed evidence on the effectiveness of policies and interventions to tackle the determinants of health inequalities, made recommendations on strategies for reducing health inequalities and developed a proposal for a permanent European clearing house on tackling health inequalities.
• DETERMINE (2007-2010), a project with the objective ‘to generate greater understanding and to change conceptions and approaches amongst policy makers and practitioners, so that all policy sectors take the issues of health and health equity into consideration when developing policy’.

Health Impact Assessment (HIA) has been defined as ‘a combination of procedures, methods and tools by which a policy, programme or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population’ (WHO, 1999d). Policy makers can use this tool to assess which particular policies would offer the best potential for reducing particular health gaps between socio-economic groups and to identify and remove particular aspects from existing policies that appear to be widening the health gap between different socio-economic groups.

The HIA process involves five steps (WHO, 2008a):

1. screening: quickly establishing the health relevance of a policy or project and whether an HIA is needed;
2. scoping: identification of key health issues and public concerns, to establish a terms of reference and to set boundaries;
3. appraisal: a rapid an in-depth assessment of health impacts using available evidence (i.e. who will be affected, baseline, prediction, significance, mitigation);
4. reporting: conclusions and recommendations to remove/mitigate negative impacts on health or to enhance positive impacts;
5. monitoring: action, where appropriate, to monitor actual impacts on health to enhance existing evidence base.

An explanation of the different stages in this process and particular case studies in which the procedure has been implemented can be found on the World Health Organisation website.

The Eurothine project has developed an instrument to assess the transferability of foreign interventions to reduce health inequalities. This instrument consists of the following four steps (Mackenbach et al., 2007a):

1. Summarize the key features and outcomes of a particular intervention study.
2. Evaluate the potential relevance of the intervention to one’s own country.
3. Evaluate problems and possibilities with the implementation of the intervention.
4. Evaluate the extent to which evidence on the effectiveness of the intervention can be generalized to one’s own country.

Each one of these steps should be supported by a series of open-ended questions, that is based on a careful literature review and on discussions among groups of experts from different disciplines.

To see how this instrument can be applied in practice see Appendix A of the Final Eurothine Report.

WHO Health Equity Target for the European region

The World Health Organisation set the following health equity target for its European region in 1998 (WHO, 1998a):

By the year 2020, the health gap between socioeconomic groups should be reduced by at least one fourth in all member states, by substantially improving the level of health of disadvantaged groups. In particular:

1. the gap in life expectancy between socioeconomic groups should be reduced by at least 25%;
2. the values for major indicators of morbidity, disability and mortality in groups across the socioeconomic gradient should be more equally distributed;
3. the socioeconomic conditions that produce adverse health effects, notably differences in income, educational achievement and access to the labour market, should be substantially improved;
4. the proportion of the population living in poverty should be greatly reduced;
5. people having special needs as the result of their health, social or economic circumstances should be protected from exclusion and given easy access to appropriate care.

Overweight

Diabetes

Diabetes Prevention and Care

Lung cancer

Cancer survival

Smoking

Smoking policies

Social support

Breastfeeding

Physical activity

Alcohol use

Alcohol policies

Blood pressure

Employment

Poverty, income distribution

Life expectancy

Healthy life expectancy

Total mortality

Disease-specific mortality

Health-EU Portal, social environment

EU Social Protection and Social Inclusion Process

Community Action Programme to Combat Social Exclusion 2002-2006

PROGRESS- Community Programme for Employment and Social Solidarity

EU Tackling Health Inequalities Summit

WHO Commission on Social Determinants of Health

WHO-Europe Programme Socioeconomic Determinants of Health

Eurothine project- Tackling Health Inequalities in Europe

DETERMINE project- an EU Consortium for Action on Socio-economic Determinants of Health

Closing the Gap project- Strategies for Action to Tackle Health Inequalities in the EU

Relative inequalities in Total mortality by level of education among men and women in selected countries

Relative indices of inequality related to education and mortality rates for total cancer mortality by population and gender

Relative indices of inequality related to education and mortality rates for total cancer mortality

Relative indices of inequality (and 95% CI) for lung cancer mortality in men in selected countries by age

Relative indices of inequality (and 95% CI) for lung cancer mortality in women in selected countries by age

Relative indices of inequality (and 95% CI) for all cause mortality and alcohol related mortality in men in selected countries by age

Relative indices of inequality (and 95% CI) for all cause mortality and alcohol related mortality in women in selected countries by age

Numbers of death, ASMR and RII for all cause mortality and all avoidable mortality in selected countries

Relative index of inequality (RII) for all avoidable mortality in selected countries

Numbers of death, ASMR and RII for group of diseases of infectious origin in selected countries

Relative index of inequality (RII) for diseases of infectious origin in selected countries

Numbers of death, ASMR and RII for group of malignant diseases in selected countries

Relative index of inequality (RII) for avoidable mortility of all malignant diseases in selected countries

Numbers of death, ASMR and RII for cardio-respiratory conditions in selected countries

Relative index of inequality (RII) for all cardio-respiratory conditions in selected countries

Numbers of death, ASMR and RII for group of acute conditions in selected countries

Relative index of inequality (RII) for all avoidable acute conditions in selected countries

RIIs in self-assessed health by level of education among men and women in selected countries

Age-standardised prevalence and prevalence ratio of diabetes by educational level in men and women, 30-64 years of age in selected countries

Age-standardised prevalence ratio of diabetes by educational level in men and women, 30-64 years of age in selected countries

Relative inequalities by level of education in current smoking in men and women in selected countries

National levels and educational inequalities in quit ratios in men in selected countries

National levels and educational inequalities in quit ratios in women in selected countries

Relative inequalities by level of education in obesity in men and women in selected countries

Percentage age-adjusted prevalence of a sedentary lifestyle by educational level in men in selected countries

Percentage age-adjusted prevalence of a sedentary lifestyle by educational level in women in selected countries

Percentage age-adjusted prevalence of a sedentary lifestyle by educational level in men and women in selected countries

Self reported unmet need for medical examination by income quintile in 2005 in EU-25 Norway and Iceland (interactive)

Private expenditure on medical service (Out-of-pocket payment) (interactive)

Relative inequalities in Total mortality by level of education among men and women in selected countries (source: Eurothine, 2007 )

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of mortality in the lowest educational group and the rate of mortality in the highest educational group.

The figures above show that the RII is higher than 1 in all selected countries, for both men and women, indicating that mortality is always higher in the lowest as compared to the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Abbreviations: FIN: Finland, SWE: Sweden, NOR: Norway, DEN: Denmark, ENG: England, BEL: Belgium, SWZ: Switzerland, FRA: France, TUR: Turin, MAD: Madrid, BSQ: Basque region, SLO: Slovenia, HUN: Hungary: CZR: Czech Republic, POL: Poland, LIT: Lithuania, EST: Estonia.

Relative indices of inequality (RII) related to education and mortality rates (MR) for total cancer mortality, by population and gender (source: Eurothine, 2007)

The above data were retrieved from Eurothine, 2007. The values for mortality rates are age adjusted using direct standardisation per 100,000 person years.

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of total cancer mortality in the lowest educational group and the rate of total cancer mortality in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s.

Also see Relative indices of inequality related to education and mortality rates for total cancer mortality and EUphacts Breast cancer and Lung cancer.

Relative indices of inequality related to education and mortality rates for total cancer mortality (source: Eurothine, 2007)

The above data were retrieved from Eurothine, 2007. The values for mortality rates are age adjusted using direct standardisation per 100,000 person years.

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of total cancer mortality in the lowest educational group and the rate of total cancer mortality in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s.

Also see Relative indices of inequality related to education and mortality rates for total cancer mortality by population and gender and EUphacts Breast cancer and Lung cancer.

Relative indices of inequality (and 95% CI) for lung cancer mortality in men in selected countries by age (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of lung cancer mortality in the lowest educational group and the rate of lung cancer mortality in the highest educational group.

The figures above show that the RII is higher than 1 in all selected countries indicating that lung cancer mortality is always higher in the lowest as compared to the highest educational group.

--------------------------------------------------------------------------------

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Also see EUphacts on Smoking, and Lung cancer.

Relative indices of inequality (and 95% CI) for lung cancer mortality in women in selected countries by age (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of lung cancer mortality in the lowest educational group and the rate of lung cancer mortality in the highest educational group.

A RII higher than 1 indicates that lung cancer mortality is higher in the lowest as compared to the highest educational group, while a RII smaller than 1 indicates that lung cancer mortality is higher in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Also see EUphacts on Smoking, and Lung cancer.

Relative indices of inequality (and 95% CI) for all cause mortality and alcohol related mortality in men in selected countries by age (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of mortality in the lowest educational group and the rate of mortality in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s.

Abbreviations: Fin: Finland, Swe: Sweden, Nor: Norway, Den: Denmark, Bel: Belgium, Swi: Switzerland, Tur: Turin, Mar: Madrid, Bar: Barcelona, Bsq: Basque region, Slo: Slovenia, Hun: Hungary: CzR: Czech Republic, Pol: Poland, Lit: Lithuania, Est: Estonia.

Also see the EUphact Alcohol use.

Relative indices of inequality (and 95% CI) for all cause mortality and alcohol related mortality in women in selected countries by age (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of mortality in the lowest educational group and the rate of mortality in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s.

Abbreviations: Fin: Finland, Swe: Sweden, Nor: Norway, Den: Denmark, Bel: Belgium, Swi: Switzerland, Tur: Turin, Mar: Madrid, Bar: Barcelona, Bsq: Basque region, Slo: Slovenia, Hun: Hungary: CzR: Czech Republic, Pol: Poland, Lit: Lithuania, Est: Estonia

Also see the EUphact Alcohol use.

Numbers of death (N), age and sex standardised mortality rates (ASMR) and relative index of inequality (RII) for all cause mortality and all avoidable mortality in selected countries (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of mortality in the lowest educational group and the rate of mortality in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Abbreviations: FIN: Finland, SWE: Sweden, NOR: Norway, DEN: Denmark, BEL: Belgium, SWZ: Switzerland, TUR: Turin, BAR: Barcelona, MAD: Madrid, BSQ: Basque region, SLO: Slovenia, HUN: Hungary: CZR: Czech Republic, POL: Poland, LIT: Lithuania, EST: Estonia.

Also see Relative index of inequality (RII) for all avoidable mortality in selected countries.

Relative index of inequality (RII) for all avoidable mortality in selected countries (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of mortality in the lowest educational group and the rate of mortality in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Also see Numbers of death, ASMR and RII for all cause mortality and all avoidable mortality in selected countries.

Numbers of death (N), age and sex standardised mortality rates (ASMR) and relative index of inequality (RII) for group of diseases of infectious origin in selected countries (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of mortality in the lowest educational group and the rate of mortality in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Abbreviations: FIN: Finland, SWE: Sweden, NRW: Norway, DEN: Denmark, BEL: Belgium, SWZ: Switzerland, TUR: Turin, BAR: Barcelona, MAD: Madrid, BSQ: Basque region, SLO: Slovenia, HUN: Hungary: CZR: Czech Republic, POL: Poland, LIT: Lithuania, EST: Estonia.

Also see Relative index of inequality (RII) for diseases of infectious origin in selected countries.

Relative index of inequality (RII) for diseases of infectious origin in selected countries (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of mortality in the lowest educational group and the rate of mortality in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Also see Numbers of death, ASMR and RII for group of diseases of infectious origin in selected countries.

Numbers of death (N), age and sex standardised mortality rates (ASMR) and relative index of inequality (RII) for group of malignant diseases in selected countries (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of mortality in the lowest educational group and the rate of mortality in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Abbreviations: FIN: Finland, SWE: Sweden, NOR: Norway, DEN: Denmark, BEL: Belgium, SWZ: Switzerland, TUR: Turin, BAR: Barcelona, MDR: Madrid, BSQ: Basque region, SLO: Slovenia, HUN: Hungary: CZR: Czech Republic, POL: Poland, LIT: Lithuania, EST: Estonia.

Also see Relative index of inequality (RII) for avoidable mortility of all malignant diseases in selected countries.

Relative index of inequality (RII) for avoidable mortility of all malignant diseases in selected countries (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of mortality in the lowest educational group and the rate of mortality in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Also see Numbers of death, ASMR and RII for group of malignant diseases in selected countries.

Numbers of death (N), age and sex standardised mortality rates (ASMR) and relative index of inequality (RII) for cardio-respiratory conditions in selected countries (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of mortality in the lowest educational group and the rate of mortality in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Abbreviations: FIN: Finland, SWE: Sweden, NOR: Norway, DEN: Denmark, BEL: Belgium, SWZ: Switzerland, TUR: Turin, BAR: Barcelona, MAD: Madrid, BSQ: Basque region, SLO: Slovenia, HUN: Hungary: CZR: Czech Republic, POL: Poland, LIT: Lithuania, EST: Estonia.

Also see Relative index of inequality (RII) for all cardio-respiratory conditions in selected countries.

Relative index of inequality (RII) for all cardio-respiratory conditions in selected countries (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of mortality in the lowest educational group and the rate of mortality in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Also see Numbers of death, ASMR and RII for cardio-respiratory conditions in selected countries.

Numbers of death (N), age and sex standardised mortality rates (ASMR) and relative index of inequality (RII) for group of acute conditions in selected countries (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of mortality in the lowest educational group and the rate of mortality in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Abbreviations: FIN: Finland, SWE: Sweden, NOR: Norway, DEN: Denmark, BEL: Belgium, SWZ: Switzerland, TUR: Turin, BAR: Barcelona, MDR: Madrid, BSQ: Basque region, SLO: Slovenia, HUN: Hungary: CZR: Czech Republic, POL: Poland, LIT: Lithuania, EST: Estonia.

Also see Relative index of inequality (RII) for all avoidable acute conditions in selected countries.

Relative index of inequality (RII) for all avoidable acute conditions in selected countries (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of mortality in the lowest educational group and the rate of mortality in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Also see Numbers of death, ASMR and RII for group of acute conditions in selected countries.

Relative inequalities in self-assessed health by level of education among men and women in selected countries (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of self-assessed health in the lowest educational group and the rate of self-assessed health in the highest educational group.

The figures above show that the RII is higher than 1 in all selected countries, for both men and women, indicating that self-assessed health is always worse in the lowest as compared to the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Abbreviations: FIN: Finland, SWE: Sweden, NOR: Norway, DEN: Denmark, IRE: Ireland, ENG: England, NET: Netherlands, BEL: Belgium, GER: Germany, FRA: France, ITA: Italy, SPA: Spain, POR: Portugal, SLV: Slovenia, HUN: Hungary: CZR: Czech Republic, LIT: Lithuania, LAT: Latvia, EST: Estonia.

Age-standardised prevalence and prevalence ratio of diabetes by educational level in men and women, 30-64 years of age in selected countries (source: Eurothine, 2007)

The prevalence ratio (PR) can be interpreted as the ratio between the prevalence of diabetes in the upper/lower secondary educational group and the prevalence of diabetes in the tertiary educational group. If the PR is larger than 1, this means that the prevalence of diabetes is higher in the upper/lower secondary educational group than in the tertiary educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Also see Age-standardised prevalence ratio of diabetes by educational level in men and women, 30-64 years of age in selected countries.

Age-standardised prevalence ratio of diabetes by educational level in men and women, 30-64 years of age in selected countries (source: Eurothine, 2007)

The prevalence ratio (PR) can be interpreted as the ratio between the prevalence of diabetes in the upper/lower secondary educational group and the prevalence of diabetes in the tertiary educational group. If the PR is larger than 1, this means that the prevalence of diabetes is higher in the upper/lower secondary educational group than in the tertiary educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Also see Age-standardised prevalence and prevalence ratio of diabetes by educational level in men and women, 30-64 years of age in selected countries.

Relative inequalities by level of education in current smoking in men and women in selected countries (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of current smoking in the lowest educational group and the rate of current smoking in the highest educational group. If the RII is larger than 1 this means that the rate of current smoking is larger in the lowest educational group than in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Abbreviations: FIN: Finland, SWE: Sweden, NOR: Norway, DEN: Denmark, IRE: Ireland, ENG: England, NET: Netherlands, BEL: Belgium, GER: Germany, FRA: France, ITA: Italy, SPA: Spain, POR: Portugal, SLV: Slovenia, HUN: Hungary: CZR: Czech Republic, LIT: Lithuania, LAT: Latvia, EST: Estonia.

National levels and educational inequalities in quit ratios in men in selected countries (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the quit ratio in the highest educational group and the quit ratio in the lowest educational group. If the RII is larger than 1, this means that the quit ratio is higher in the highest educational group than in the lowest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Also see EUphacts Smoking and Smoking policies.

National levels and educational inequalities in quit ratios in women in selected countries (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the quit ratio in the highest educational group and the quit ratio in the lowest educational group. If the RII is larger than 1, this means that the quit ratio is higher in the highest educational group than in the lowest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Also see EUphacts Smoking and Smoking policies.

Relative inequalities by level of education in obesity in men and women in selected countries (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of obesity in the lowest educational group and the rate of obesity in the highest educational group. If the RII is larger than 1, this means that the rate of obesity is higher in the lowest educational group than in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Abbreviations: FIN: Finland, SWE: Sweden, NOR: Norway, DEN: Denmark, IRE: Ireland, ENG: England, NET: Netherlands, BEL: Belgium, GER: Germany, FRA: France, ITA: Italy, SPA: Spain, POR: Portugal, SLV: Slovenia, HUN: Hungary: CZR: Czech Republic, LIT: Lithuania, LAT: Latvia, EST: Estonia.

Percentage age-adjusted prevalence of a sedentary lifestyle by educational level in men in selected countries (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of a sedentary lifestyle in the lowest educational group and the rate of a sedentary lifestyle in the highest educational group. If the RII is larger than 1 this means that the rate of a sedentary lifestyle is higher in the lowest educational groups than in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Also see Percentage age-adjusted prevalence of a sedentary lifestyle by educational level in men and women in selected countries and EUphact Physical activity.

Percentage age-adjusted prevalence of a sedentary lifestyle by educational level in women in selected countries (source: Eurothine, 2007)

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of a sedentary lifestyle in the lowest educational group and the rate of a sedentary lifestyle in the highest educational group. If the RII is larger than 1 this means that the rate of a sedentary lifestyle is higher in the lowest educational group than in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Also see Percentage age-adjusted prevalence of a sedentary lifestyle by educational level in men and women in selected countries and EUphact Physical activity.

Percentage age-adjusted prevalence of a sedentary lifestyle by educational level in men and women in selected countries (source: Eurothine, 2007)

PRR is relative index of inequality, calculated as RII. PRR is adjusted for all age group and country (only total); Totals are weighted for country size.

The Relative Index of Inequality (RII) can be interpreted as the ratio between the rate of a sedentary lifestyle in the lowest educational group and the rate of a sedentary lifestyle in the highest educational group. If the RII is larger than 1 this means that the rate of a sedentary lifestyle is higher in the lowest educational group than in the highest educational group.

The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.

Also see Percentage age-adjusted prevalence of a sedentary lifestyle by educational level in men in selected countries, Percentage age-adjusted prevalence of a sedentary lifestyle by educational level in women in selected countries and EUphact Physical activity.

Self reported unmet need for medical examination is the respondent’s own assessment of whether he or she needed a medical examination or treatment, but did not have one. The indicator is expressed as percentages within population layers defined by the background variable of income group.

The above data were retrieved from the European Statistics of Income and Living Condition (EU-SILC) survey in Eurostat database. For more information see Eurostat Metadata.

The data shown in the above presentation was retrieved from OECD Health Data.