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.