Trends of socioeconomic inequalities and socioeconomic inequalities in self-perceived health in Spain

OBJECTIVE: To study the trends of socioeconomic inequalities and socioeconomic inequalities in self-perceived health in Spain between 1987 and 2001. METHODS: We estimated the distribution of educational level and per capita provincial income, and the differences in less-than-good self-perceived health by educational level and per capita provincial income in each period. RESULTS: The percentage of the population that had completed secondary or higher education was larger and inequality in per capita provincial income was smaller in 2001 than in 1987. In general, the differences in less-than-good self-perceived health by educational level and provincial income were greater in 2001 than in 1987, in both absolute and relative terms. However, when the effect of residual correlation within provinces was taken into account, the differences by per capita provincial income were smaller in 1987 than in 2001. CONCLUSIONS: The redistribution of socioeconomic resources achieves greater social justice, but probably does not lead to reduced health inequalities in all cases.     

Trends in mental health inequalities in urban Canada

ObjectivesCanadians do not all enjoy equal levels of health. The presence of income-related health inequalities has been well established in Canada, but there is a lack of consistent reporting of mental health inequalities in Canada’s largest cities. This study reports the prevalence and inequalities in mental health outcomes at the city, provincial, and national levels over time.MethodsSelf-reported poor mental health, life stress, and physician-diagnosed self-reported mood and anxiety disorder from the Canadian Community Health Survey were pooled over five-year intervals and combined with neighbourhood income information from the Canadian Census. First, prevalence rates were calculated for each interval at the neighbourhood level for urban communities. Second, the distributions of these neighbourhood rates were summarized at the city level and for Canada as a whole using overall prevalence rates and concentration indices of inequality. Finally, trends in these city- and country-level outcomes were also explored.ResultsAt the national level, starting from 2001 to 2005, the prevalence of poor mental health (27.9%), mood disorder (7.3%), and anxiety disorder (6.8%) had significantly increased by 2011–2015. Inequalities were present in 2001–2005 and worsened over time. The prevalence rate at the national level of life stress was 66.6% in 2001–2005 and decreased over time.ConclusionThe large and increasing values of inequalities and the difference in prevalence rates and inequalities in cities highlight the necessity for mental disorder-specific data and for city-level analysis of inequalities. The next steps in reducing inequalities involve deconstructing the health inequalities, and continued monitoring.     

How does evidence influence public health policy? Tackling health inequalities in England

This paper examines the place of evidence in the policy‐making process, considering as a case study the development of a Programme for Action to tackle health inequalities in England. It attempts to identify ways in which we can maximise the use of evidence in the development of policies to support public health, and the ways in which research can be managed to support public health policy development. It identifies that evidence‐based policy is an aspirational goal rather than something that will easily be achieved in the complex, politicised environment of policy making. Key challenges include the need to develop public health evidence that is ‘fit for purpose’ – research that is more overtly directed towards informing policy and producing evidence derived from practical interventions that would allow examination of the relative costs and benefits of different policy options. Research evidence also needs to be provided at the time it is needed, and improved techniques need to found for communicating and managing the uncertainties that arise through scientific research. For the public servants who use evidence in policy making, there is the challenge to develop skills in the critical appraisal of evidence and to judge how to achieve the best ‘fit’ between available evidence, current political priorities, and practical actions to achieve the desired outcomes. In this more complex environment, the development of networks and cultivation of relationships between public health practitioners, advocates and policymakers (public servants and their political masters) will often provide more adaptable and durable opportunities to influence the policy process.     

Trends in socioeconomic inequalities in self-assessed health in 10 European countries

BACKGROUND: Changes over time in inequalities in self-reported health are studied for increasingly more countries, but a comprehensive overview encompassing several countries is still lacking. The general aim of this article is to determine whether inequalities in self-assessed health in 10 European countries showed a general tendency either to increase or to decrease between the 1980s and the 1990s and whether trends varied among countries. METHODS: Data were obtained from nationally representative interview surveys held in Finland, Sweden, Norway, Denmark, England, The Netherlands, West Germany, Austria, Italy, and Spain. The proportion of respondents with self-assessed health less than 'good' was measured in relation to educational level and income level. Inequalities were measured by means of age-standardized prevalence rates and odds ratios (ORs). RESULTS: Socioeconomic inequalities in self-assessed health showed a high degree of stability in European countries. For all countries together, the ORs comparing low with high educational levels remained stable for men (2.61 in the 1980s and 2.54 in the 1990s) but increased slightly for women (from 2.48 to 2.70). The ORs comparing extreme income quintiles increased from 3.13 to 3.37 for men and from 2.43 to 2.86 for women. Increases could be demonstrated most clearly for Italian and Spanish men and women, and for Dutch women, whereas inequalities in health in the Nordic countries showed no tendency to increase. CONCLUSIONS: The results underscore the persistent nature of socioeconomic inequalities in health in modern societies. The relatively favourable trends in the Nordic countries suggest that these countries' welfare states were able to buffer many of the adverse effects of economic crises on the health of disadvantaged groups.     

The contribution of smoking and obesity to income-related inequalities in health in England

Reducing avoidable inequalities in health is a priority in many health care systems, including the NHS in Great Britain. Evidence suggests that lifestyle factors may play a role in explaining socioeconomic inequalities in health. In this paper we measure the contribution of smoking and obesity to income-related inequality in health. We use the corrected concentration index to measure inequality across time and areas of England, and decomposition methods to quantify directly the contribution of smoking and obesity to income-related inequality. Instrumental variables regression is used to test the endogeneity of smoking and obesity. We use data from nine rounds of the Health Survey for England (1998–2006). The results show that there are significant income-related health inequalities in England, that the extent of the inequality varies by area, and that in some areas it has increased over time. Nationally, smoking and obesity make a significant but modest contribution to income-related inequality in health (2.3% and 1.2%, respectively). Despite the reduction in smoking prevalence, the contribution of smoking has slightly increased over time, due to its increasing concentration among the poor and its negative effect on health. While the prevalence of obesity is increasing, it is more equally distributed across society. The prevalence of these problems varies between areas, and so does the contribution they make to income-related inequalities in health.     

Examining ethnic inequalities in health and tenure in England: A repeated cross-sectional analysis

Ethnic minorities experience multiple inequalities across different domains including health and tenure. Notwithstanding extensive research demonstrating a clear connection between tenure and health, the relationship between health, tenure and ethnicity is under-explored. In this paper, we examine ethnic inequalities in health and tenure in England using cross-sectional census microdata for 1991, 2001 and 2011. We find that ethnic inequalities in health persist over time while the relationship between health and tenure varies between ethnic groups. These results suggest that traditional explanations linking health and tenure are not sufficient to adequately capture the myriad experiences of different ethnic groups.     

Trends in socioeconomic health inequalities in the Netherlands, 1981-1999

STUDY OBJECTIVE: To determine changes in socioeconomic inequalities in self reported health in both the 1980s and the 1990s in the Netherlands. DESIGN: Analysis of trends in socioeconomic health inequalities during the last decades of the 20th century were made using data from the Health Interview Survey (Nethhis) and the subsequent Permanent Survey on Living Conditions (POLS) from Statistics Netherlands. Socioeconomic inequalities in self assessed health, short-term disabilities during the past 14 days, long term health problems and chronic diseases were studied in relation to both educational level and household income. Trends from 1981 to 1999 were studied using summary indices for both the relative and absolute size of socioeconomic inequalities in health. SETTING: The Netherlands. PARTICIPANTS: For the period 1981-1999 per year a random sample of about 7000 respondents of 18 years and older from the non-institutionalised population. MAIN RESULTS: Socioeconomic inequalities in self assessed health showed a fairly consistent increase over time. Socioeconomic inequalities in the other health indicators were more or less stable over time. In no case did socioeconomic inequalities in health seemed to have decreased over time. Socioeconomic inequalities in self assessed health increased both in the 1980s and the 1990s. This increase was more pronounced for income (as compared with education) and for women (as compared with men). CONCLUSION: There are several possible explanations for the fact that, in addition to stable health inequalities in general, income related inequalities in some health indicators increased in the Netherlands, especially in the early 1990s. Most influential were perhaps selection effects, related to changing labour market policies in the Netherlands. The fact that the health inequalities did not decrease over recent years underscores the necessity of policies that explicitly aim to tackle these inequalities.     

Trends in socioeconomic health inequalities in Korea: use of mortality and morbidity measures

STUDY OBJECTIVE: To examine trends in educational mortality and morbidity inequalities in Korea. DESIGN: Census data (1990, 1995, 2000) and death certificate data (1990-91, 1995-96, 2000-01) were used for mortality. For morbidity, four waves (1989, 1992, 1995, and 1999) of Social Statistics Survey from Korea's National Statistical Office were used. Morbidity indicators were self rated health and self reported illness in the past two weeks. Trends were studied using indices for both the relative and absolute size of socioeconomic inequalities in health. SETTING: South Korea. Patients (or Participants): Representative annual samples of the adult population aged 30-59 in Korea. Main results: Based on trends in relative index of inequalities, the relative level of socioeconomic mortality inequality remained virtually unchanged in men and women in the past 10 years. Meanwhile, inequalities in self rated health have increased over time in both sexes. Most of the total increase in health inequalities happened between 1995 and 1999. Inequalities in self reported acute illness increased in the past 10 years. CONCLUSIONS: The rise in inequalities in morbidity requires increased social discourse and policy discussions about health inequalities in Korean society.     

Trends in health inequalities by educational level in a Norwegian total population study

OBJECTIVE: To describe levels of inequality and trends in self reported morbidity by educational level in a total Norwegian county population in the mid-1980s and mid-1990s. DESIGN: Two cross sectional health surveys at an interval of 10 years in the Nord-Tr?ndelag Health Study, HUNT I (1984-86) and HUNT II (1995-97). SETTING: Primary health care, total county population study. PARTICIPANTS: Men and women, 25-69 years. MAIN RESULTS: There was a consistent pattern of increasing self reported health problems with decreasing educational level for three health variables: perceived health, any longstanding health problem, and having a chronic condition. A stable or slight decrease in inequalities over time was found. The prevalence odds ratio for perceived health less than good were 2.71 for men (95% confidence intervals (CI): 2.39 to 3.09) and 2.13 for women (95% CI: 1.85 to 2.46) in the first survey, 2.51 for men (95% CI: 2.27 to 2.78) and 2.06 for women (95% CI: 1.88 to 2.26) 10 years later. CONCLUSIONS: The magnitude of the socioeconomic gradients in health in this population seemed somewhat lower than in Norway as a whole and close to the average in studies from other European countries. There was a slight trend towards smaller differences despite rapid structural changes in working life, turbulence in economy, and more people experiencing unemployment.     

Socioeconomic inequalities in health among Indigenous peoples living off-reserve in Canada: Trends and determinants

Using three nationally representative Aboriginal Peoples Surveys (2001, 2006 and 2012, n = 68,040), we examined income-related inequalities in self-perceived poor/fair general health status among Indigenous adults (18+) living off-reserve in Canada. We used the relative and absolute concentration indices (RC and AC, respectively) to quantify income-related inequalities in health for men and women, within the three Indigenous populations (First Nations, Métis, and Inuit), and in different geographic regions. Moreover, we performed decomposition analysis to determine factors that explain income-related inequality in health within the Indigenous peoples living off-reserve in Canada. The prevalence of poor/fair health status among the Indigenous population living off-reserve increased from 18% in 2001 to 22% in 2012. The extent of pro-rich relative (absolute) income-related inequalities in health increased by 23% (42%) from 2001 to 2012. Income-related inequalities in health increased statistically significantly within First Nations and Métis populations as well as in Atlantic provinces, Ontario, Alberta, British Columbia and Territories. Decomposition analyses indicated that, besides income itself, occupational status and educational attainment were the most important factors contributing to the pro-rich distribution of health among Indigenous peoples living off-reserve. Growing socioeconomic inequalities in health among Indigenous peoples should warrant more attention. Policies designed to address the broader array of social determinants of health may mitigate the continuing inequalities in health among Indigenous peoples living off-reserve in Canada.     

A Qualitative Comparative Analysis of factors associated with trends in narrowing health inequalities in England

This study explores why progress with tackling health inequalities has varied among a group of local authority areas in England that were set targets to narrow important health outcomes compared to national averages. It focuses on premature deaths from cancers and cardiovascular disease (CVD) and whether the local authority gap for these outcomes narrowed. Survey and secondary data were used to create dichotomised conditions describing each area. For cancers, ten conditions were found to be associated with whether or not narrowing occurred: presence/absence of a working culture of individual commitment and champions; spending on cancer programmes; aspirational or comfortable/complacent organisational cultures; deprivation; crime; assessments of strategic partnership working, commissioning and the public health workforce; frequency of progress reviews; and performance rating of the local Primary Care Trust (PCT). For CVD, six conditions were associated with whether or not narrowing occurred: a PCT budget closer or further away from target; assessments of primary care services, smoking cessation services and local leadership; presence/absence of a few major programmes; and population turnover. The method of Qualitative Comparative Analysis was used to find configurations of these conditions with either the narrowing or not narrowing outcomes. Narrowing cancer gaps were associated with three configurations in which individual commitment and champions was a necessary condition, and not narrowing was associated with a group of conditions that had in common a high level of bureaucratic-type work. Narrowing CVD gaps were associated with three configurations in which a high assessment of either primary care or smoking cessation services was a necessary condition, and not narrowing was associated with two configurations that both included an absence of major programmes. The article considers substantive and theoretical arguments for these configurations being causal and as pointing to ways of improving progress with tackling health inequalities.     

Unfair inequalities in health and health care

Inequalities in health and health care are caused by different factors. Measuring "unfair" inequalities implies that a distinction is introduced between causal variables leading to ethically legitimate inequalities and causal variables leading to ethically illegitimate inequalities. An example of the former could be life-style choices, an example of the latter is social background. We show how to derive measures of unfair inequalities in health and in health care delivery from a structural model of health care and health production: "direct unfairness", linked to the variations in medical expenditures and health in the hypothetical distribution in which all legitimate sources of variation are kept constant; "fairness gap", linked to the differences between the actual distribution and the hypothetical distribution in which all illegitimate sources of variation have been removed. These two approaches are related to the theory of fair allocation. In general they lead to different results. We propose to analyse the resulting distributions with the traditional apparatus of Lorenz curves and inequality measures. We compare our proposal to the more common approach using concentration curves and analyse the relationship with the methods of direct and indirect standardization. We discuss how inequalities in health care can be integrated in an overall evaluation of social inequality.     

Changes in socioeconomic inequalities in census measures of health in England and Wales, 1991-2001

STUDY OBJECTIVES: To investigate changes in socioeconomic inequalities in census measures of health in England and Wales between 1991 and 2001. DESIGN: Indirect standardisation was used to calculate age standardised rates of limiting long term illness and permanent sickness in men and women in all residential wards in England and Wales in 1991 and 2001. The socioeconomic position of each ward was determined using Townsend deprivation scores. SETTING: All residential wards in England and Wales in 1991 and 2001. PARTICIPANTS: All people aged 16-65 who provided census information in the 1991 or 2001 censuses. MAIN RESULTS: There was strong evidence that Townsend deprivation score quintile could predict both logged standardised permanent sickness rate and logged standardised limiting long term illness rate. There was evidence that socioeconomic inequalities in standardised limiting long term illness rates decreased between 1991 and 2001 in both men and women and that socioeconomic inequalities in standardised permanent sickness rates decreased in women but increased in men between 1991 and 2001. CONCLUSIONS: As permanent sickness rates seem to reflect labour market accessibility, this study may have found evidence that socioeconomic inequalities in self reported morbidity decreased but inequalities in labour market participation in men increased between 1991 and 2001.