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. 2016 Apr 11:353:i1732.
doi: 10.1136/bmj.i1732.

Changes in mortality inequalities over two decades: register based study of European countries

Johan P Mackenbach  1 , Ivana Kulhánová  2 , Barbara Artnik  3 , Matthias Bopp  4 , Carme Borrell  5 , Tom Clemens  6 , Giuseppe Costa  7 , Chris Dibben  6 , Ramune Kalediene  8 , Olle Lundberg  9 , Pekka Martikainen  10 , Gwenn Menvielle  11 , Olof Östergren  12 , Remigijus Prochorskas  8 , Maica Rodríguez-Sanz  5 , Bjørn Heine Strand  13 , Caspar W N Looman  2 , Rianne de Gelder  2
Affiliations

Changes in mortality inequalities over two decades: register based study of European countries

Johan P Mackenbach et al. BMJ. .

Abstract

Objective: To determine whether government efforts in reducing inequalities in health in European countries have actually made a difference to mortality inequalities by socioeconomic group.

Design: Register based study.

Data source: Mortality data by level of education and occupational class in the period 1990-2010, usually collected in a census linked longitudinal study design. We compared changes in mortality between the lowest and highest socioeconomic groups, and calculated their effect on absolute and relative inequalities in mortality (measured as rate differences and rate ratios, respectively).

Setting: All European countries for which data on socioeconomic inequalities in mortality were available for the approximate period between years 1990 and 2010. These included Finland, Norway, Sweden, Scotland, England and Wales (data applied to both together), France, Switzerland, Spain (Barcelona), Italy (Turin), Slovenia, and Lithuania.

Results: Substantial mortality declines occurred in lower socioeconomic groups in most European countries covered by this study. Relative inequalities in mortality widened almost universally, because percentage declines were usually smaller in lower socioeconomic groups. However, as absolute declines were often smaller in higher socioeconomic groups, absolute inequalities narrowed by up to 35%, particularly among men. Narrowing was partly driven by ischaemic heart disease, smoking related causes, and causes amenable to medical intervention. Progress in reducing absolute inequalities was greatest in Spain (Barcelona), Scotland, England and Wales, and Italy (Turin), and absent in Finland and Norway. More detailed studies preferably using individual level data are necessary to identify the causes of these variations.

Conclusions: Over the past two decades, trends in inequalities in mortality have been more favourable in most European countries than is commonly assumed. Absolute inequalities have decreased in several countries, probably more as a side effect of population wide behavioural changes and improvements in prevention and treatment, than as an effect of policies explicitly aimed at reducing health inequalities.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: financial support from the European Commission for the submitted work: no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

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Fig 1 Absolute and relative changes (95% CI) in all cause mortality among men with low and high education, between years 1990-94 versus 2005-09, by country. All data are age standardised. In England and Wales, the low educated group contained both the low educated (that is, according to ISCED 0-2) and mid educated (ISCED 3-4)
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Fig 2 Absolute and relative changes (95% CI) in all cause mortality among women with low and high education, between years 1990-94 versus 2005-09, by country. All data are age standardised. In England and Wales, the low educated group contained both the low educated (that is, according to ISCED 0-2) and mid educated (ISCED 3-4)
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Fig 3 Changes in absolute and relative educational inequalities in all cause mortality in (A) men and (B) women, between 1990-94 and 2004-09. Change in absolute inequalities calculated as: 100×(RD2004-09−RD1990-94)÷RD1990-94 (where RD=rate difference). Change in relative inequalities calculated as: 100×(RR2004-09−RR1990-94) ÷(RR2004-09−1) (where RR=rate ratio). All data are age standardised. Lithuania not included because of the deviant trends
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Fig 4 Differences between the low educated and the high educated in absolute mortality change for (A) men and (B) women, between 1990-94 and 2004-09, by country and for five specific causes of death. Difference in mortality change (in deaths per 100 000 person years) between the low and high educated was calculated as: (ASMR2004-09, low–ASMR1990-04, low)–(ASMR2004-09, high–ASMR1990-04, high) (where ASMR=age standardised mortality rate). Road traffic accident data were not available for Scotland and Slovenia
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