Trends in health inequalities in 27 European countries

Abstract

Unfavorable health trends among the lowly educated have recently been reported from the United States. We analyzed health trends by education in European countries, paying particular attention to the possibility of recent trend interruptions, including interruptions related to the impact of the 2008 financial crisis. We collected and harmonized data on mortality from ca 1980 to ca 2014 for 17 countries covering 9.8 million deaths and data on self-reported morbidity from ca 2002 to ca 2014 for 27 countries covering 350,000 survey respondents. We used interrupted time-series analyses to study changes over time and country-fixed effects analyses to study the impact of crisis-related economic conditions on health outcomes. Recent trends were more favorable than in previous decades, particularly in Eastern Europe, where mortality started to decline among lowly educated men and where the decline in less-than-good self-assessed health accelerated, resulting in some narrowing of health inequalities. In Western Europe, mortality has continued to decline among the lowly and highly educated, and although the decline of less-than-good self-assessed health slowed in countries severely hit by the financial crisis, this affected lowly and highly educated equally. Crisis-related economic conditions were not associated with widening health inequalities. Our results show that the unfavorable trends observed in the United States are not found in Europe. There has also been no discernible short-term impact of the crisis on health inequalities at the population level. Both findings suggest that European countries have been successful in avoiding an aggravation of health inequalities.

Keywords: Europe; financial crisis; health inequalities; morbidity; mortality.

Fig. 1.

Trends in all-cause mortality by education, men, ca. 1980 to ca. 2014. Dashed lines represent Eastern Europe. The dotted line represents Spain, the Western European country most severely hit by the economic crisis. ASMR, age-standardized mortality rate; pyrs, person-years. Results for women are shown in SI Appendix, Fig. S2.

Fig. 2.

Trends in age-specific mortality among lowly educated men and women between ca. 1980 and ca. 2008 and after ca. 2008, by region and sex. Graphs show average percent annual change in mortality as estimated in interrupted time-series analyses (the trend for 1980–2008 is based on β₁; the trend after 2008 is based on β₁ and β₂; see Materials and Methods for details). Asterisks indicate statistically significant (P < 0.05) differences between the two periods. For distinctions between Western and Eastern Europe, see SI Appendix, Table S1.

Fig. 3.

Trends in less-than-good SAH and activity limitations among the lowly and highly educated between 2002 and 2008 and after 2008, by region and sex. Graphs show the average percent annual change in prevalence as estimated in interrupted time-series analysis (the trend for 1980–2008 is based on β₁; the trend after 2008 is based on β₁ and β₂; see Materials and Methods for details). Asterisks indicate statistically significant (P < 0.05) differences between the two periods. For distinctions between Western and Eastern Europe, see SI Appendix, Table S3. The five crisis countries in Western Europe were Ireland, Spain, Portugal, Greece, and Cyprus. GALI, global activity limitations indicator.