Johan P Mackenbach1, Ivana Kulhánová1, Gwenn Menvielle2, Matthias Bopp3, Carme Borrell4, Giuseppe Costa5, Patrick Deboosere6, Santiago Esnaola7, Ramune Kalediene8, Katalin Kovacs9, Mall Leinsalu10, Pekka Martikainen11, Enrique Regidor12, Maica Rodriguez-Sanz4, Bjørn Heine Strand13, Rasmus Hoffmann1, Terje A Eikemo14, Olof Östergren15, Olle Lundberg16. 1. Department of Public Health, Erasmus MC, Rotterdam, The Netherlands. 2. Centre for research in Epidemiology and Population Health (CESP), U1018, INSERM, Villejuif, France University of Versailles Saint Quentin, Versailles, France. 3. Institute of Social and Preventive Medicine, University of Zurich, Zurich, Switzerland. 4. Agència de Salut Pública de Barcelona, Barcelona, Spain. 5. Department of Clinical Medicine and Biology, University of Turin, Turin, Italy. 6. Department of Sociology, Vrije Universiteit Brussel, Brussels, Belgium. 7. Department of Public Health, Basque Government, Vitoria, Spain. 8. Lithuanian University of Health Sciences, Kaunas, Lithuania. 9. Demographic Research Institute of the Central Statistical Office, Budapest, Hungary. 10. Stockholm Centre on Health of Societies in Transition, Södertörn University, Huddinge, Sweden Department of Epidemiology and Biostatistics, National Institute for Health Development, Tallinn, Estonia. 11. Department of Sociology, University of Helsinki, Helsinki, Finland. 12. Department of Preventive Medicine and Public Health, Universidad Complutense de Madrid, Madrid, Spain. 13. Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway. 14. Department of Public Health, Erasmus MC, Rotterdam, The Netherlands Department of Sociology and Political Science, NTNU, Trondheim, Norway. 15. Center for Health Equity Studies, Stockholm, Sweden. 16. Center for Health Equity Studies, Stockholm, Sweden Department of Health Sciences, Mid Sweden University, Östersund, Sweden.
Abstract
BACKGROUND: Over the last decades of the 20th century, a widening of the gap in death rates between upper and lower socioeconomic groups has been reported for many European countries. For most countries, it is unknown whether this widening has continued into the first decade of the 21st century. METHODS: We collected and harmonised data on mortality by educational level among men and women aged 30-74 years in all countries with available data: Finland, Sweden, Norway, Denmark, England and Wales, Belgium, France, Switzerland, Spain, Italy, Hungary, Lithuania and Estonia. RESULTS: Relative inequalities in premature mortality increased in most populations in the North, West and East of Europe, but not in the South. This was mostly due to smaller proportional reductions in mortality among the lower than the higher educated, but in the case of Lithuania and Estonia, mortality rose among the lower and declined among the higher educated. Mortality among the lower educated rose in many countries for conditions linked to smoking (lung cancer, women only) and excessive alcohol consumption (liver cirrhosis and external causes). In absolute terms, however, reductions in premature mortality were larger among the lower educated in many countries, mainly due to larger absolute reductions in mortality from cardiovascular disease and cancer (men only). Despite rising levels of education, population-attributable fractions of lower education for mortality rose in many countries. CONCLUSIONS: Relative inequalities in premature mortality have continued to rise in most European countries, and since the 1990s, the contrast between the South (with smaller inequalities) and the East (with larger inequalities) has become stronger. While the population impact of these inequalities has further increased, there are also some encouraging signs of larger absolute reductions in mortality among the lower educated in many countries. Reducing inequalities in mortality critically depends upon speeding up mortality declines among the lower educated, and countering mortality increases from conditions linked to smoking and excessive alcohol consumption such as lung cancer, liver cirrhosis and external causes. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
BACKGROUND: Over the last decades of the 20th century, a widening of the gap in death rates between upper and lower socioeconomic groups has been reported for many European countries. For most countries, it is unknown whether this widening has continued into the first decade of the 21st century. METHODS: We collected and harmonised data on mortality by educational level among men and women aged 30-74 years in all countries with available data: Finland, Sweden, Norway, Denmark, England and Wales, Belgium, France, Switzerland, Spain, Italy, Hungary, Lithuania and Estonia. RESULTS: Relative inequalities in premature mortality increased in most populations in the North, West and East of Europe, but not in the South. This was mostly due to smaller proportional reductions in mortality among the lower than the higher educated, but in the case of Lithuania and Estonia, mortality rose among the lower and declined among the higher educated. Mortality among the lower educated rose in many countries for conditions linked to smoking (lung cancer, women only) and excessive alcohol consumption (liver cirrhosis and external causes). In absolute terms, however, reductions in premature mortality were larger among the lower educated in many countries, mainly due to larger absolute reductions in mortality from cardiovascular disease and cancer (men only). Despite rising levels of education, population-attributable fractions of lower education for mortality rose in many countries. CONCLUSIONS: Relative inequalities in premature mortality have continued to rise in most European countries, and since the 1990s, the contrast between the South (with smaller inequalities) and the East (with larger inequalities) has become stronger. While the population impact of these inequalities has further increased, there are also some encouraging signs of larger absolute reductions in mortality among the lower educated in many countries. Reducing inequalities in mortality critically depends upon speeding up mortality declines among the lower educated, and countering mortality increases from conditions linked to smoking and excessive alcohol consumption such as lung cancer, liver cirrhosis and external causes. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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