Elsevier

Public Health

Volume 118, Issue 1, January 2004, Pages 3-10
Public Health

Socio-economic inequalities in health expectancy in Belgium

https://doi.org/10.1016/S0033-3506(03)00130-6Get rights and content

Abstract

Various international studies have demonstrated socio-economic differences in health. Linking the 1991 Census to the National Register and using the Health Interview Survey 1997 has enabled assessment of the association between the level of education and health in Belgium using the composite indicator ‘health expectancy’.

The Sullivan method was used to calculate health expectancy on the basis of current probability of death and prevalence of perceived health. Two measures of educational attainment were used: absolute educational attainment and the position on a relative hierarchical educational scale obtained by a regression-based method. The latter measure enables international comparisons.

Differences in health expectancy by education were spread over the whole range of the educational hierarchy, and were consistently larger among females than males. At 25 years of age, the difference in health expectancy between different levels of education reached up to 17.8 and 24.7 years in males and females, respectively. Compared with people with the highest educational attainment, males and females at the lowest level of education spent more than 10 and 20 additional years in poor perceived health, respectively. Between ages 25 and 75 years, the difference in health expectancy between people with the lowest and highest levels of education was 17 years among males and 21 years among females. Compared with people at the top of the relative educational scale, males and females at the bottom of the scale had 13.6 and 19.7 additional years in poor perceived health, respectively.

The conclusions of this study in Belgium are consistent with studies in other countries. People with a low level of education have shorter lives than people with a higher level of education. They also have fewer years in good perceived health, and can expect more years in poor health in their shorter lives. The inequality in health expectancy seems to be greater in females than males.

Introduction

Numerous studies have demonstrated socio-economic differences in health, both with regard to mortality and morbidity/disability. In certain Western countries, despite increased welfare, these differences have not been reduced and have even increased in some countries.1., 2.

The state of health of a population can be described using either mortality or morbidity indicators. Morbidity and mortality data form the basic information. The figures are clear and different populations can easily be compared over time and location. On the other hand, only one aspect of population health is revealed and no account is taken of the often-complex interaction between mortality and morbidity.3., 4. That is why the health status of a population is increasingly being assessed using a composite indicator that contains information on both mortality and morbidity. Monitoring the state of health over time using such an indicator, e.g. health expectancy, can also provide more clarity over whether morbidity is increasing or decreasing.3., 5., 6.

Health expectancy7 is one such composite measure and, analogous to life expectancy, gives the number of years that a person of a certain age can expect to continue living in good health. The benefits of health expectancy over other composite indicators, such as Disability Adjusted Life Years (DALY),8 lie in its simplicity and conceptual relationship with a well-understood indicator (life expectancy), the availability of basic data and the scope for visual presentation.9 Alongside the basic indicator of health expectancy, derived statistics (such as the number of years in poor health, the percentage of life spent in good health, the lost life expectancy and the lost health expectancy) can widen understanding.

An individual's position within the social hierarchy is mainly determined by occupation, income and education. Although these three dimensions of socio-economic status are strongly related to one another, each has its own specific influence on health. The education dimension has some clear benefits. The information is available for practically everyone in the community, and educational attainment remains relatively stable over time.10 However, due to its stability, using education alone as a dimension of socio-economic status may mask important changes in individuals' circumstances.11 Also, a cohort effect may occur as the socio-economic status of a certain educational attainment has probably changed over time.

In most studies of this type, differences in health or mortality have been determined against one dimension.12 This study also used one dimension, the highest level of education reached, because Census data on occupation and income were not available for many females who were not in paid employment. Moreover, the Census questionnaire on income and occupation was different from the Health Interview Survey so data were not comparable. Therefore, no adjustments could be made for other markers of socio-economic status (e.g. income and occupation). Risk factors could not be taken into account either, because information on risk factors was not present in the Census data.

Both the absolute and relative differences in health between socio-economic groups can be calculated. Relative differences are generally easy to understand, but the importance for public health is sometimes more clearly demonstrated by absolute differences.9

Recently, mortality figures according to socio-economic status have become available in Belgium. The data were provided by a follow-up study of the entire Belgian population at the individual level. Combining these data with the results of the Health Interview Survey allowed assessment of socio-economic differences in health on a large scale and gave rise to a number of new studies in this area. The aim of this study was to estimate the relationship between educational attainment and health status using the composite measure ‘health expectancy’.

Section snippets

Data

The Belgian 1991 Census and the National Register were linked over a follow-up period of 5 years (1991–1996) to draw up life tables by socio-economic status. The National Health Interview Survey 1997 provided morbidity data. In total, 10 221 people (0.1% of the total Belgian population) from 4664 households were interviewed. They were selected at random using the National Register, which covers the entire Belgian population.

Socio-economic status

Socio-economic position was determined on the basis of the highest

Absolute level of education

At 25 years of age, life expectancy is 49.6 and 55.9 years among males and females, respectively. At this age, life expectancy increases with increasing level of education.

Among males, health expectancy increases with increasing educational attainment (Table 3). The difference from the highest educational category is significant at the 0.05 level for all but two of the preceding educational categories. A comparison of the highest and lowest levels of education gives an idea of the maximum

International comparisons

Health expectancy according to socio-economic status has only been calculated in a few Western countries, either on the basis of perceived health,16., 17. or on the basis of disability.18., 19., 20. The current results corroborate the previous publications, i.e. that people in a lower socio-economic position do not live as long, have fewer years of life in good perceived health, and spend more years of their shorter lives in poor perceived health, so that the number of years in poor perceived

Conclusion

Some important conclusions can be drawn from the findings of this study. The current results are in agreement with previous publications, i.e. that people in a lower socio-economic position do not live as long, have fewer years of life in good perceived health and more years in poor perceived health, and that the number of years in poor perceived health takes up a greater percentage of their total lifetime. In comparison with Norway and Finland, Belgium appears to have a good overall life

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