Elsevier

The Lancet

Volume 349, Issue 9066, 7 June 1997, Pages 1655-1659
The Lancet

Articles
Socioeconomic inequalities in morbidity and mortality in western Europe*

https://doi.org/10.1016/S0140-6736(96)07226-1Get rights and content

Summary

Background

Previous studies of variation in the magnitude of socioeconomic inequalities in health between countries have methodological drawbacks. We tried to overcome these difficulties in a large study that compared inequalities in morbidity and mortality between different countries in western Europe.

Methods

Data on four indicators of self-reported morbidity by level of education, occupational class, and/or level of income were obtained for 11 countries, and years ranging from 1985 to 1992. Data on total mortality by level of education and/or occupational class were obtained for nine countries for about 1980 to about 1990. We calculated odds ratios or rate ratios to compare a broad lower with a broad upper socioeconomic group. We also calculated an absolute measure for inequalities in mortality, a risk difference, which takes into account differences between countries in average rates of illhealth.

Findings

Inequalities in health were found in all countries. Odds ratios for morbidity ranged between about 1·5 and 2·5, and rate ratios for mortality between about 1·3 and 1·7. For men's perceived general health, for instance, inequalities by level of education in Norway were larger than in Switzerland or Spain (odds ratios [95% CI]: 2·57 [2·07–3·18], 1·60 [1·30–1·96], 1·65 [1·44–1·88], respectively). For mortality by occupational class, in men aged 30–44, the rate ratio was highest in Finland (1·76 [1·69–1·83]), although there was no large difference in the size of the inequality in those countries with data. For men aged 45–59, for whom France did have data, this country had the largest inequality (1·71 [1·66–1·77]). In the agegroup 45–64, the absolute risk difference ranked Finland second after France (9·8% [9·1–10·4], 11·5% [10·7–12·4]), with Sweden and Norway coming out more favourably than on the basis of rate ratios. In a scatter-plot of average rank scores for morbidity versus mortality, Sweden and Norway had larger relative inequalities in health than most other countries for both measures; France fared badly for mortality but was average for morbidity.

Interpretation

Our results challenge conventional views on the between-country pattern of inequalities in health in western European countries.

Introduction

Socioeconomic inequalities in health have been reported to vary between countries,1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 although comparative studies have methodological drawbacks. Thus looking for conditions that reduce health inequalities is difficult. We have done a large between-country comparison of inequalities in mortality and morbidity in western Europe in which we tried to overcome some of these difficulties. Our full-length report was published in 1996.12

Section snippets

Morbidity

Data on morbidity were obtained from nationally representative health interview, level of living, or multipurpose surveys in 11 countries (table 1) over 1985–92 covering around 5000–132 000 (median about 11 000) respondents. Generally, institutionalised populations were excluded in the surveys. We report on persons aged 25–69. Great Britain comprises England, Wales, and Scotland. Germany means the former West Germany.

We selected four health indicators to compare countries: perceived general

Morbidity

For inequalities in morbidity within countries, for men, the odds ratios by level of education ranged from about 1·3 to 2·6 (table 1). For perceived general health, for instance, eight of the 11 countries had odds ratios of almost 2 or higher. The 95% CIs indicate that inequalities for this measure were larger in Norway than in Switzerland or Spain. For long-term disabilities we could not obtain data for all the countries, but Switzerland was better off than Norway or the Netherlands.

The

Discussion

Countries in western Europe were generally similar in the size of socioeconomic inequalities in health. In all countries, risks of morbidity and mortality were higher in the lower socioeconomic groups. Surprisingly, we found that relative inequalities were larger than average in Sweden and Norway (both for morbidity and mortality). France had the highest inequality for mortality.

Large inequalities for morbidity have been reported in the Nordic countries and the Netherlands,1, 4 but one study

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