Tackling health inequalities in Europe

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Tackling health inequalities in Europe

• Results from the EUROTHINE project
• I. Stirbu, AJ Roskam, M Schaap, G. Menvielle, A.
  Kunst,
• and J.P. Mackenbach
• Department of Public Health, Erasmus University

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Background

• Descriptive studies have identified the scale of
  the problem
• health inequalities exist in all European
  countries
• a common problem, but with variations
• Reviews of intervention studies have suggested
  ways to reduce health inequalities
• evidence for effectiveness is limited
• European countries are at different stage of
  policy development vis-à-vis health inequalities
• important to learn lessons from other countries

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Objectives

• To improve the description of health inequalities
  in Europe and to enhance the evidence-base for
  policies to reduce inequalities in health
• To prepare international overviews that provide
  bench-marking data on inequalities in mortality,
  morbidity and health determinants to
  participating countries
• To assess evidence on the effectiveness of
  policies and interventions to tackle health
  inequalities, and to make recommendations on
  strategies for reducing health inequalities in
  participating countries

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Added value

• Extension to new member states (25 countries
  total)
• Inclusion of more health determinants
• More contribution to explanation of inequalities
• Assessment of evidence contribution to policy
  decision making
• Improvement in monitoring of health inequalities
  in EU

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Geographic coverage
NORTH Finland Sweden Norway Denmark
WEST England Ireland
BALTIC Estonia Latvia Lithuania
Continental Netherlands Belgium
Germany Switzerland France
EAST Slovenia Hungary Czech Rep Slovakia Poland
SOUTH Italy (Turin) Spain (BAR, MAD, BSQ) Portugal
Total 22 countries
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Structure international collaboration
 
 
Coordinating Center Erasmus MC, Prof.Dr.
Mackenbach
Consortium (61 individuals in 25 countries)
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Methods

• National mortality registries (16 countries)
• National health surveys (18 countries)
• International surveys (SHARE, ECHP, ESS)
• Socio-economic variables
• Educational level
• Occupational class
• Statistical measures
• Absolute inequalities
• Relative inequalities
• Outcome measures
• Determinants of health inequalities

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Data collection experience and lessons learnt

• Basic information is not universally available
• Discrepancies in data collections methodology
  cross-sectional vs longitudinal studies, sample
  sizes, frequency of data collection
• Information on major outcomes (SAH, mortality),
  but not in more specific outcomes
• Little information on relevant health
  determinants living conditions, psychological
  factors, health care utilization
• International comparability is poor

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Inequalities in Europe
Relative inequalities in mortality by education
among men in Europe
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Relative inequalities by occupational class
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Inequalities in self-assessed health
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Increase of inequalities in Eastern Europe
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Overview of inequalities in Europe Main
conclusions

• Variations versus ubiquity
• Universal welfare policies necessary but
  insufficient in reducing inequalities in health
• Innovative approaches geared to the nature of
  health inequalities are needed
• Opportunities for reducing health inequalities
  health inequalities which are smaller in some
  populations
• Priorities for reducing health inequalities
  health inequalities which are larger in some
  populations
• Central and Easter European populations
• Inequalities in specific diseases

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Determinants of health inequalities
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Inequalities in smoking
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Correlation between lung cancer mortality and
smoking
RII for lung cancer mortality and current smoking
in Europe, Men and women aged 40-59
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Inequalities in obesity
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Inequalities in obesity and diabetes
The relationship between educational inequalities
(RII) in diabetes (y-axis) and obesity (x-axis)
across Europe for women
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Inequalities in leisure time physical activity
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Health care utilization specialist care
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Health care utilization preventive services
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Determinants of health inequalities Main
conclusions

• Health related behaviors - entry points for
  policies to tackle health inequalities
• Improvements in health care system can play a
  role in reducing health inequalities in many
  countries, especially in Eastern European
  countries

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Effectiveness of interventions and policies
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Challenges in learning from interventions to
reduce inequalities in health

• Previous health promotion interventions have
  proved to be effective for higher SE classes,
  thus increasing inequalities in health
• Limited studies evaluate interventions with
  difference in effectiveness between low and high
  SE groups
• Many studies are based on US interventions

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Evaluation of the effectiveness of policies and
interventions Smoking case study UK

• Evaluation of the national program of services to
  help people quitting with smoking in England
• Intervention smoking cessation treatment
  (counselling, intensive support, and nicotine
  replacement therapy)
• National program with disadvantaged smokers as
  priority group
• Lower success rate among SE disadvantaged people
  coupled with higher proportion of them being
  treated gt greater proportion of quitters among
  smokers living in the most disadvantaged areas.
• Lower success rates for disadvantaged groups do
  not necessarily exacerbate inequalities

Total prevalence
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Effect of tobacco control policies in Europe
Smoking cessation among women
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Inequalities in healthcare review of evidence

• Conceptual framework identifying ways in which
  health care may affect health inequalities
• Review of studies on improving utilization of
  breast and cervix cancer screening programs among
  women
• Centralized population based cancer screening
  programs leave fewer chances for SE inequalities
• Primary care physicians play a key role in
  promoting breast and cervix cancer screening
  among women with lower SE status
• Access could be effectively enhanced through
  cost-reduction interventions

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Interventions and policies Main conclusions

• General paucity of evidence -gt important to
  continue constructing a systematic evidence base
  on international level
• Review of specific interventions indicate large
  potential in reducing inequalities in health
  through health related behaviors and health care

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General conclusions

• Socioeconomic inequalities in health are
  substantial throughout Europe
• Variations in the magnitude suggests feasibility
  but warns against optimism
• Policies and interventions should be tailored to
  the specific pattern of health inequalities
• Policies addressing upstream determinants are
  necessary but not sufficient
• Health-related behaviors and health care
  represent important entry-points for
  interventions
• Monitoring of health inequalities should be
  improved
• Elimination of health inequalities is not
  realistic, but a substantial reduction is within
  the realm of possibility.

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Additional information

• www.eurothine.org (final report available online)
• International publications
• Department of Public Health,
• Erasmus Medical Center,
• Rotterdam,
• the Netherlands
• mgz_at_erasmusmc.nl