IJE Advance Access originally published online on November 24, 2004
International Journal of Epidemiology 2005 34(2):295-305; doi:10.1093/ije/dyh342
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Article |
Trends in socioeconomic inequalities in self-assessed health in 10 European countries
1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
2 Department of Public Health, University of Helsinki, Helsinki, Finland
3 Department of Epidemiology and Public Health, University College, London, United Kingdom
4 National Institute of Public Health, Copenhagen, Denmark
5 Department of Epidemiology, Ministry of Health, Madrid, Spain
6 GSF Institute of Health Economics and Health Care Management, Neuherberg, Germany
7 Department of Social Research, University of Piemonte Orientale, Allessandria, Italy
8 Division KPE, Statistics Netherlands, Heerlen, The Netherlands
9 Centre for Social Policy Research, University of Bremen, Bremen, Germany
10 Swedish Institute for Social Research, Stockholm University, Stockholm, Sweden
11 Health Division, Statistics Norway, Oslo, Norway
12 Department of Public Health and Microbiology, Turin University, Turin, Italy
13 Institute of Social Medicine and Epidemiology, University of Graz, Graz, Austria
* Corresponding author. Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands. E-mail: a.kunst{at}erasmusmc.nl
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Abstract |
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Background Changes over time in inequalities in self-reported health are studied for increasingly more countries, but a comprehensive overview encompassing several countries is still lacking. The general aim of this article is to determine whether inequalities in self-assessed health in 10 European countries showed a general tendency either to increase or to decrease between the 1980s and the 1990s and whether trends varied among countries.
Methods Data were obtained from nationally representative interview surveys held in Finland, Sweden, Norway, Denmark, England, The Netherlands, West Germany, Austria, Italy, and Spain. The proportion of respondents with self-assessed health less than ‘good’ was measured in relation to educational level and income level. Inequalities were measured by means of age-standardized prevalence rates and odds ratios (ORs).
Results Socioeconomic inequalities in self-assessed health showed a high degree of stability in European countries. For all countries together, the ORs comparing low with high educational levels remained stable for men (2.61 in the 1980s and 2.54 in the 1990s) but increased slightly for women (from 2.48 to 2.70). The ORs comparing extreme income quintiles increased from 3.13 to 3.37 for men and from 2.43 to 2.86 for women. Increases could be demonstrated most clearly for Italian and Spanish men and women, and for Dutch women, whereas inequalities in health in the Nordic countries showed no tendency to increase.
Conclusions The results underscore the persistent nature of socioeconomic inequalities in health in modern societies. The relatively favourable trends in the Nordic countries suggest that these countries' welfare states were able to buffer many of the adverse effects of economic crises on the health of disadvantaged groups.
Keywords Educational level, poverty, income, socioeconomic status, socioeconomic factors, inequalities, self-assessed health, health surveys, trends, international perspectives, European Union
Accepted 24 August 2004
Ever since the Black Report,1 a key question in health inequalities research has been whether inequalities in mortality and morbidity are narrowing or widening over time. Many trend studies are motivated by the concern that socioeconomic inequalities in health have increased owing to unfavourable social and economic developments.2 During the 1980s and 1990s, several European countries experienced serious economic crises or widening income inequalities—changes that might affect the health of national populations as a whole, and of disadvantaged groups in particular.3–5 Reducing inequalities in health now figures high on the health agendas of many national governments,6 and targets have been set to reduce these inequalities in the near future.7–9 In order to evaluate progress towards reaching these targets, monitoring trends in health inequalities will remain important.
Until recently, trends in inequalities in health have been documented mostly by using data on differences in premature mortality according to occupational class or educational level. A widening of relative inequalities in mortality was observed consistently for all European countries for which data were available.5,10–18 This widening appeared to be a long-term trend that can be traced back to 1950s for both England and Wales and The Netherlands,19 and to the 1960s and 1970s for other northern European countries.11,16–18,20 A recent overview showed that these trends continued until the 1990s in all northern European countries.21 However, the evidence from southern European countries is limited and does not consistently show that the social distribution of premature death has become more unequal over the last decade.12,15,22
These observations prompt the question of what trends would be observed if data on inequalities in morbidity instead of mortality were used. A main source of information is national health interview (and similar) surveys. In the 1980s, these surveys were used to produce detailed descriptions of socioeconomic inequalities in health and risk factors for health in most European countries.23,24 During the late 1990s, a second and even a third round of national health surveys were conducted in most European countries, offering an opportunity to assess whether inequalities in self-reported health have increased or decreased between the 1980s and thus 1990s. Results of national studies from several countries have been published recently.4,25–35
These results are not as consistent as those for mortality. For example, with regards to self-assessed general health, some studies observed a widening of inequalities between the 1980s and the 1990s whereas other studies suggested narrowing inequalities.25,26,28–33,36 It is uncertain whether this variation between studies reflects real differences among the countries studied. International overviews and comparisons are needed to assess whether there was a general tendency for inequalities in self-assessed health either to increase or to decrease and whether trends varied among countries.
This article is based on the first European study of trends in socioeconomic inequalities in mortality and morbidity.37 It provides a comprehensive overview of changes in inequalities in self-reported morbidity. This overview includes 10 European countries, considers both men and women, and assesses health differences according to both education and income. The specific objectives were to determine (i) whether there was a general tendency for inequalities in morbidity either to increase or to decrease between the 1980s and the 1990s and (ii) whether the direction and magnitude of change varied among countries.
Self-assessed health is used as the health indicator because nearly identical questions on this indicator are included in interview surveys from almost all European countries. This measure has been shown to be a reliable and valid indicator of general health and well-being38 and is recommended for international overviews and comparisons.39
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Materials and methods |
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Table 1 gives an overview of the countries and surveys that are included in this article. Data were obtained from nationally representative health interview surveys or from multipurpose surveys with a significant health component. Data were obtained from surveys that were at least 7 years apart, with the first survey held in the 1980s and the second survey held in the 1990s. The selected surveys differ with respect to the interview method used and the non-response rate. In no country, however, have there been major changes over time in these aspects.
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In addition to the 10 countries included in this article, several other European countries have two or more national health interview surveys.40 We had to exclude these countries from our overview either because the first survey was held in the 1990s instead of the 1980s (e.g. Switzerland, some Eastern European countries) or because the 1980s survey did not include a question on self-assessed health (e.g. France and Ireland).
In most countries, first- and second-generation migrants were included in the surveys. In Germany, however, those with non-German nationality were excluded from the surveys. Exclusion of these people might have biased health inequality estimates because most migrants have a low socioeconomic status and may have generally worse health than native people of the same status. On the other hand, selection on good health during immigration may result in relatively good health among recent migrants. Unfortunately, no reliable estimates are available on the general health of migrants as compared with the native German population.
The data presented in this paper relate to men and women aged 25–69 years. Younger respondents were excluded because many had not completed full-time education. Older respondents were excluded because of the bias that the exclusion of the institutionalized population might cause at higher ages. The number of respondents aged 25–69 years varies among countries. The Austrian and Italian surveys and also the first Spanish survey include relatively large numbers.
For each country, the two surveys had comparable data on educational levels. Unfortunately, comparable data on income were available only for the surveys from Finland, Sweden, The Netherlands, and West Germany. In order to add another country to these four, we included the results of an analysis of data from the British General Household Surveys of 1984 and 1996: for both years this survey had comparable data on both self-assessed health and income.
Measurement of self-assessed health
The health indicator is quantified as the proportion of respondents who state that their general health is ‘good’ or ‘fair/poor’ when asked a question similar to ‘How do you rate your general state of health: very good, good, fair, poor, or very poor?’. In nearly all countries, the same survey question with five answer categories was used in both surveys. Some of the Swedish and English surveys used a three-fold distinction, but they retained the essential distinction between ‘good’ and ‘fair’. A major exception is that the first Italian survey made a distinction only between ‘felt good’ and ‘not good’.
The German survey used answer categories that lacked a clear distinction between ‘good’ and ‘fair’ health. The categories were ‘very good’, ‘good’, ‘satisfying’, ‘not so good’, and ‘poor’. Therefore, we used two indicators for Germany, one that is restricted to ‘not so good’ and ‘poor’ and another that includes ‘satisfying’. Since the two indicators showed nearly identical changes over time, only the latter indicator will be presented in this article.
In addition to using the ‘fair/poor’ indicator, we also assessed inequalities in ‘poor’ health only. Generally, larger relative inequalities were observed for ‘poor’ health than those reported in this article for ‘fair/poor’ health. Unfortunately, owing to the small number of respondents reporting ‘poor’ health, confidence intervals for these inequality estimates were wide in many countries, and changes over time could not be determined with sufficient precision.
Measurement of educational level
In each survey, men and women were classified into three categories according to their completed educational level. These categories correspond broadly to levels 1 and 2 (elementary and lower secondary education), level 3 (upper secondary education), and levels 4–6 (post-secondary education) of the International Standard Classification of Education.41 For some countries, however, deviations from this standard classification had to be made in order to ensure as even a distribution of the survey population as possible over the three levels.
Table 2 shows the resulting distribution of the respondents according to these levels. As might be expected, in every country the share of the highest educational level is higher among men than among women, and this share increases over time. Relatively large changes are observed for Norway and Spain, probably resulting from slight changes in the educational classification applied in the two surveys.
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The share of the highest educational level is about the same in most countries, but it is smaller in Spain and Italy. The educational distributions for Germany and Austria are somewhat different because of different educational systems in which, among other factors, more emphasis is given to vocational training at secondary levels.
Measurement of income level
Income level was measured as the household equivalent income (HEI). Its calculation involved three steps. First, basic data on income were obtained from the national surveys. Income had to be measured for the entire household (or family). Where necessary, we added the income of all household members with substantial earnings. If data were available on different income components, all available income components were added. Income was measured as net income, that is, after deductions of taxes and social security premiums.
Second, the net household income was adjusted for the household size. The size of the household was measured as the total number of members of that household, including children and the elderly. The HEI was calculated by dividing the net household income by the square root of the household size. This formula is similar to the one used in a previous comparative project.42
Third, respondents were classified on the basis of their HEI into income quintile groups. These five groups had about the same proportion of the total number of male and female respondents aged 25–69 years.
In the British and Dutch surveys, income levels were unknown for about 20% of the respondents in both periods. Income was unknown for about 8% of the respondents to the two German surveys. In the Finnish and Swedish surveys, income levels were known for all respondents as a result of linkage to data from the tax registry.
Statistical methods
The prevalence of ‘fair/poor’ health per socioeconomic group was measured by means of standardized prevalence rates. Standardization by 5-year age group was done by means of the direct method, with the European population of 1987 as the standard. This age standardization procedure allowed us to control for differences in age structure among socioeconomic groups and, in addition, between men and women, among countries, and among periods.
In order to facilitate comparisons over time, odds ratios (ORs) were calculated that compared the lowest educational level (or income quintile) with the highest educational level (or income quintile). ORs were estimated by means of logistic regression analysis with the proportion of respondents with ‘fair/poor’ health as the dependent variable. The independent variables were a series of dummy variables representing 5-year age groups and a variable that represented the contrast between the highest and lowest educational levels (or income quintiles).
The difference between the ORs for the two periods is used to measure changes over time in the magnitude of health inequalities. Confidence intervals were calculated for this difference by means of a standard formula on the difference between the estimates for two independent samples.
For each period separately, we also calculated an unweighted average of the ORs for all countries together. Confidence intervals for this pooled measure were calculated by means of a standard formula on the average of the estimates from independent samples. Italy was excluded from this pooled estimate because of a problem with the comparability of the question on self-assessed health in the two Italian surveys (see ‘Discussion’ for details).
In trend analyses that are presented elsewhere,37 we also assessed trends with respect to the absolute (instead of relative) difference in prevalence rates between the highest and lowest groups. Moreover, we assessed changes over time using the Relative Index of Inequality, which has the advantage of being able to take into account all socioeconomic groups separately and to account for changes in the population distribution across these groups.43 Finally, trends in health inequalities were also assessed by applying prevalence rate ratios instead of ORs.34 These different health inequality indices are not presented in this article because they showed basically the same changes over time as those presented in the next section.37
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Results |
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Table 3 presents estimates of the prevalence of ‘fair/poor’ general health for the total male and female survey populations. The overall prevalence of ‘fair/poor’ health varies considerably among countries, with the highest rates observed for Finland and Italy. In Germany, the prevalence rates are much higher than elsewhere, but this is due to the inclusion of ‘satisfying’ health. Excluding ‘satisfying’ reduces the German prevalence rate to about 15%. In most cases, the national prevalence of ‘fair/poor’ health declined over time. The major exception is Italy, where prevalence rates increased by more than 6 percentage points for the population at large. This increase is probably due to changes in the Italian survey question on self-assessed health (see ‘Material and Methods’).
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In Table 4, a distinction is made by educational level. In most countries, the extent to which prevalence rates changed over time varies according to educational level. In several countries, notably The Netherlands, Italy, and Spain, changes were least favourable among the lowest educated men and women. (Trends in the national rates, presented in Table 3, are generally more favourable because these rates also reflect the increase in the percentage of the population belonging to higher educational levels.)
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Although Table 4 demonstrates that inequalities in self-assessed health persisted over time in each country, it is not clear to what extent these inequalities increased or decreased over time. In Table 5, the magnitude of health inequalities is expressed by means of ORs. A substantial increase in ORs is observed in a few countries, especially Italy and Spain. The opposite trend of decreasing inequalities is observed in a few other cases, for example, Norwegian and Danish men. For all countries together (see last row), the ORs comparing low with high educational levels remained stable for men (2.61 in the 1980s and 2.54 in the 1990s) but increased slightly for women (from 2.48 to 2.70).
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The confidence intervals for the ORs of Table 5 are large, implying that the observed changes in health inequalities may be strongly influenced by chance fluctuations. Their effect is evaluated in Figure 1, which presents estimates of the absolute change in ORs together with 95% confidence intervals for these change estimates. In only a few cases (Italian men and women, Spanish women) do confidence intervals not overlap the 0 value, implying that a widening of health inequalities can be demonstrated with statistical significance. In a few other cases (English women, Dutch women, Spanish men), the increase in health inequalities reaches borderline significance. In most other situations, especially in the Nordic countries, confidence intervals are so wide that no precise estimates can be made of the extent to which health inequalities changed over time.
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Results for income are given in Table 6. In each country for which data are available, men and women with lower income more often assess their health as ‘fair’ or ‘poor’. The association between income and self-assessed health is generally linear, with no consistent evidence of a threshold effect separating the poorest from the remainder of the population. In only a few cases, especially British men and women, is a large gap found between the prevalence rates of the lowest quintile and the rates observed for the remainder of the population. Changes over time in prevalence rates are not consistently related to income level. An exception to this rule is The Netherlands, where the prevalence of ‘fair/poor’ health declined in most income groups but increased in the lowest groups.
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The ORs given in Table 7 help to assess whether income-related health differences widened or narrowed between the 1980s and the 1990s. These differences were more or less stable in most cases. However, substantial increases were observed for Sweden (women), Great Britain (women), and The Netherlands (men and women). For all countries together, income-related inequalities increased among men (ORs increased from 3.06 to 3.40) and to a larger extent among women (from 2.43 to 2.86).
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Figure 2 shows the extent of the increase in individual countries and adds 95% confidence intervals in order to assess the precision of the change estimates. Increases in inequalities can be demonstrated with statistical significance for Dutch women only. In all other cases, changes cannot be demonstrated with statistical significance. It would, however, be erroneous to interpret this non-significance as a sign of stability. The figure shows that the confidence intervals for the change estimates are wide and that they do not exclude the possibility that substantial increases or decreases did occur.
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Evaluation of data sources
Until recently, studies on trends in health inequalities relied mainly on mortality data. Increasingly, however, national interview surveys are used to assess whether health inequalities widened or narrowed over time. Data from health interview surveys are used not only because of the wish to move from mortality to morbidity, but also because these surveys offer a number of specific advantages. First, these surveys are available for many of the European countries that still lack national longitudinal mortality studies. In addition, health surveys allow the consideration of a broader set of variables than is usually available for mortality studies, including different health indicators, a set of complementary socioeconomic indicators, and information on health-related behaviours and other health determinants.27,40,44
Nonetheless, the use of interview surveys to monitor inequalities in health poses a number of problems. A comprehensive discussion of all potential data problems is given elsewhere.37 In this article, we discuss only those that are probably most influential.
One major problem is the low statistical power of most interview surveys. Estimates of the magnitude of changes over time in health inequalities were found to have generally low levels of precision (large confidence intervals). This may seem surprising given the fact that the national surveys used here are among the largest available in the respective countries and given the experience that their sample sizes are sufficiently large for many purposes. For example, they can be used to demonstrate inequalities in health at a single moment in time with high levels of statistical significance. However, estimates of the magnitude of these inequalities have large confidence intervals, with the consequence that changes in this magnitude cannot be estimated with much precision. This problem is compounded by the fact that during the relatively short time periods covered in this study (between 7 and 10 years in each country), the true changes in health inequalities were probably modest.
A second problem, which is inherent in the use of any interview survey, relates to the reliance on reporting by respondents. The indicator used in this study, self-assessed health, has been extensively evaluated for both its validity and reliability. In both aspects, this indicator performs fairly well, implying that it enables a valid and reliable assessment of a person's general health and well-being.38,45–47 Nonetheless, one cannot exclude the possibility that changes over time in its overall prevalence rates are influenced by shifts in, for example, the expectations that people have with regard to their health and factors that may change the awareness of health problems, such as improved detection of diseases. If these changes differ by socioeconomic group, they would bias estimates of changes in health inequalities. The extent of this bias cannot be measured and should perhaps not be exaggerated, especially for studies that cover a relatively short time period.
A third problem relates to changes over time in survey designs and questionnaires. Even though we selected the surveys on the basis of a high degree of continuity and comparability over time, some changes may have biased our trend estimates. One particular problem is that the question on self-assessed health used in the Italian surveys changed over time. This change is likely to have caused the large increase in overall prevalence rates which was observed for Italy only (Table 3). One cannot exclude the possibility that this effect might be larger among lower educational groups than among higher groups. A similar problem is that large increases in overall prevalence rates were also observed for Great Britain when using the General Household Surveys (GHSs) of 1984 and 1996 (Table 6), but not when using the other British surveys (Tables 3 and 4). The causes of this discrepancy are not known, but they may be related to changes in the GHS questionnaire. Therefore, the substantial changes in the size of health inequalities that we observed for Italy (by education) and for Great Britain (by income) should be viewed with caution.
The last problem that needs to be discussed are the high rates of non-response for some surveys. This applies particularly to the survey of The Netherlands, where the total non-response rate is about 40% and where item non-response on income is 20%. Together, these two factors imply that income-related inequalities in health in The Netherlands are estimated for only about one-half of the initial survey sample. The effects of non-response are perhaps less dramatic than one might fear, because response rates in The Netherlands do not clearly differ according to socioeconomic status,48 and response rates changed only slightly over time. Based on more detailed evaluations,35,37 we judged that non-response problems are unlikely to explain the increase in income-related health differences observed for The Netherlands.
The data problems discussed above warn that results from individual surveys should be treated with some caution. They underscore the fact that it may be highly problematic to determine for individual countries the extent to which health inequalities have widened or narrowed during recent years. In the discussion below, we will therefore concentrate on the few international patterns that are not likely to be due to specific data problems.
Discussion of key findings
The main finding from this study is that socioeconomic inequalities in self-assessed health showed a high degree of stability in European countries. This finding adds to the increasing evidence that socioeconomic inequalities are highly persistent in Europe. The same persistence was observed in our previous cross-national comparisons for the 1980s, in which we observed that there was no European country where socioeconomic inequalities in morbidity and mortality were clearly smaller than elsewhere.42,49 The persistence of large health inequalities stresses that these inequalities are deeply rooted in the social stratification systems of modern societies. It also underlines the increasing recognition that health and social disadvantage are intimately related as a result of multiple links that unfold and persist over a person's life course.50,51 Finally, the observed persistence of health inequalities warns that it would not be realistic to expect a substantial reduction in health inequalities within a short period. Targets for policies that aim to reduce inequalities in morbidity or mortality should therefore avoid overoptimism.52
A second tendency in our international overview—and perhaps a tendency that will give rise to more optimistic interpretations—is that changes in health inequalities seem to be more favourable in the Nordic countries. Even though estimates from individual Nordic countries were not precise because of the small sample size of each Nordic survey, health differences according to educational level (the only indicator available for all Nordic countries) did not show a general tendency to increase. Similar findings were obtained from a series of national studies that analysed the same Nordic surveys with different analytical methods or that analysed data from other surveys.4 The relatively favourable record of the Nordic countries is remarkable given the economic crises that most experienced in the late 1980s or early 1990s.53 Even though Nordic studies reported adverse effects of the economic crises on the psychological well-being of the population, especially the younger generations,54 improvements in somatic health outcomes seem to have continued, also among lower socioeconomic groups. These trends suggest that Nordic welfare states may have been able to moderate, at least in the short term, the adverse effects that economic crises could have had on the general health of disadvantaged sections of the population.4
A country where inequalities in health might have widened over time is Great Britain, where income inequalities increased at an unprecedented rate in the 1980s.53 Our results suggest that inequalities in self-assessed health tended to increase as well. However, this increase was not clearly larger than those observed in many other European countries. Similar patterns were observed for mortality. In England and Wales, substantial increases are observed for inequalities in mortality, measured both at the area level5 and according to occupational class.5,10 However, the pace of increase does not appear to be larger than in other northern European countries.21 Thus, the exceptionally strong rise in income inequalities in England does not seem to be accompanied by a more-than-average increase in inequalities in mortality or morbidity. This finding does not necessarily imply that health inequalities are insensitive to income inequalities, as the full effect of increasing income inequalities may appear later over the life course of those who are affected.55
Firm evidence on the impact of social and economic change should come from future studies of trends in socioeconomic inequalities in health. Economic developments and socioeconomic policies are expected to have large effects on the health of disadvantaged population groups.55–57 Attention needs to be given to different stages of the economic cycle, including the occurrence of major economic crises,3 and to gradual socioeconomic change, such as changes in welfare state provision4,58 and economic reform.59 The impact of these changes on health inequalities can be assessed by studying trends over a longer span of time and by studying social gradients in intermediate factors such as living standards, working conditions, and health-related behaviours.25,36,60,61 Important opportunities for such studies will arise in the coming years, when a new round of health interview surveys will be completed in many European countries.
KEY MESSAGES
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Acknowledgments |
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This study was supported financially by the Health Monitoring Program of the European Commission under contract number SOC 98 201376 05F03. We very much thank Charlie Owen of the Institute of Education at London for analysing data from the General Household Survey on income-related health inequalities. During two workshops, in Rotterdam (1999) and Bielefeld (2000), useful comments on the design and preliminary results of this study were given by several colleagues, and especially by Seeromanie Harding, Örjan Hemström, Hubert Isnard, Christophe Koller, Richard Layte, and Tapani Valkonen.
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