Trends in health inequalities in 27 European countries.

Unfavorable health trends among the lowly educated have recently been reported from the United States. We analyzed health trends by education in European countries, paying particular attention to the possibility of recent trend interruptions, including interruptions related to the impact of the 2008 financial crisis. We collected and harmonized data on mortality from ca 1980 to ca 2014 for 17 countries covering 9.8 million deaths and data on self-reported morbidity from ca 2002 to ca 2014 for 27 countries covering 350,000 survey respondents. We used interrupted time-series analyses to study changes over time and country-fixed effects analyses to study the impact of crisis-related economic conditions on health outcomes. Recent trends were more favorable than in previous decades, particularly in Eastern Europe, where mortality started to decline among lowly educated men and where the decline in less-than-good self-assessed health accelerated, resulting in some narrowing of health inequalities. In Western Europe, mortality has continued to decline among the lowly and highly educated, and although the decline of less-than-good self-assessed health slowed in countries severely hit by the financial crisis, this affected lowly and highly educated equally. Crisis-related economic conditions were not associated with widening health inequalities. Our results show that the unfavorable trends observed in the United States are not found in Europe. There has also been no discernible short-term impact of the crisis on health inequalities at the population level. Both findings suggest that European countries have been successful in avoiding an aggravation of health inequalities.

'Fundamental causes' of inequalities in mortality: an empirical test of the theory in 20 European populations.

The 'fundamental causes' theory stipulates that when new opportunities for lowering mortality arise, higher socioeconomic groups will benefit more because of their greater material and non-material resources. We tested this theory using harmonised mortality data by educational level for 22 causes of death and 20 European populations from the period 1980-2010. Across all causes and populations, mortality on average declined by 2.49 per cent (95%CI: 2.04-2.92), 1.83% (1.37-2.30) and 1.34% (0.89-1.78) per annum among the high, mid and low educated, respectively. In 69 per cent of cases of declining mortality, mortality declined faster among the high than among the low educated. However, when mortality increased, less increase among the high educated was found in only 46 per cent of cases. Faster mortality decline among the high educated was more manifest for causes of death amenable to intervention than for non-amenable causes. The difference in mortality decline between education groups was not larger when income inequalities were greater. While our results provide support for the fundamental causes theory, our results suggest that other mechanisms than the theory implies also play a role.

Socioeconomic inequalities in cancer mortality between and within countries in Europe: a population-based study.

Background: Reducing socioeconomic inequalities in cancer is a priority for the public health agenda. A systematic assessment and benchmarking of socioeconomic inequalities in cancer across many countries and over time in Europe is not yet available. Methods: Census-linked, whole-of-population cancer-specific mortality data by socioeconomic position, as measured by education level, and sex were collected, harmonized, analysed, and compared across 18 countries during 1990-2015, in adults aged 40-79. We computed absolute and relative educational inequalities; temporal trends using estimated-annual-percentage-changes; the share of cancer mortality linked to educational inequalities. Findings: Everywhere in Europe, lower-educated individuals have higher mortality rates for nearly all cancer-types relative to their more highly-educated counterparts, particularly for tobacco/infection-related cancers [relative risk of lung cancer mortality for lower- versus higher-educated = 2.4 (95% confidence intervals: 2.1-2.8) among men; = 1.8 (95% confidence intervals: 1.5-2.1) among women]. However, the magnitude of inequalities varies greatly by country and over time, predominantly due to differences in cancer mortality among lower-educated groups, as for many cancer-types higher-educated have more similar (and lower) rates, irrespective of the country. Inequalities were generally greater in Baltic/Central/East-Europe and smaller in South-Europe, although among women large and rising inequalities were found in North-Europe (relative risk of all cancer mortality for lower- versus higher-educated ≥1.4 in Denmark, Norway, Sweden, Finland and the England/Wales). Among men, rate differences (per 100,000 person-years) in total-cancer mortality for lower-vs-higher-educated groups ranged from 110 (Sweden) to 559 (Czech Republic); among women from approximately null (Slovenia, Italy, Spain) to 176 (Denmark). Lung cancer was the largest contributor to inequalities in total-cancer mortality (between-country range: men, 29-61%; women, 10-56%). 32% of cancer deaths in men and 16% in women (but up to 46% and 24%, respectively in Baltic/Central/East-Europe) were associated with educational inequalities. Interpretation: Cancer mortality in Europe is largely driven by levels and trends of cancer mortality rates in lower-education groups. Even Nordic-countries, with a long-established tradition of equitable welfare and social justice policies, witness increases in cancer inequalities among women. These results call for a systematic measurement, monitoring and action upon the remarkable socioeconomic inequalities in cancer existing in Europe. Funding: This study was done as part of the LIFEPATH project, which has received financial support from the European Commission (Horizon 2020 grant number 633666), and the DEMETRIQ project, which received support from the European Commission (grant numbers FP7-CP-FP and 278511). SV and WN were supported by the French Institut National du Cancer (INCa) (Grant number 2018-116). PM was supported by the Academy of Finland (#308247, # 345219) and the European Research Council under the European Union's Horizon 2020 research and innovation programme (grant agreement No 101019329). The work by Mall Leinsalu was supported by the Estonian Research Council (grant PRG722).

The contribution of educational inequalities to lifespan variation.

BACKGROUND: Studies of socioeconomic inequalities in mortality consistently point to higher death rates in lower socioeconomic groups. Yet how these between-group differences relate to the total variation in mortality risk between individuals is unknown. METHODS: We used data assembled and harmonized as part of the Eurothine project, which includes census-based mortality data from 11 European countries. We matched this to national data from the Human Mortality Database and constructed life tables by gender and educational level. We measured variation in age at death using Theil's entropy index, and decomposed this measure into its between- and within-group components. RESULTS: The least-educated groups lived between three and 15 years fewer than the highest-educated groups, the latter having a more similar age at death in all countries. Differences between educational groups contributed between 0.6% and 2.7% to total variation in age at death between individuals in Western European countries and between 1.2% and 10.9% in Central and Eastern European countries. Variation in age at death is larger and differs more between countries among the least-educated groups. CONCLUSIONS: At the individual level, many known and unknown factors are causing enormous variation in age at death, socioeconomic position being only one of them. Reducing variations in age at death among less-educated people by providing protection to the vulnerable may help to reduce inequalities in mortality between socioeconomic groups.

Socioeconomic inequalities in homicide mortality: a population-based comparative study of 12 European countries.

Recent research has suggested that violent mortality may be socially patterned and a potentially important source of health inequalities within and between countries. Against this background the current study assessed socioeconomic inequalities in homicide mortality across Europe. To do this, longitudinal and cross-sectional data were obtained from mortality registers and population censuses in 12 European countries. Educational level was used to indicate socioeconomic position. Age-standardized mortality rates were calculated for post, upper and lower secondary or less educational groups. The magnitude of inequalities was assessed using the relative and slope index of inequality. The analysis focused on the 35-64 age group. Educational inequalities in homicide mortality were present in all countries. Absolute inequalities in homicide mortality were larger in the eastern part of Europe and in Finland, consistent with their higher overall homicide rates. They contributed 2.5% at most (in Estonia) to the inequalities in total mortality. Relative inequalities were high in the northern and eastern part of Europe, but were low in Belgium, Switzerland and Slovenia. Patterns were less consistent among women. Socioeconomic inequalities in homicide are thus a universal phenomenon in Europe. Wide-ranging social and inter-sectoral health policies are now needed to address the risk of violent victimization that target both potential offenders and victims.

Socioeconomic inequalities in mortality from conditions amenable to medical interventions: do they reflect inequalities in access or quality of health care?

BACKGROUND: Previous studies have reported large socioeconomic inequalities in mortality from conditions amenable to medical intervention, but it is unclear whether these can be attributed to inequalities in access or quality of health care, or to confounding influences such as inequalities in background risk of diseases. We therefore studied whether inequalities in mortality from conditions amenable to medical intervention vary between countries in patterns which differ from those observed for other (non-amenable) causes of death. More specifically, we hypothesized that, as compared to non-amenable causes, inequalities in mortality from amenable causes are more strongly associated with inequalities in health care use and less strongly with inequalities in common risk factors for disease such as smoking. METHODS: Cause-specific mortality data for people aged 30-74 years were obtained for 14 countries, and were analysed by calculating age-standardized mortality rates and relative risks comparing a lower with a higher educational group. Survey data on health care use and behavioural risk factors for people aged 30-74 years were obtained for 12 countries, and were analysed by calculating age-and sex-adjusted odds ratios comparing a low with a higher educational group. Patterns of association were explored by calculating correlation coefficients. RESULTS: In most countries and for most amenable causes of death substantial inequalities in mortality were observed, but inequalities in mortality from amenable causes did not vary between countries in patterns that are different from those seen for inequalities in non-amenable mortality. As compared to non-amenable causes, inequalities in mortality from amenable causes are not more strongly associated with inequalities in health care use. Inequalities in mortality from amenable causes are also not less strongly associated with common risk factors such as smoking. CONCLUSIONS: We did not find evidence that inequalities in mortality from amenable conditions are related to inequalities in access or quality of health care. Further research is needed to find the causes of socio-economic inequalities in mortality from amenable conditions, and caution should be exercised in interpreting these inequalities as indicating health care deficiencies.

The history of public health use of fluorides in caries prevention.

AIM: The aim of our study was to chronologically analyse various public health measures of fluoride use in caries prevention. METHODS: We systematically searched the PubMed database on the preventive role of fluorides in public health, published from 1984 to 2014. The search process was divided into four steps, where inclusion and exclusion criteria were defined. Qualitative methodology was used for the article analysis. In the research process, the described forms of F use, diversity of the described F agents, and the observed population group were analysed. RESULTS: In our systematic review, 40 relevant reviews were revealed. Fluorides have been used in many different forms, but only a few studies showed their significant role in public health. Water fluoridation was the most important public health measure. In the recent decades, the number of studies on topical fluorides is constantly rising. The most extensively described topical forms of fluorides are professionally applied fluoride agents and fluoride toothpaste for home-use. The use of fluoride containing toothpaste in caries prevention is a safe and successful public health measure (PHM) if their use is widespread, and it is recommended for all. The results on other topical forms of fluorides are insufficient to be suggested as an important PHM. CONCLUSIONS: The role of fluorides in public health prevention has changed in accordance with the knowledge about the fluoride cariostatic mechanism. Previously the most important pre-eruptive effect of fluorides was supplemented by the post eruptive effect. Abundant evidence exists to show the effectiveness of systemic and topical fluorides.

Trends In Inequalities In Mortality Amenable To Health Care In 17 European Countries.

Little is known about the effectiveness of health care in reducing inequalities in health. We assessed trends in inequalities in mortality from conditions amenable to health care in seventeen European countries in the period 1980-2010 and used models that included country fixed effects to study the determinants of these trends. Our findings show remarkable declines over the study period in amenable mortality among people with a low level of education. We also found stable absolute inequalities in amenable mortality over time between people with low and high levels of education, but widening relative inequalities. Higher health care expenditure was associated with lower mortality from amenable causes, but not from nonamenable causes. The effect of health care expenditure on amenable mortality was equally strong, in relative terms, among people with low levels of education and those with high levels. As a result, higher health care expenditure was associated with a narrowing of absolute inequalities in amenable mortality. Our findings suggest that in the European context, more generous health care funding provides some protection against inequalities in amenable mortality.

Educational expansion and inequalities in mortality-A fixed-effects analysis using longitudinal data from 18 European populations.

OBJECTIVE: The aim of this paper is to empirically evaluate whether widening educational inequalities in mortality are related to the substantive shifts that have occurred in the educational distribution. MATERIALS AND METHODS: Data on education and mortality from 18 European populations across several decades were collected and harmonized as part of the Demetriq project. Using a fixed-effects approach to account for time trends and national variation in mortality, we formally test whether the magnitude of relative inequalities in mortality by education is associated with the gender and age-group specific proportion of high and low educated respectively. RESULTS: The results suggest that in populations with larger proportions of high educated and smaller proportions of low educated, the excess mortality among intermediate and low educated is larger, all other things being equal. CONCLUSION: We conclude that the widening educational inequalities in mortality being observed in recent decades may in part be attributed to educational expansion.

Premature mortality in Slovenia in relation to selected biological, socioeconomic, and geographical determinants.

AIM: To determine biological (sex and age), socioeconomic (marital status, education, and mother tongue) and geographical (region) factors connected with causes of death and lifespan (age at death, years-of-potential-life-lost, and mortality rate) in Slovenia in the 1990s. METHODS: In this population-based cross-sectional study, we analyzed all deaths in the 25-64 age group (N=14 816) in Slovenia in 1992, 1995, and 1998. Causes of death, classified into groups according to the 10th revision of International Classification of Diseases, were linked to the data on the deceased from the 1991 Census. Stratified contingency-table analyses were performed. Years-of-potential-life-lost (YPLL) were calculated on the basis of population life-tables stratified by region and linearly modeled by the characteristics of the deceased. Poisson regression was applied to test the differences in mortality rate. RESULTS: Across all socioeconomic strata, men died at younger age than women (index of excess mortality in men exceeded 200 for all studied years) and from different prevailing causes (injuries in men aged <45 years; neoplasms in women aged >35 years). For men, higher education was associated with fewer deaths from digestive and respiratory system diseases. The least educated women died relatively often from circulatory diseases, but rarely from neoplasms. Single people died from neoplasms less often. Marriage in comparison with divorce reduced the mortality rate by 1.9-fold in both men and women (P<0.001). Mortality rate in both men and women decreased with increasing education level (P<0.001). Mortality rate of ethnic Slovenians was half the mortality rate of ethnic minority members and immigrants (P<0.001). Analysis of YPLL revealed limited and nonlinear impact of education level on premature mortality. The share of neoplasms was the highest in the cluster of socioeconomically prosperous regions, whereas the share of circulatory diseases was increased in poorer regions. Significant differences were found between individual regions in age at death and mortality rate, and the differences decreased over the studied period. CONCLUSION: These data may aid in understanding the nature, prevalence and consequences of mortality as related to socioeconomic inequalities, and thus serve as a basis for setting health and social policy goals and planning health measures.

FLUORIDE: A REVIEW OF USE AND EFFECTS ON HEALTH.

INTRODUCTION: Appropriate oral health care is fundamental for any individual's health. Dental caries is still one of the major public health problems. The most effective way of caries prevention is the use of fluoride. AIM: The aim of our research was to review the literature about fluoride toxicity and to inform physicians, dentists and public health specialists whether fluoride use is expedient and safe. METHODS: Data we used in our review were systematically searched and collected from web pages and documents published from different international institutions. RESULTS: Fluoride occurs naturally in our environment but we consume it in small amounts. Exposure can occur through dietary intake, respiration and fluoride supplements. The most important factor for fluoride presence in alimentation is fluoridated water. Methods, which led to greater fluoride exposure and lowered caries prevalence, are considered to be one of the greatest accomplishments in the 20th century`s public dental health. During pregnancy, the placenta acts as a barrier. The fluoride, therefore, crosses the placenta in low concentrations. Fluoride can be transmitted through the plasma into the mother's milk; however, the concentration is low. The most important action of fluoride is topical, when it is present in the saliva in the appropriate concentration. The most important effect of fluoride on caries incidence is through its role in the process of remineralization and demineralization of tooth enamel. Acute toxicity can occur after ingesting one or more doses of fluoride over a short time period which then leads to poisoning. Today, poisoning is mainly due to unsupervised ingestion of products for dental and oral hygiene and over-fluoridated water. CONCLUSION: Even though fluoride can be toxic in extremely high concentrations, it`s topical use is safe. The European Academy of Paediatric Dentistry (EAPD) recommends a preventive topical use of fluoride supplements because of their cariostatic effect.

Changes in mortality inequalities over two decades: register based study of European countries.

OBJECTIVE: To determine whether government efforts in reducing inequalities in health in European countries have actually made a difference to mortality inequalities by socioeconomic group. DESIGN: Register based study. DATA SOURCE: Mortality data by level of education and occupational class in the period 1990-2010, usually collected in a census linked longitudinal study design. We compared changes in mortality between the lowest and highest socioeconomic groups, and calculated their effect on absolute and relative inequalities in mortality (measured as rate differences and rate ratios, respectively). SETTING: All European countries for which data on socioeconomic inequalities in mortality were available for the approximate period between years 1990 and 2010. These included Finland, Norway, Sweden, Scotland, England and Wales (data applied to both together), France, Switzerland, Spain (Barcelona), Italy (Turin), Slovenia, and Lithuania. RESULTS: Substantial mortality declines occurred in lower socioeconomic groups in most European countries covered by this study. Relative inequalities in mortality widened almost universally, because percentage declines were usually smaller in lower socioeconomic groups. However, as absolute declines were often smaller in higher socioeconomic groups, absolute inequalities narrowed by up to 35%, particularly among men. Narrowing was partly driven by ischaemic heart disease, smoking related causes, and causes amenable to medical intervention. Progress in reducing absolute inequalities was greatest in Spain (Barcelona), Scotland, England and Wales, and Italy (Turin), and absent in Finland and Norway. More detailed studies preferably using individual level data are necessary to identify the causes of these variations. CONCLUSIONS: Over the past two decades, trends in inequalities in mortality have been more favourable in most European countries than is commonly assumed. Absolute inequalities have decreased in several countries, probably more as a side effect of population wide behavioural changes and improvements in prevention and treatment, than as an effect of policies explicitly aimed at reducing health inequalities.

More variation in lifespan in lower educated groups: evidence from 10 European countries.

BACKGROUND: Whereas it is well established that people with a lower socio-economic position have a shorter average lifespan, it is less clear what the variability surrounding these averages is. We set out to examine whether lower educated groups face greater variation in lifespans in addition to having a shorter life expectancy, in order to identify entry points for policies to reduce the impact of socio-economic position on mortality. METHODS: We used harmonized, census-based mortality data from 10 European countries to construct life tables by sex and educational level (low, medium, high). Variation in lifespan was measured by the standard deviation conditional upon survival to age 35 years. We also decomposed differences between educational groups in lifespan variation by age and cause of death. RESULTS: Lifespan variation was higher among the lower educated in every country, but more so among men and in Eastern Europe. Although there was an inverse relationship between average life expectancy and its standard deviation, the first did not completely predict the latter. Greater lifespan variation in lower educated groups was largely driven by conditions causing death at younger ages, such as injuries and neoplasms. CONCLUSIONS: Lower educated individuals not only have shorter life expectancies, but also face greater uncertainty about the age at which they will die. More priority should be given to efforts to reduce the risk of an early death among the lower educated, e.g. by strengthening protective policies within and outside the health-care system.

Educational inequalities in avoidable mortality in Europe.

BACKGROUND: The magnitude of educational inequalities in mortality avoidable by medical care in 16 European populations was compared, and the contribution of inequalities in avoidable mortality to educational inequalities in life expectancy in Europe was determined. METHODS: Mortality data were obtained for people aged 30-64 years. For each country, the association between level of education and avoidable mortality was measured with the use of regression-based inequality indexes. Life table analysis was used to calculate the contribution of avoidable causes of death to inequalities in life expectancy between lower and higher educated groups. RESULTS: Educational inequalities in avoidable mortality were present in all countries of Europe and in all types of avoidable causes of death. Especially large educational inequalities were found for infectious diseases and conditions that require acute care in all countries of Europe. Inequalities were larger in Central Eastern European (CEE) and Baltic countries, followed by Northern and Western European countries, and smallest in the Southern European regions. This geographic pattern was present in almost all types of avoidable causes of death. Avoidable mortality contributed between 11 and 24% to the inequalities in Partial Life Expectancy between higher and lower educated groups. Infectious diseases and cardiorespiratory conditions were the main contributors to this difference. CONCLUSIONS: Inequalities in avoidable mortality were present in all European countries, but were especially pronounced in CEE and Baltic countries. These educational inequalities point to an important role for healthcare services in reducing inequalities in health.

Population groups at high risk for poor oral self care: the basis for oral health promotion.

OBJECTIVES: Identification of population groups at high risk for poor oral self-care in adults was needed in order to enable more focused planning of oral health promotion actions in Slovenia. METHODS: The study was based on the national health behaviour database in adults aged 25-64. Data collected in 2001 were used. The sample size was 15,379. The overall response rate was 64%, and 8,392 questionnaires were eligible for oral self-care assessment. A complex indicator based on oral hygiene, frequency of visiting a dentist, and nutritional habits was derived. The outcome of interest was poor oral self-care. Logistic regression was used to test multivariate associations between several factors (gender, age, educational level, social class, etc.) and poor oral self-care. RESULTS: The overall prevalence of poor oral self-care was 6.9%. The odds for this outcome were higher for men (OR(males vs. females) = 7.49, p < 0.001), (or participants with the lowest educational levels (OR(uncompleted primary vs. university) = 5.95, p < 0.001; OR(primary vs. university) = 4.95, p < 0.001), and for participants from the lowest social classes (OR(lower vs. upper-middle) = 6.20, p < 0.001; OR(labour vs. upper-middle) = 4.05, p = 0.001). CONCLUSIONS: Special attention should be paid to oral health promotion for men, for those with low educational level, and for those belonging to the lowest social classes.