Nordic research on health inequalities: A scoping review of empirical studies published in Scandinavian Journal of Public Health 2000-2021.

AIMS: An important task for the Scandinavian Journal of Public Health is to address health inequality topics. This scoping review characterises Nordic empirical studies within this research field, published 2000-2021 by the Scandinavian Journal of Public Health. METHODS: Original empirical research studies using data from Denmark, Finland, Iceland, Norway and/or Sweden, which linked differences in health or health-related aspects to socioeconomic positions, immigrant status, family structures and/or residential areas, were included in the review. The initial search in the Web of Science article database resulted in 294 possibly relevant articles, and 171 were judged to comply with our criteria. RESULTS: Only one study was based on qualitative data, while all others used either surveys or register data, or both in combination. A wide variety of outcomes was addressed. Most studies had a social causation design, but 16 studies analysed health-related mobility processes and four reported intervention results. The most common statistical method was logistic regression. Poisson, Cox and ordinary least squares regression were less used. Few studies engaged explicitly with health inequality theories or with rigorous causality designs. CONCLUSIONS: The empirical health inequality studies published by the Scandinavian Journal of Public Health are rich sources for knowledge on a large array of health and health-related inequalities in Nordic countries. Drawbacks are underuse of qualitative data, few theoretical discussions and lack of studies assessing effects of interventions and policies.

Impact of growing up with somatic long-term health challenges on school completion, NEET status and disability pension: a population-based longitudinal study.

BACKGROUND: Young adulthood is an important transitional life phase that can determine a person's educational and employment trajectories. The aim of this study was to examine the impact of somatic long-term health challenges in adolescence on upper secondary school completion, not in education, employment or training (NEET status) and receiving disability pension in early adulthood. Additional disparities in educational and employment achievements were also investigated in relation to socioeconomic background. METHODS: The sample consisted of all young adults born in the period 1990 to 1996, (N = 421,110). Data were obtained from the Norwegian Patient Registry which is linked to the Central Population Register, education and income registries and the Historical Event Database in Statistics Norway. These data sources provide longitudinal population data. Statistical analyses were performed using multiple logistic regression and computed average marginal effects after the multiple logistic regression. RESULTS: The results showed that, compared to young adults without long-term health challenges, young adults with the diagnoses inflammatory bowel disease, epilepsy, diabetes, sensory impairment, spinal muscular atrophy (SMA), spina bifida (SB) and cerebral palsy (CP) had lower odds of completing upper secondary education. Moreover, young adults with long-term health challenges had higher odds of NEET status by age 21 compared to those without a long-term health challenge. As for the odds of NEET status by age 21, the results showed that young adults with epilepsy, SMA, SB and CP in particular had the highest odds of receiving disability pension compared to young adults without long-term health challenges. CONCLUSIONS: This longitudinal study revealed that on average young adults with long-term health challenges, compared to those without, struggle to participate in education and employment. The findings highlight the need for preventive measures especially in relation to young adults with neurological conditions such as epilepsy, SMA, SB, and CP.

Disentangling the dynamics of social assistance: A linked survey-Register data cohort study of long-term social assistance recipients in Norway.

Social assistance is a means-tested benefit that is supposed to be a short-term, temporary economic support. Understanding why some individuals are in repeated or continuous need of social assistance is thus of obvious policy relevance, but the dynamics of social assistance receipt remain poorly understood. In 2005, a survey among long-term recipients of social assistance in Norway collected data on (a) childhood disadvantages, (b) health status, (c) health behaviors, (d) psychological resources, and (e) social ties, in addition to basic sociodemographic information. This rich survey data has been linked with tax register data from 2005-2013, enabling us to explore the detailed characteristics of long-term social assistance recipients who are unable to reach financial self-sufficiency. Results from linear probability models show that surprisingly few of the 28 explanatory variables are statistically associated with social assistance dynamics, with two important exceptions: People with drug problems and immigrants both have a much higher probability of social assistance receipt. Yet overall, it is challenging to 'predict' social assistance dynamics, indicating that randomness most likely plays a non-negligible role. The 28 explanatory variables do a far better job in predicting both labor market success (employment), labor market preparation (work assessment allowance), and labor market withdrawal (disability benefit utilization). Thus, there seems to be something distinctive about the processes leading to continued social assistance recipiency, where randomness could be a more influential force.

29 recommendations to combat social inequalities in health. The Norwegian Council on Social Inequalities in Health.

All political parties in Norway agree that social inequalities in health comprise a public health problem and should be reduced. Against this background, the Council on Social Inequalities in Health has taken action to provide specific advice to reduce social health differences. Our recommendations focus on the entire social gradient rather than just poverty and the socially disadvantaged. By proposing action on the social determinants of health such as affordable child-care, education, living environments and income structures, we aim to facilitate a possible re-orientation of policy away from redistribution to universalism. The striking challenges of the causes of health differences are complex, and the 29 recommendations to combat social inequality of health demand cross sectorial actions. The recommendations are listed thematically and have not been prioritized. Some are fundamental and require pronounced changes across sectors, whereas others are minor and sector-specific.

Socioeconomic inequalities in health during the Great Recession: A scoping review of the research literature.

Aims: The so-called 'Great Recession' in Europe triggered widespread concerns about population health, as reflected by an upsurge in empirical research on the health impacts of the economic crisis. A growing body of empirical studies has also been devoted to socioeconomic inequalities in health during the Great Recession. The aim of the current study is to summarise this health inequality literature by means of a scoping review. Methods: We have performed a scoping review of the research literature (English language) published in the years 2012-2017. Only empirical papers with (a) health status measured on the individual level, (b) information on socioeconomic position (i.e. employment status, educational level, income/wealth, and/or occupational class), and (c) data from European countries in both pre- and post-crisis years were considered relevant. In total, 49 empirical studies fulfilled these inclusion criteria. Results: The empirical findings in the 49 included studies predominantly show that socioeconomic inequalities in health either increased or remained stable from pre- to post-crisis years. Two-thirds (65%) of the studies found evidence of either increasing or partially increasing health inequalities. Thus, people in lower socioeconomic strata fared worse overall in terms of health during the Great Recession, compared to people with higher socioeconomic status. Conclusions: The Great Recession in Europe tends to be followed by increasing socioeconomic inequalities in health. Policymakers should take note of this finding. Widening socioeconomic inequalities in health is a major cause of concern, in particular if health deterioration among 'vulnerable groups' is caused by accelerating cumulative disadvantages.

European health inequality through the 'Great Recession': social policy matters.

This paper investigates the association between the Great Recession and educational inequalities in self-rated general health in 25 European countries. We investigate four different indicators related to economic recession: GDP; unemployment; austerity and a 'crisis' indicator signifying severe simultaneous drops in GDP and welfare generosity. We also assess the extent to which health inequality changes can be attributed to changes in the economic conditions and social capital in the European populations. The paper uses data from the European Social Survey (2002-2014). The analyses include both cross-sectional and lagged associations using multilevel linear regression models with country fixed effects. This approach allows us to identify health inequality changes net of all time-invariant differences between countries. GDP drops and increasing unemployment were associated with decreasing health inequalities. Austerity, however, was related to increasing health inequalities, an association that grew stronger with time. The strongest increase in health inequality was found for the more robust 'crisis' indicator. Changes in trust, social relationships and in the experience of economic hardship of the populations accounted for much of the increase in health inequality. The paper concludes that social policy has an important role in the development of health inequalities, particularly during times of economic crisis.

Tackling health inequality at the local level: Some critical reflections on the future of Norwegian policies.

AIM: In this paper we discuss recent developments in the policy to reduce health inequalities in Norway in relation to challenges and opportunities associated with tackling health inequality at the local level. METHODS: We discuss government documents and research findings on the implementation of policies to diminish health inequalities at the municipality level. Recent policy developments are briefly reviewed in relation to the 10-year strategy to reduce health inequalities passed by the Parliament in 2007. We then identify opportunities and obstacles to successful action on health inequalities at the local level. RESULTS: The 2012 Public Health Act represented a powerful reinforcement of the strategy to reduce health inequalities at all three levels of government: the national, the regional and the local. However, some aspects of the policies pursued by the current government are likely to make local action to tackle health inequality an uphill struggle. In particular, health equity policies that have hitherto been based on universalism and had a focus on the gradient seem to be running out of fuel. Other challenges are an insufficient capacity for effective action particularly in smaller municipalities, and a rather weak knowledge base, including systems to monitor social inequalities and a general lack of evaluations of trials and new initiatives. CONCLUSIONS: We conclude that the Public Health Act opened up many new opportunities, but that a number of municipalities face obstacles that they need to overcome to tackle health inequalities comprehensively. Furthermore, local efforts need to be coupled with sustained national momentum to be efficient.

A fuzzy set approach to economic crisis, austerity and public health. Part I. European countries' conformity to ideal types during the economic downturn.

AIMS: This is the first part of a two-part paper that takes an explorative approach to assess crisis and austerity in European countries during the Great Recession. The ultimate aim of this two-part paper is to explore the "crisis-austerity" thesis by Stuckler and Basu and assess whether it is the interplay between austerity and crisis, rather than the current economic crisis per se, that can led to deterioration in population health. In Part I of this paper we offer one way of operationalizing crisis severity and austerity. We examine countries as specific configurations of crisis and policy responses and classify European countries into "ideal types." METHODS: Cases included were 29 countries participating in the European Union Statistics on Income and Living Conditions (EU-SILC) surveys. Based on fuzzy set methodology, we constructed two fuzzy sets, "austerity" and "severe crisis." Austerity was measured by changes in welfare generosity; severe crisis was measured by changes in gross domestic product (GDP) per capita growth. RESULTS: In the initial phase of the Great Recession, most countries faced severe crisis combined with no austerity. From 2010-2011 onward, there was a divide between countries. Some countries consistently showed signs of austerity policies (with or without severe crisis); others consistently did not. CONCLUSIONS: The fuzzy set ideal-type analysis shows that the European countries position themselves, by and large, in configurations of crisis and austerity in meaningful ways that allow us to explore the "crisis-austerity" thesis by Stuckler and Basu. This exploration is the undertaking of Part II of this paper.

A fuzzy set approach to economic crisis, austerity and public health. Part II: How are configurations of crisis and austerity related to changes in population health across Europe?

AIMS: Based on the ideal type classification of European countries done in Part I of this paper, Part II explores whether the real 'danger' to public health is the interplay between austerity and crisis, rather than recession itself. METHODS: We constructed two fuzzy sets of changes in population health based on a pooled file of European Union Statistics on Income and Living Conditions (EU-SILC) data (2008 and 2013) including 29 European countries. The linear probability analyses of 'limiting long-standing illness' and 'less than good' health were restricted to the age group 20-64 years. We performed fuzzy set qualitative comparative analysis (fsQCA) and studied whether configurations of 'severe crisis' and 'austerity' were linked to changes in population health. RESULTS: Overall, the results of this fsQCA do not support the 'crisis-austerity' thesis. Results on 'less than good' health were highly inconsistent, while results on 'limiting long-standing illness', contrary to the thesis, showed a two-path model. Countries with either no severe crisis or no austerity were subsets of the set of countries that experienced deteriorated health. Results also show that several countries combined both paths. CONCLUSIONS: This fuzzy set analysis does not support Stuckler and Basu's 'crisis-austerity' thesis, as those European countries that experienced recession and austerity were not consistently the countries with deteriorating health. There may be multiple reasons for this result, including analytical approach and operationalization of key concepts, but also resilient forces such as family support. We suggest more research on the topic based on more recent data and possibly other, or more, dimensions of austerity.

Shape of the association between income and mortality: a cohort study of Denmark, Finland, Norway and Sweden in 1995 and 2003.

OBJECTIVES: Prior work has examined the shape of the income-mortality association, but work has not compared gradients between countries. In this study, we focus on changes over time in the shape of income-mortality gradients for 4 Nordic countries during a period of rising income inequality. Context and time differentials in shape imply that the relationship between income and mortality is not fixed. SETTING: Population-based cohort study of Denmark, Finland, Norway and Sweden. PARTICIPANTS: We collected data on individuals aged 25 or more in 1995 (n=12.98 million individuals, 0.84 million deaths) and 2003 (n=13.08 million individuals, 0.90 million deaths). We then examined the household size equivalised disposable income at the baseline year in relation to the rate of mortality in the following 5 years. RESULTS: A steep income gradient in mortality in men and women across all age groups except the oldest old in Denmark, Finland, Norway and Sweden. From the 1990s to 2000s mortality dropped, but generally more so in the upper part of the income distribution than in the lower part. As a consequence, the shape of the income gradient in mortality changed. The shift in the shape of the association was similar in all 4 countries. CONCLUSIONS: A non-linear gradient exists between income and mortality in most cases and because of a more rapid mortality decline among those with high income the income gradient has become steeper over time.

Individual-level changes in self-rated health before and during the economic crisis in Europe.

BACKGROUND: Changes over time in self-rated health (SRH) are increasingly documented during the current economic crisis, though whether these are due to selection, causation, or methodological artefacts is unclear. This study accordingly investigates changes in SRH, and social inequalities in these changes, before and during the economic crisis in 23 European countries. METHODS: We used balanced panel data, 2005-2011, from the European Union Statistics on Income and Living Conditions (EU-SILC). We included the working-age population (25-60 years old) living in 23 European countries. The data cover 65,618 respondents, 2005-2007 (pre-recession cohort), and 43,188 respondents, 2008-2011 (recession cohort). The data analyses used mixed-effects ordinal logistic regression models considering the degree of recession (i.e., pre, mild, and severe). RESULTS: Individual-level changes in SRH over time indicted a stable trend during the pre-recession period, while a significant increasing trend in fair and poor SRH was found in the mild- and severe-recession cohorts. Micro-level demographic and socio-economic status (SES) factors (i.e., age, gender, education, and transitions to employment/unemployment), and macro-level factors such as welfare generosity are significantly associated with SRH trends across the degrees of recession. CONCLUSIONS: The current economic crisis accounts for an increasing trend in fair and poor SRH among the general working-age population of Europe. Despite the general SES inequalities in SRH, the health of vulnerable groups has been affected the same way before and during the current recession.

Unemployment and health selection in diverging economic conditions: Compositional changes? Evidence from 28 European countries.

UNLABELLED: Unemployment and health selection in diverging economic conditions: Compositional changes? Evidence from 28 european countries. INTRODUCTION: People with ill health tend to be overrepresented among the unemployment population. The relationship between health and unemployment might, however, be sensitive to the overall economic condition. Specifically, the health composition of the unemployment population could change dramatically when the economy takes a turn for the worse. METHODS: Using EU-SILC cross sectional data from 2007 (pre-crisis) and 2011 (during crisis) and linear regression models, this paper investigates the relationship between health and unemployment probabilities under differing economic conditions in 28 European countries. The countries are classified according to (i) the level of and (ii) increase in unemployment rate (i.e. >10 percent and doubling of unemployment rate = crisis country). RESULTS: Firstly, the unemployment likelihood for people with ill health is remarkably stable over time in Europe: the coefficients are very similar in pre-crisis and crisis years. Secondly, people with ill health have experienced unemployment to a lesser extent than those with good health status in the crisis year (when we pool the data and compare 2007 and 2011), but only in the countries with a high and rising unemployment rate. CONCLUSION: The health composition of the unemployment population changes significantly for the better, but only in those European countries that have been severely hit by the current economic crisis.

Prospective register-based study of the impact of immigration on educational inequalities in mortality in Norway.

BACKGROUND: Differences in mortality with regard to socioeconomic status have widened in recent decades in many European countries, including Norway. A rapid upsurge of immigration to Norway has occurred since the 1990s. The article investigates the impact of immigration on educational mortality differences among adults in Norway. METHODS: Two linked register-based data sets are analyzed; the first consists of all registered inhabitants aged 20-69 in Norway January 1, 1993 (2.6 millions), and the second of all registered inhabitants aged 20-69 as of January 1, 2008 (2.8 millions). Deaths 1993-1996 and 2008-2011, respectively, immigrant status, and other background information are available in the data. Mortality is examined by Cox regression analyses and by estimations of age-adjusted deaths per 100,000 personyears. RESULTS: Both relative and absolute educational inequality in mortality increased from the 1993-1996 period to 2008-2011, but overall mortality levels went down during these years. Immigrants in general, and almost all the analyzed immigrant subcategories, had lower mortality than the native majority. This was due to comparatively low mortality among lower educated immigrants, while mortality among higher educated immigrants was similar to the mortality level of highly educated natives. CONCLUSIONS: The widening of educational inequality in mortality during the 1990s and 2000s in Norway was not due to immigration. Immigration rather contributed to slightly lower overall mortality in the population and a less steep educational gradient in mortality.

Health related social exclusion in Europe: a multilevel study of the role of welfare generosity.

INTRODUCTION: The aim of this paper was to investigate the association between health, social position, social participation and the welfare state. Extending recent research on the social consequences of poor health, we asked whether and how welfare generosity is related to the risk of social exclusion associated with combinations of poor health, low education and economic inactivity. METHODS: Our analyses are based on data from the European Social Survey, round 3 (2006/7), comprising between 21,205 and 21,397 individuals, aged 25-59 years, within 21 European welfare states. The analyses were conducted by means of multilevel logistic regression analysis in STATA 12. RESULTS: The results demonstrated that the risk of non-participation in social networks decreased as welfare generosity increased. The risk of social exclusion, i.e. non-participation in social networks among disadvantaged groups, seldom differed from the overall association, and in absolute terms it was invariably smaller in more generous welfare state contexts. CONCLUSIONS: The results showed that there were no indications of higher levels of non-participation among disadvantaged groups in more generous welfare states. On the contrary, resources made available by the welfare state seemed to matter to all individuals in terms of overall lower levels of non-participation. As such, these results demonstrate the importance of linking health related social exclusion to the social policy context.

Educational inequalities in health in European welfare states: a social expenditure approach.

A puzzle in comparative health inequality research is the finding that egalitarian welfare states do not necessarily demonstrate narrow health inequalities. This paper interrogates into this puzzle by moving beyond welfare regimes to examine how welfare spending affect inequalities in self-rated across Europe. We operationalise welfare spending in four different ways and compare both absolute and relative health inequalities, as well as the level of poor self-rated health in the low education group across varying levels of social spending. The paper employs data from the EU Statistics of Income and Living Conditions (EU-SILC) and includes a sample of approximately 245,000 individuals aged 25-80+ years from 18 European countries. The data were examined by means of gender stratified multilevel logistic regression analyses. The results show that social expenditures are associated with lower health inequalities among women and, to a lesser degree, among men. Especially those with primary education benefit from high social transfers as compared with those who have tertiary education. This means that lower educational inequalities in health - in absolute and relative terms- are linked to higher social spending. The four different operationalisations of social spending produce similar patterns.

Selection and mortality: a ten-year follow-up of income decile mortality in Norway.

BACKGROUND: There is universal agreement that higher mortality goes with lower income. Opinions differ on causality: the association may reflect the damaging effect of poverty on health and survival chances. Conversely, it may reflect selection/reverse causation: low income indicates health problems, and from health problems follow a higher risk of dying. METHODS: We studied all deaths in Norway (111,504) during the 10-year period 1994-2003 among persons aged 25-66 years in 1993 (2,261,076). For each year, age-standardized mortality rates were calculated for each 1993 income decile for men and women separately. Income was calculated as family size-adjusted income after taxes but including cash welfare transfers. If the selection theory was correct, one would expect to see the excess mortality in the lower income fractiles decline as the bad risks, over-represented among the poorer, died away. RESULTS: Large income decile variations in mortality remained at the end of the 10-year period: after 10 years, the age-standardized mortality rate for men and women was still much higher in the lower income deciles. CONCLUSION: As the excess mortality in the poorer income deciles was not much reduced during the 10-year period, excess mortality among persons in bad health in the lower income deciles does not explain the income inequality in mortality in our data set.

The potential impact of a social redistribution of specific risk factors on socioeconomic inequalities in mortality: illustration of a method based on population attributable fractions.

BACKGROUND: Socioeconomic differences in health are a major challenge for public health. However, realistic estimates to what extent they are modifiable are scarce. This problem can be met through the systematic application of the population attributable fraction (PAF) to socioeconomic health inequalities. METHODS: The authors used cause-specific mortality data by educational level from Belgium, Norway and Czech Republic and data on the prevalence of smoking, alcohol, lack of physical activity and high body mass index from national health surveys. Information on the impact of these risk factors on mortality comes from the epidemiological literature. The authors calculated PAFs to quantify the impact on socioeconomic health inequalities of a social redistribution of risk factors. The authors developed an Excel tool covering a wide range of possible scenarios and the authors compare the results of the PAF approach with a conventional regression. RESULTS: In a scenario where the whole population gets the risk factor prevalence currently seen among the highly educated inequalities in mortality can be reduced substantially. According to the illustrative results, the reduction of inequality for all risk factors combined varies between 26% among Czech men and 94% among Norwegian men. Smoking has the highest impact for both genders, and physical activity has more impact among women. CONCLUSIONS: After discussing the underlying assumptions of the PAF, the authors concluded that the approach is promising for estimating the extent to which health inequalities can be potentially reduced by interventions on specific risk factors. This reduction is likely to differ substantially between countries, risk factors and genders.