Subnational inequalities in years of life lost and associations with socioeconomic factors in pre-pandemic Europe, 2009-19: an ecological study.

BACKGROUND: Health inequalities have been associated with shorter lifespans. We aimed to investigate subnational geographical inequalities in all-cause years of life lost (YLLs) and the association between YLLs and socioeconomic factors, such as household income, risk of poverty, and educational attainment, in countries within the European Economic Area (EEA) before the COVID-19 pandemic. METHODS: In this ecological study, we extracted demographic and socioeconomic data from Eurostat for 1390 small regions and 285 basic regions for 32 countries in the EEA, which was complemented by a time-trend analysis of subnational regions within the EEA. Age-standardised YLL rates per 100 000 population were estimated from 2009 to 2019 based on methods from the Global Burden of Disease study. Geographical inequalities were assessed using the Gini coefficient and slope index of inequality. Socioeconomic inequalities were assessed by investigating the association between socioeconomic factors (educational attainment, household income, and risk of poverty) and YLLs in 2019 using negative binomial mixed models. FINDINGS: Between Jan 1, 2009, and Dec 31, 2019, YLLs lowered in almost all subnational regions. The Gini coefficient of YLLs across all EEA regions was 14·2% (95% CI 13·6-14·8) for females and 17·0% (16·3 to 17·7) for males. Relative geographical inequalities in YLLs among women were highest in the UK (Gini coefficient 11·2% [95% CI 10·1-12·3]) and among men were highest in Belgium (10·8% [9·3-12·2]). The highest YLLs were observed in subnational regions with the lowest levels of educational attainment (incident rate ratio [IRR] 1·19 [1·13-1·26] for females; 1·22 [1·16-1·28] for males), household income (1·35 [95% CI 1·19-1·53]), and the highest poverty risk (1·25 [1·18-1·34]). INTERPRETATION: Differences in YLLs remain within, and between, EEA countries and are associated with socioeconomic factors. This evidence can assist stakeholders in addressing health inequities to improve overall disease burden within the EEA. FUNDING: Research Council of Norway; Development, and Innovation Fund of Hungary; Norwegian Institute of Public Medicine; and COST Action 18218 European Burden of Disease Network.

Inequalities in the burden of non-communicable diseases across European countries: a systematic analysis of the Global Burden of Disease 2019 study.

BACKGROUND: Although overall health status in the last decades improved, health inequalities due to non-communicable diseases (NCDs) persist between and within European countries. There is a lack of studies giving insights into health inequalities related to NCDs in the European Economic Area (EEA) countries. Therefore, the aim of the present study was to quantify health inequalities in age-standardized disability adjusted life years (DALY) rates for NCDs overall and 12 specific NCDs across 30 EEA countries between 1990 and 2019. Also, this study aimed to determine trends in health inequalities and to identify those NCDs where the inequalities were the highest. METHODS: DALY rate ratios were calculated to determine and compare inequalities between the 30 EEA countries, by sex, and across time. Annual rate of change was used to determine the differences in DALY rate between 1990 and 2019 for males and females. The Gini Coefficient (GC) was used to measure the DALY rate inequalities across countries, and the Slope Index of Inequality (SII) to estimate the average absolute difference in DALY rate across countries. RESULTS: Between 1990 and 2019, there was an overall declining trend in DALY rate, with larger declines among females compared to males. Among EEA countries, in 2019 the highest NCD DALY rate for both sexes were observed for Bulgaria. For the whole period, the highest DALY rate ratios were identified for digestive diseases, diabetes and kidney diseases, substance use disorders, cardiovascular diseases (CVD), and chronic respiratory diseases - representing the highest inequality between countries. In 2019, the highest DALY rate ratio was found between Bulgaria and Iceland for males. GC and SII indicated that the highest inequalities were due to CVD for most of the study period - however, overall levels of inequality were low. CONCLUSIONS: The inequality in level 1 NCDs DALYs rate is relatively low among all the countries. CVDs, digestive diseases, diabetes and kidney diseases, substance use disorders, and chronic respiratory diseases are the NCDs that exhibit higher levels of inequality across countries in the EEA. This might be mitigated by applying tailored preventive measures and enabling healthcare access.

Assessing the long-term health impact of COVID-19: The importance of using self-reported health measures.

It is estimated that at least one out of 10 people who contracted COVID-19 continue to experience health problems long after the clearance of the acute infection. These belong to the growing group of people who have post-acute sequelae of SARS CoV-2 infection or long COVID, a multifaceted condition involving multiple organ systems. Given the lack of clear definition and diagnosis, this marked increase in the number of people who have long COVID might not be fully reflected in data on population health in the years to come. In this editorial, we argue that the use of self-reported health measures is vital for fully assessing the long-term impact of the COVID-19 pandemic on health and health inequalities. After briefly introducing self-reported health measures, we discuss strengths and limitations of specific measures that capture direct self-reports of long COVID. We then outline how the impact of long COVID may also be reflected in response patterns to more general self-reported health measures and give suggestions on how these can be used to examine the long-term health impact of the COVID-19 pandemic.

Components and effectiveness of patient navigation programmes to increase participation to breast, cervical and colorectal cancer screening: A systematic review.

BACKGROUND: Inequalities in cancer incidence and mortality can be partly explained by unequal access to high-quality health services, including cancer screening. Several interventions have been described to increase access to cancer screening, among them patient navigation (PN), a barrier-focused intervention. This systematic review aimed to identify the reported components of PN and to assess the effectiveness of PN to promote breast, cervical and colorectal cancer screening. METHODS: We searched Embase, PubMed and Web of Science Core Collection databases. The components of PN programmes were identified, including the types of barriers addressed by navigators. The percentage change in screening participation was calculated. RESULTS: The 44 studies included were mainly on colorectal cancer and were conducted in the USA. All described their goals and community characteristics, and the majority reported the setting (97.7%), monitoring and evaluation (97.7%), navigator background and qualifications (81.4%) and training (79.1%). Supervision was only referred to in 16 studies (36.4%). Programmes addressed mainly barriers at the educational (63.6%) and health system level (61.4%), while only 25.0% reported providing social and emotional support. PN increased cancer screening participation when compared with usual care (0.4% to 250.6% higher) and educational interventions (3.3% to 3558.0% higher). CONCLUSION: Patient navigation programmes are effective at increasing participation to breast, cervical and colorectal cancer screening. A standardized reporting of the components of PN programmes would allow their replication and a better measure of their impact. Understanding the local context and needs is essential to design a successful PN programme.

Educational inequalities in adult mortality: a systematic review and meta-analysis of the Asia Pacific region.

OBJECTIVES: In this study, we aim to analyse the relationship between educational attainment and all-cause mortality of adults in the high-income Asia Pacific region. DESIGN: This study is a comprehensive systematic review and meta-analysis with no language restrictions on searches. Included articles were assessed for study quality and risk of bias using the Joanna Briggs Institute critical appraisal checklists. A random-effects meta-analysis was conducted to evaluate the overall effect of individual level educational attainment on all-cause mortality. SETTING: The high-income Asia Pacific Region consisting of Japan, South Korea, Singapore and Brunei Darussalam. PARTICIPANTS: Articles reporting adult all-cause mortality by individual-level education were obtained through searches conducted from 25 November 2019 to 6 December 2019 of the following databases: PubMed, Web of Science, Scopus, EMBASE, Global Health (CAB), EconLit and Sociology Source Ultimate. PRIMARY AND SECONDARY OUTCOME MEASURES: Adult all-cause mortality was the primary outcome of interest. RESULTS: Literature searches resulted in 15 345 sources screened for inclusion. A total of 30 articles meeting inclusion criteria with data from the region were included for this review. Individual-level data from 7 studies covering 222 241 individuals were included in the meta-analyses. Results from the meta-analyses showed an overall risk ratio of 2.40 (95% CI 1.74 to 3.31) for primary education and an estimate of 1.29 (95% CI 1.08 to 1.54) for secondary education compared with tertiary education. CONCLUSION: The results indicate that lower educational attainment is associated with an increase in the risk of all-cause mortality for adults in the high-income Asia Pacific region. This study offers empirical support for the development of policies to reduce health disparities across the educational gradient and universal access to all levels of education. PROSPERO REGISTRATION NUMBER: CRD42020183923.

Sick of social status: A Bourdieusian perspective on morbidity and health inequalities.

Self-reported health (SRH) is one of the most frequently used measures for examining socioeconomic inequalities in health. Studies find that when faced with 'identical objective health', individuals in lower socioeconomic groups consistently report worse SRH than those in higher socioeconomic groups. Such findings are often dismissed as being the result of reporting bias, and existing literature dominated by the biomedical conception of SRH has not investigated the underlying social mechanisms at work. To address this limitation, drawing on the work of Bourdieu we employ a relational thinking between health and social position. By way of multiple correspondence analysis, we construct social space of health determinants for three European countries from different welfare states and map the trajectories of educational groups experiencing similar levels of morbidity and their relation to SRH. Differences in SRH observed among social groups for the same level of morbidity are understood in relation to the position and the relative power of individuals in different educational groups to maintain or improve their social conditions, especially with increasing levels of health loss. Our analysis indicates that reporting differences in SRH among educational groups emerges from objectively healthy individuals and follows differences in accumulation of social advantages and disadvantages.

The Gender Pain Gap: gender inequalities in pain across 19 European countries.

AIMS: Chronic pain is increasingly considered to be an international public health issue, yet gender differences in chronic pain in Europe are under-examined. This work aimed to examine gender inequalities in pain across Europe. METHODS: Data for 27,552 men and women aged 25-74 years in 19 European countries were taken from the social determinants of health module of the European Social Survey (2014). Inequalities in reporting pain were measured by means of adjusted rate differences (ARD) and relative adjusted rate risks (ARR). RESULTS: At the pooled pan-European level, a greater proportion of women (62.3%) reported pain than men (55.5%) (ARD 5.5% (95% confidence intervals (CI) 4.1, 6.9), ARR 1.10 (95% CI 1.08, 1.13)). These inequalities were greatest for back/neck pain (ARD 5.8% (95% CI 4.4, 7.1), ARR 1.15 (95% CI 1.12, 1.19)), but were also significant for hand/arm pain (ARD 4.6% (95% CI 3.5, 5.7), ARR 1.24 (95% CI 1.17, 1.30)) and foot/leg pain (ARD 2.6% (95% CI 1.5, 3.8), ARR 1.12 (95% CI 1.07, 1.18)). There was considerable cross-national variation in gender pain inequalities across European countries. CONCLUSIONS: Significant gender pain inequalities exist across Europe whereby women experience more pain than men. The extent of the gender pain gap varies by country. The gender pain gap is a public health concern and should be considered in future prevention and management strategies.

COVID-19 and the Nordic Paradox: a call to measure the inequality reducing benefits of welfare systems in the wake of the pandemic.

The Nordic Paradox of inequality describes how the Nordic countries have puzzlingly high levels of relative health inequalities compared to other nations, despite extensive universal welfare systems and progressive tax regimes that redistribute income. However, the veracity and origins of this paradox have been contested across decades of literature, as many scholars argue it relates to measurement issues or historical coincidences. Disentangling between potential explanations is crucial to determine if widespread adoption of the Nordic model could represent a sufficient panacea for lowering health inequalities, or if new approaches must be pioneered. As newfound challenges to welfare systems continue to emerge, evidence describing the benefits of welfare systems is becoming ever more important. Preliminary evidence indicates that the COVID-19 pandemic is drastically exacerbating social inequalities in health across the world, via direct and indirect effects. We argue that the COVID-19 pandemic therefore represents a unique opportunity to measure the value of welfare systems in insulating their populations from rising social inequalities in health. However, COVID-19 has also created new measurement challenges and interrupted data collection mechanisms. Robust academic studies will therefore be needed-drawing on novel data collection methods-to measure increasing social inequalities in health in a timely fashion. In order to assure that policies implemented to reduce inequalities can be guided by accurate and updated information, policymakers, academics, and the international community must work together to ensure streamlined data collection, reporting, analysis, and evidence-based decision-making. In this way, the pandemic may offer the opportunity to finally clarify some of the mechanisms underpinning the Nordic Paradox, and potentially more firmly establish the merits of the Nordic model as a global example for reducing social inequalities in health.

Parental education and inequalities in child mortality: a global systematic review and meta-analysis.

BACKGROUND: The educational attainment of parents, particularly mothers, has been associated with lower levels of child mortality, yet there is no consensus on the magnitude of this relationship globally. We aimed to estimate the total reductions in under-5 mortality that are associated with increased maternal and paternal education, during distinct age intervals. METHODS: This study is a comprehensive global systematic review and meta-analysis of all existing studies of the effects of parental education on neonatal, infant, and under-5 child mortality, combined with primary analyses of Demographic and Health Survey (DHS) data. The literature search of seven databases (CINAHL, Embase, MEDLINE, PsycINFO, PubMed, Scopus, and Web of Science) was done between Jan 23 and Feb 8, 2019, and updated on Jan 7, 2021, with no language or publication date restrictions. Teams of independent reviewers assessed each record for its inclusion of individual-level data on parental education and child mortality and excluded articles on the basis of study design and availability of relevant statistics. Full-text screening was done in 15 languages. Data extracted from these studies were combined with primary microdata from the DHS for meta-analyses relating maternal or paternal education with mortality at six age intervals: 0-27 days, 1-11 months, 1-4 years, 0-4 years, 0-11 months, and 1 month to 4 years. Novel mixed-effects meta-regression models were implemented to address heterogeneity in referent and exposure measures among the studies and to adjust for study-level covariates (wealth or income, partner's years of schooling, and sex of the child). This study was registered with PROSPERO (CRD42020141731). FINDINGS: The systematic review returned 5339 unique records, yielding 186 included studies after exclusions. DHS data were compiled from 114 unique surveys, capturing 3 112 474 livebirths. Data extracted from the systematic review were synthesized together with primary DHS data, for meta-analysis on a total of 300 studies from 92 countries. Both increased maternal and paternal education showed a dose-response relationship linked to reduced under-5 mortality, with maternal education emerging as a stronger predictor. We observed a reduction in under-5 mortality of 31·0% (95% CI 29·0-32·6) for children born to mothers with 12 years of education (ie, completed secondary education) and 17·3% (15·0-18·8) for children born to fathers with 12 years of education, compared with those born to a parent with no education. We also showed that a single additional year of schooling was, on average, associated with a reduction in under-5 mortality of 3·04% (2·82-3·23) for maternal education and 1·57% (1·35-1·72) for paternal education. The association between higher parental education and lower child mortality was significant for both parents at all ages studied and was largest after the first month of life. The meta-analysis framework incorporated uncertainty associated with each individual effect size into the model fitting process, in an effort to decrease the risk of bias introduced by study design and quality. INTERPRETATION: To our knowledge, this study is the first effort to systematically quantify the transgenerational importance of education for child survival at the global level. The results showed that lower maternal and paternal education are both risk factors for child mortality, even after controlling for other markers of family socioeconomic status. This study provides robust evidence for universal quality education as a mechanism to achieve the Sustainable Development Goal target 3.2 of reducing neonatal and child mortality. FUNDING: Research Council of Norway, Bill & Melinda Gates Foundation, and Rockefeller Foundation-Boston University Commission on Social Determinants, Data, and Decision Making (3-D Commission).

The European epidemic: Pain prevalence and socioeconomic inequalities in pain across 19 European countries.

BACKGROUND: Using data from the European Social Survey (ESS) 2014, this study presents an update of pain prevalence amongst men and women across Europe and undertakes the first analysis of socioeconomic inequalities in pain. METHODS: Data from the ESS 2014 survey were analysed for three pain variables: back/neck pain (n = 11,032), hand/arm pain (n = 5,954) and foot/leg pain (n = 6,314). Education was used as the indicator of socioeconomic status (SES). Age-adjusted risk differences and age-adjusted risk ratios were calculated from predicted probabilities generated by means of binary logistic regression. These analyses compared the lower education group with the higher education group (the socioeconomic gap), and the medium education group with the higher education group (the gradient). RESULTS: High prevalence rates were reported for all three types of pain across European countries. At a pan-European level, back/neck pain was the most prevalent with 40% of survey participants experiencing pain; then hand/arm pain at 22%, and then foot/leg pain at 21%. There was considerable cross-national variation in pain across European counties, as well as significant socioeconomic inequalities in the prevalence of pain-with social gradients or socioeconomic gaps evident for both men and women; socioeconomic inequalities were most pronounced for hand/arm pain, and least pronounced for back/neck pain. The magnitudes of the socioeconomic pain inequalities differed between countries, but were generally higher for women. CONCLUSIONS: Future strategies to reduce the burden of pain should acknowledge and consider the associated socioeconomic inequalities of pain to ensure the "pain gap" does not widen. SIGNIFICANCE: This is a pan European study that has explored socioeconomic inequalities in pain. Across Europe, pain is more prevalent in people of lower socioeconomic position; these pain inequalities were most significant for hand/arm pain, and least significant for back/neck pain.

The effects of community pharmacy public health interventions on population health and health inequalities: a systematic review of reviews protocol.

BACKGROUND: Community pharmacies have great potential to deliver services aimed at promoting health and preventing disease, and are embedded within communities. In the light of a rapid increase in community pharmacy-delivered public health services and an accompanying increase in the evidence base, this systematic review of reviews will synthesise systematic reviews of public health community pharmacy interventions and assess their effects on public health and health inequalities. METHODS/DESIGN: Systematic review methodology will be used to identify all systematic reviews that describe the health and health equity effects of community pharmacy public health interventions. Twenty databases will be searched using a pre-determined search strategy to evaluate community pharmacy-delivered public health interventions. Findings from the included reviews will be pooled, and a narrative synthesis executed to identify overarching patterns and results. DISCUSSION: Findings will support future decision-making around how community pharmacy public health services can be used alongside other strategies to promote health, prevent disease and reduce health inequalities. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration number: CRD42017056264 .

The social determinants of inequalities in self-reported health in Europe: findings from the European social survey (2014) special module on the social determinants of health.

Background: Health inequalities persist between and within European countries. Such inequalities are usually explained by health behaviours and according to the conditions in which people work and live. However, little is known about the relative contribution of these factors to health inequalities in European countries. This paper aims to investigate the independent and joint contribution of a comprehensive set of behavioural, occupational and living conditions factors in explaining social inequalities in self-rated health (SRH). Method: Data from 21 countries was obtained from the 2014 European Social Survey and examined for respondents aged 25-75. Adjusted rate differences (ARD) and adjusted rate risks (ARR), generated from binary logistic regression models, were used to measure health inequalities in SRH and the contribution of behavioural, occupational and living conditions factors. Result: Absolute and relative inequalities in SRH were found in all countries and the magnitude of socio-economic inequalities varied considerably between countries. While factors were found to differentially contribute to the explanation of educational inequalities in different European countries, occupational and living conditions factors emerged as the leading causes of inequalities across most of the countries, contributing both independently and jointly with behavioural factors. Conclusion: The observed shared effects of different factors to health inequalities points to the interdependent nature of occupational, behavioural and living conditions factors. Tackling health inequalities should be a concentred effort that goes beyond interventions focused on single factors.

The socioeconomic distribution of non-communicable diseases in Europe: findings from the European Social Survey (2014) special module on the social determinants of health.

Background: A range of non-communicable diseases (NCDs) has been found to follow a social pattern whereby socioeconomic status predicts either a higher or lower risk of disease. Comprehensive evidence on the socioeconomic distribution of NCDs across Europe, however, has been limited. Methods: Using cross-sectional 2014 European Social Survey data from 20 countries, this paper examines socioeconomic inequalities in 14 self-reported NCDs separately for women and men: heart/circulatory problems, high blood pressure, back pain, arm/hand pain, foot/leg pain, allergies, breathing problems, stomach/digestion problems, skin conditions, diabetes, severe headaches, cancer, obesity and depression. Using education to measure socioeconomic status, age-controlled adjusted risk ratios were calculated and separately compared a lower and medium education group with a high education group. Results: At the pooled European level, a social gradient in health was observed for 10 NCDs: depression, diabetes, obesity, heart/circulation problems, hand/arm pain, high blood pressure, breathing problems, severe headaches, foot/leg pain and cancer. An inverse social gradient was observed for allergies. Social gradients were observed among both genders, but a greater number of inequalities were observed among women. Country-specific analyses show that inequalities in NCDs are present everywhere across Europe and that inequalities exist to different extents for each of the conditions. Conclusion: This study provides the most up-to-date overview of socioeconomic inequalities for a large number of NCDs across 20 European countries for both women and men. Future investigations should further consider the diseases, and their associated determinants, for which socioeconomic differences are the greatest.

The contribution of housing and neighbourhood conditions to educational inequalities in non-communicable diseases in Europe: findings from the European Social Survey (2014) special module on the social determinants of health.

Background: Social gradients have been found across European populations, where less affluent groups are more often affected by poor housing and neighbourhood conditions. While poor housing and neighbourhood quality have been associated with a range of non-communicable diseases (NCDs), these conditions have rarely been applied to the examination of socioeconomic differences in NCDs. This study therefore asks 'to what extent does adjusting for poor housing and neighbourhood conditions reduce inequalities in NCDs among men and women in Europe'? Methods: Our analysis used pooled-data from 20 European countries for women (n= 12 794) and men (n= 11 974), aged 25­75, from round 7 of the European Social Survey. Fourteen NCDs were investigated: heart/circulatory problems, high blood pressure, back pain, arm/hand pain, foot/leg pain, allergies, breathing problems, stomach/digestion problems, skin conditions, diabetes, severe headaches, cancer, obesity and depression. We used binary logistic regression models, stratified by gender, and adjusted rate ratios to examine whether educational inequalities in NCDs were reduced after controlling for poor housing and neighbourhood quality. Results: Overall, we find that adjusting for poor housing and neighbourhood quality reduces inequalities in NCDs. While reductions were relatively small for some NCDs­for high blood pressure, reductions were found in the range of 0­4.27% among women­for other conditions reductions were more considerable. Controlling for both housing and neighbourhood conditions for example, reduced inequalities by 16­24% for severe headaches and 14­30% for breathing problems. Conclusions: Social gradients in poor housing and neighbourhood quality could be an important contributor to educational inequalities in some NCDs.

Occupational inequalities in self-rated health and non-communicable diseases in different regions of Europe: findings from the European Social Survey (2014) special module on the social determinants of health.

Background: Socioeconomic inequalities in the prevalence of non-communicable diseases (NCDs) are evident across European populations. Several previous studies have addressed the question of whether occupational inequalities in health differ across European regions. It is uncertain however, the degree to which occupational inequalities in NCDs are similar or dissimilar across different European regions. Methods: Using 2014 European Social Survey data from 20 countries, this article examines occupational inequalities in poor self-rated health (SRH) and 14 self-reported NCDs separately for women and men, by European region: heart/circulatory problems, high blood pressure, back pain, arm/hand pain, foot/leg pain, allergies, breathing problems, stomach/digestion problems, skin conditions, diabetes, severe headaches, cancer, obesity and depression. Age-controlled adjusted risk ratios were calculated and separately compared a working class and intermediate occupational group with a salariat group. Results: Working class Europeans appear to have the highest risk of reporting poor SRH and a number of NCDs. We find inequalities in some NCDS to be the largest in the Northern region, suggesting further evidence of a Nordic paradox. Like some previous work, we did not find larger inequalities in poor SRH in the Central/East region. However, we did find the largest inequalities in this region for some NCDs. Our results do not align completely with previous work which finds smaller health inequalities in Southern Europe. Conclusions: This work provides a first look at occupational inequalities across a range of NCDs for European men and women by region. Future work is needed to identify the underlying determinants behind regional differences.

The health of European populations: introduction to the special supplement on the 2014 European Social Survey (ESS) rotating module on the social determinants of health.

This introduction summarizes the main findings of the Supplement 'Social inequalities in health and their determinants' to the European Journal of Public Health. The 16 articles that constitute this supplement use the new ESS (2014) health module data to analyze the distribution of health across European populations. Three main themes run across these articles: documentation of cross-national variation in the magnitude and patterning of health inequalities; assessment of health determinants variation across populations and in their contribution to health inequalities; and the examination of the effects of health outcomes across social groups. Social inequalities in health are investigated from an intersectional stance providing ample evidence of inequalities based on socioeconomic status (occupation, education, income), gender, age, geographical location, migrant status and their interactions. Comparison of results across these articles, which employ a wide range of health outcomes, social determinants and social stratification measures, is facilitated by a shared theoretical and analytical approach developed by the authors in this supplement.