10.6.2. Socio-economic determinants

 

 

10.6.2.1. Introduction

 

In line with the model of Dahlgren and Whitehead (1991), social epidemiological research has shown that the socio-economic determinants are indeed associated to health and life expectancy. The fact someone is imbedded into social structures and receives instrumental or emotional social support is significantly associated with mortality and morbidity. Social isolation kills as confirmed by many studies (for an overview see Berkman and Glass, 2000)

 

Inequality in health is not confined to the poorest members of the society, although there is a gradient of mortality and morbidity across the entire society depending on low education, low occupational standing and/or small income. Apart from age, sex and constitutional characteristics, health behaviour, social networks as well as living and working conditions can strongly influence health. These health determinants are socially patterned with higher risks in lower status people.

 

10.6.2.2. Data sources

 

 

The main data sources for this Section are :

·          an independent comprehensive expert Report on “Health inequalities: Europe in profile“ (Mackenbach, 2006), commissioned and published under the auspices of the UK presidency of the EU in October 2005;

·          the EUROTHINE project, published in 2007;

·          the Communication on “Unequal Welfare States, Distributive Consequences of Population Ageing in Six European Countries”. DG Employment and Social Affairs, 2004;

·          the European project ‘Closing the Gap: Strategies for Action to Tackle Health Inequalities in Europe’ which was carried out from 2004 to 2007 thanks to the collaboration of 21 national health promotion and prevention organisations; and

·          other documents listed in the References Section.

 

 

 

10.6.2.3. Data description and analysis

 

Among the living and working conditions, access to food, water, housing and health care services are obvious prerequisites for health. The health burden of adverse job conditions has been discussed in terms of physical demands and psychosocial stress. Most health determinants are socially patterned: an inverse social gradient of adverse health behaviour is found across the life course as early as not being breast fed. Later on, smoking, physical inactivity, unfavourable nutrition, obesity and high TV consumption is detected. Moreover, the risk of being socially isolated, having no confidant, getting inadequate instrumental and emotional support is elevated in low status people.

With regard to living and working conditions, it is obvious that nice, healthy food and housing require financial prosperity. Educational assets are significantly associated with parental social status. The risk of unemployment and poor physical and psychosocial working conditions is more prevalent in lower socio-economic groups. Last but not least, the access to the medical system is unevenly distributed across the society,  especially for what concerns the use of preventive medicine which displays a strong social gradient.

The higher exposure of vulnerability towards these social risk factors in lower status groups across one’s life course leads to substantial inequalities in health and life expectancy in all Western societies. Often it is even transferred from one generation to the next, leading to persisting or even increasing social and health inequalities.

 

Mortality and life expectancy

 

 

The expert Report on “Health inequalities: Europe in profile“ (Mackenbach, 2006) and other documents clearly indicate that:

 

·          in all countries with available data, rates of premature mortality are higher among those with lower levels of education, occupational class, or income;

·          inequalities in mortality exist from the youngest to the oldest ages and in both genders, but tend to be smaller among women than among men; and

·          inequalities in mortality can also be found for many specific causes of death, including cardiovascular disease, many types of cancers, and injury.

 

 

The final report of the EUROTHINE project (EUROTHINE, 2007) showed that, in the EU, cardiovascular diseases are the main causes of inequalities, accounting for 33 and 50% of inequalities in mortality associated with educational class in men and women, respectively, and that injuries and cancers, particularly lung cancer, are the most important causes of health inequalities in men than in women (Figure 10.6.2.1). Inequalities in mortality related to occupation follow a distribution similar to those due to education (Figure 10.6.2.2). These inequalities in mortality lead to substantial inequalities in life expectancy at birth (4 to 6 years among men, 2 to 4 years among women). In many Western European countries mortality differences between socio-economic groups widened during the last three decades of the 20th century. This continued into the 1990s and led to considerable increases of the relative excess risk of dying in the lowest socio-economic groups. One important aspect is that the widening of the relative gap in death rates is generally the result of a difference between socio-economic groups in the speed of mortality decline.

 

Figure 10.6.2.1. Educational inequalities in mortality in selected European Countries per cause

 

Figure 10.6.2.2. Inequalities in mortality of men

 

 

 

The explanation of this disturbing phenomenon is only partially known. One aspect which should certainly be taken into account, however, is that this widening of the relative gap in death rates is generally the result of a difference between socio-economic groups in the speed of mortality decline. While mortality has declined in all socio-economic groups, the decline has been proportionally faster in the higher socio-economic groups than in the lower. The faster mortality declines in higher socio-economic groups were in their turn mostly due to faster mortality declines for cardiovascular diseases. In many Western European countries, the 80s and 90s were decades of substantial improvements in cardiovascular disease mortality. This was due to improvements in health-conducive behaviours (e.g. less smoking, modest improvements in diet and more physical exercise), and to the introduction of effective health care interventions (e.g. hypertension detection and treatment, surgical interventions and thrombolytic therapy). Apparently, while these improvements were to some extent taken up by all socio-economic groups, the higher socio-economic groups were the ones who experienced the greatest benefits.

 

Available evidence suggests that during the late 1980s, inequalities in mortality were in Eastern Europe at least as big, and perhaps even bigger than in Western Europe. For example, a study looking at the differences in mortality per level of education in Finland, Norway, Italy, Hungary, the Czech Republic and Estonia in the late 1980s, showed substantial inequalities in mortality in all countries, both among men and women. Among men, the excess mortality ranged between 50 and 78 per cent in the three Eastern European countries, as compared to between 25 and 41 per cent in the three Western European countries. Among women, however, relative inequalities in mortality were of similar magnitude in the Eastern as compared to the Western countries. Since the political transition, mortality rates have changed dramatically in many countries in Eastern Europe, sometimes for the better (e.g. in the Czech Republic), but often for the worse (e.g. in Hungary and Estonia), particularly among men. This is probably due to a combination of (interlinked) factors: a rise in economic insecurity and poverty; a breakdown of protective social, public health and health care institutions; and a rise in excessive drinking and other risk factors for premature mortality. The available evidence clearly shows that these changes in mortality have not been equally shared between socio-economic groups: in the countries with available data, mortality rates have generally improved less, or deteriorated more, in the lower socio-economic groups. Apparently, people with higher levels of education have been able to protect themselves better against increased health risks and/or have been able to benefit more from new opportunities for health gains. An example is provided by Estonia where a considerable rise of inequalities in mortality has occurred. Evidence from some other Eastern European countries (Hungary) suggests a similar widening gap in death rates. The fact this is not seen in some other countries (Czech Republic), however, suggests that a widening of the health gap in a period of important political and economic change is not unavoidable.

 

Morbidity

 

As for mortality, rates of morbidity are usually higher among those with a lower educational level, occupational class or income level:

·          substantial inequalities are also found in the prevalence of most specific diseases (including mental illness) and most specific forms of disability;

·          over the past decades, inequalities in morbidity by socio-economic position have been rather stable; and

·          together with inequalities in mortality, inequalities in morbidity contribute to large inequalities in 'healthy life expectancy' (number of years lived in good health).

Inequalities are also evident in the prevalence of self-reported chronic conditions per level of education among people aged 25-79, as confirmed by data of the 1990s coming from eight European countries and indicating that most chronic diseases have a higher prevalence in the lower educational groups (Table 10.6.2.1).

 

Table 10.6.2.1. Odds Ratio Chronic diseases in eight European countries

Moreover, the European Commission has also released the Communication on “Unequal Welfare States, Distributive Consequences of Population Ageing in Six European Countries”. DG Employment and Social Affairs, 2004. As retired people generally have lower incomes than employed workers, ageing will lead to a slight rise in income inequality in Europe in the next 20 years. Larger numbers of people with lower incomes will in turn lead to higher poverty rates.

 

Accessibility of health services

 

While health care systems have contributed to significant improvements in health across the EU, access to health care remains uneven across social groups. High risk populations in Europe, indicated by low level of education, occupational class, income level, or other groups such as migrants, differ in incidence and prevalence rates, treatment and cure rates, and access to health services.

 

A major challenge is to guarantee to everyone access to high quality care reflecting recent technological progress while ensuring sustainability. Hence, Member States are implementing policies to reduce these inequalities, e.g. by: addressing risk factors through health promotion; reducing the prevalence and incidence of certain diseases; and ensuring more effective prevention activities in various settings (at home, school, work). Also important are the steps made to increase population coverage, address financial barriers towards care, emphasize promotion and prevention activities over curative care, and address cultural barriers to the use of services. The Structural funds will be used to support reform and capacity building mainly to improve access and develop human resources. A combination of general policies and those tailored to lower socio-economic groups is needed. Virtually, all Member States have implemented universal or almost universal rights to care and have adapted services to reach those who have difficulty in accessing conventional services due to physical or mental disability or to linguistic or cultural differences. Few have begun to address health inequalities systematically and comprehensively by reducing social differences, preventing the ensuing health differences or addressing the poor health that results from the differences above. This would ensure really equal access for equal needs. Finally, policies outside the health sector are also central for improving the health of the population and reducing the existing gaps in health care provision.

 

10.6.2.4. Control tools, actions and policies.

 

 

Currently, there are promising strategies and projects at European, national and local level to tackle health inequalities by recognizing social determinants for health,. This evidence puts policy makers before a challenge. Reducing health inequalities has become one of the main issues within the public health sector in Europe and its member countries. The last part of this chapter illustrates some strategies which aim at takling health inequalities, especially by targeting socio-economic determinants at global, European, national and community level. Examples presented here resulted from a mapping action in the frame of the European project ‘Closing the Gap: Strategies for Action to Tackle Health Inequalities in Europe’ which was carried out from 2004 to 2007, thanks to the collaboration of 21 national health promotion and prevention organisations (www.health-inequalities.eu).

 

Global level

At this level, the work of the Commission on Social Determinants of Health (CSDH) should be further emphasized. The Commission supports countries and global health partners to address the social factors leading to ill health and inequities. It draws the attention of society towards the social determinants of health known to be among the worst causes of poor health and inequalities between and within countries. The determinants include unemployment, unsafe workplaces, urban slums, globalization and lack of access to health systems (http://www.who.int/social_determinants/en/).

 

European level

The European Health and Consumer Protection Directorate General (DG) has declared ‘Socio-economic determinants of health - health inequalities’ as an important strand in their past and current public health strategy (http://ec.europa.eu/health/ph_determinants/healthdeterminants_en.htm). The DG’s action to reduce health inequalities aims at improving everyone's level of health closer to that of the most advantaged; ensure that the health needs of the most disadvantaged are fully addressed; help the health of people in countries and regions with lower levels of health so that they can improve faster. At EU level this involves many policy areas including:

 

·          Economic, employment and social policy - through the Lisbon process to strengthen the European economy and - at the same time - ensure social protection and measures to improve social inclusion.

·          Regional Policy - to support the economies and health infrastructure of countries and regions of the EU which are lagging behind or have special needs.

·          Research - to identify the causes of socio-economic health inequalities as well as develop and evaluate measures to combat them.

 

More specifically, the public health action programme 2003-2008 supported the development of strategies and measures on socio-economic health determinants and identified health inequalities using data from the Community health information system. Health inequalities also form an important dimension of the current Community Action Programme in Public Health 2007-2013. DG aims at encouraging and supporting the development of actions and networks for gathering, providing and exchanging information in order to assess and develop policies, strategies and measures in order to establish effective interventions aimed at tackling health determinants. Moreover, DG aims at promoting and stimulating Member States' efforts in this field, for example, by developing innovative projects which will stand as examples of effective practice, e.g. ‘Closing the Gap’ and the aforementioned ‘EUROTHINE’.

 

National level

Member states should develop strategies to improve the health of vulnerable groups within their societies. A typical example of how social determinants can be recognized in this sort of strategy has been shown by Sweden.

The overall aim of the Swedish public health policy established in 2003 is to create social conditions which ensure good health to the entire population. It was also established that improving the public health of the most vulnerable to ill-health is particularly vital. The most important aim of the bill is to make public health a fundamental part of social policy. Since public health concerns and is influenced by many different sectors of society, it is important to set objectives that can act as guiding principles for the work made within the various sectors. The Swedish public health policy is based on eleven objectives containing the most important determinants of public health :

 

 

1.      Participation and influence in society

2.      Economic and social security

3.      Secure and favourable conditions during childhood and adolescence

4.      Healthier working life

5.      Healthy and safe environments and products

6.      Health and medical care that more actively promotes good health

7.      Effective protection against communicable diseases

8.      Safe sexuality and good reproductive health

9.      Increased physical activity

10.  Good eating habits and safe food

11.  Reduced use of tobacco and alcohol, a society free from illicit drugs and doping, and a reduction in the harmful effects of excessive gambling.

 

 

The first six objectives relate to what are normally considered to be structural factors, i.e. conditions in society and our surroundings that can be influenced mainly by moulding public opinion and by taking political decisions at different levels. The last five objectives concern lifestyles through which an individual can influence him/herself, but in which the social environment normally plays a very important part. Political responsibility for implementing the policy is divided among different sectors and different levels of society (municipalities, county councils and government authorities). The task of the National Institute of Public Health is to formulate interim targets as and when necessary and develop indicators to establish how well the objectives are being fulfilled (http://www.fhi.se/shop/material_pdf/newpublic0401.pdf).

The horizontal linking of the different sectors involved in population health is the idea behind ‘Health in all Policies’. Health in All Policies (HiAP) was the main health theme of the Finnish European Union (EU) Presidency in 2006 and was called the natural continuation of Finland’s long term horizontal health policy. While the health sector has gradually increased its cooperation with other government sectors, industry and nongovernmental organizations in the past four decades, other sectors have increasingly taken health and the well-being of citizens into account in their policies. The key factor enabling such a development has been that health and well-being are shared values across societal sectors. Finland devoted a conference and reader to this topic to present how measures in sectors other than the health sector affect the population’s health and how population health can be promoted through measures in other sectors . Moreover, a significant step forward in this sector took place with the Declaration on HiAP, approved in Rome on 18 December 2007 during a Ministerial Conference called jointly by the Italian Ministry of Health, the European Commission and the WHO/EURO.

 

Local level

Having mentioned activities at European and national level, we would like to conclude by presenting some practical examples on how social determinants can be recognized to tackle health inequalities within communities. All project examples have been taken from the Good Practice database of the Closing the Gap project (www.health-inequalities.eu). Clearly “closing the gap” is a different objective than “ ensuring good health for the entire population”; this is clearly highlighted in the English strategy that was developed since the independent Acheson inquiry, appointed in 1997, that reviewed the current state of health inequalities and identified the evidence base for future policy developments.

 

 

·          Work: ‘Environment Task Force’ is a Norwegian low barrier method to provide employment for vulnerable groups. All participants are people who have been outside the labour market for years and socially excluded. Most of them suffer from a combination of mental health problems or drug abuse. The project is located in an area with a tradition of very poor socio-economic situations over generations. Participants work on a daily basis and carry out social tasks such as keeping streets clean from rubbish, helping older people from Elderly Institutions, working with a skilled carpenter in preschools. The ultimate goal is to help participants to find a regular job. Another goal is to reduce alcohol and drug abuse and improve health through physical activity. Indeed, most tasks involve considerable physical activity outdoors. Further goals are better nutrition and improved dental care. Rebuilding individual self-confidence is a key task of the process; the same goes for the development of  a social network based on shared work experience.

·          Education: The Dutch project ‘Supervision by the youth practitioner’ aims at reducing school non-attendance rates due to illness. Pupils who are not attending school because of self reported illness are transferred to the youth physician who tries to gain insight into the medical and social condition of the pupil. The intervention contributes to reducing health inequalities by trying to prevent young people from dropping out of school and thus having no job opportunities.

·          Health care system: The German Federal Centre for Health Education (BZgA) has developed a project entitled ‘I go to the U! And You?’ in order to increase the use of early detection measures (U) in kindergarten children. Originally, these services aimed at evaluating the physical and psychological development of children and detect illness and handicaps. Unfortunately, they are not sufficiently used by socially disadvantaged families. The intervention project is carried out in socially disadvantaged areas and works on the basis of two principles: incentive and peer pressure. The kindergarten plays an important role. Parents are addressed through posters and flyers that raise awareness on the importance of early detection and on the services available. All children who frequent U7, U8 and U9 receive a funny T-shirt. When all children in a kindergarten have got the shirt, a group photo is taken and sent for a competition.

 

10.6.2.5. Future developments

 

By recognizing the importance of social determinants to tackle health inequalities, the national health promotion and prevention organisations have joined in a new European project called ‘Determine’. The European Commission funded project started in 2007 and brings together a high level Consortium to apply evidence based approaches across policy sectors in the EU and its member states (www.health-inequalities.eu). Bodies from 26 countries will analyse and apply important knowledge on socio-economic determinants of health, introduce innovative pilot projects, develop and implement awareness and capacity building programmes. The objective is to generate greater understanding and change conceptions and approaches among policy makers and practitioners, so that other policy sectors can take the issues of health and health equity into consideration when developing policy.

 

10.6.2.6. References

 

Berkman, L. & Glass, T. (2000). Social integration, social networks, social support, and health. In L.Berkman & I. Kawachi (Eds.), Social Epidemiology (pp. 137-173). New  York: Oxford University Press.

 

Dahlgren, G. & Whitehead, M. (1991). Policies and Strategies to Promote Equity in Health. Stockholm: Institute for Future Studies.

 

Dalstra JAA, Kunst AE, Borrell C, Breeze E, Cambois E, Costa G, Geurts JJM, Lahelma E, Van Oyen H, Rasmussen NK, Regidor E, Spadea T, and Mackenbach JP (2005): Socio-economic differences in the prevalence of common chronic diseases: an overview of eight European countries. Int J Epidemiol 34: 316-326.

 

EUROTHINE (2007): Tackling health inequalities in Europe: An integrated approach. EUROTHINE Final Report [On line publication available at:

http://mgzlx4.erasmusmc.nl/eurothine/uploads/eurothine_final_report_complete.zip]

 

Mackenbach JP (2006): Health inequalities: Europe in profile [on-line publication available at: http://ec.europa.eu/health/ph_determinants/socio_economics/documents/ev_060302_rd06_en.pdf].

 

 

 

10.6.2.7. Acronyms

 

CSDH              Commission on Social Determinants of Health