This study compares eleven countries with respect to the magnitude of mortality differences by occupational class, paying particular attention to problems with the reliability and comparability of the data that are available for different countries. Nationally representative data on mortality by occupational class among men 30-64 years at death were obtained from longitudinal and cross-sectional studies. A common social class scheme was applied to most data sets. The magnitude of mortality differences was quantified by three summary indices. Three major data problems were identified and their potential effect on inequality estimates was quantified for each country individually. For men 45-59 years, the mortality rate ratio comparing manual classes to non-manual classes was about equally large for four Nordic countries, England and Wales, Ireland, Switzerland, Italy, Spain and Portugal. Relatively large ratios were only observed for France. The same applied to men 60 64 years (data for only 5 countries, including France). For men 30-44 years, there was evidence for smaller mortality differences in Italy and larger differences in Norway, Sweden and especially Finland (no data for France and Spain). Application of other summary indices to men 45-59 years showed slightly different patterns. When the population distribution over occupational classes was taken into account, relatively small differences were observed for Switzerland, Italy and Spain. When national mortality levels were taken into account, relatively large differences were observed for Finland and Ireland. For each summary index, however, France leads the international league table. Data problems were found to have the potential to bias inequality estimates, substantially especially those for Ireland, Spain and Portugal. This study underlines the similarities rather than the dissimilarities between European countries. There is no evidence that mortality differences are smaller in countries with more egalitarian socio-economic and other policies.
OBJECTIVES: To compare countries in western Europe with respect to class differences in mortality from specific causes of death and to assess the contributions these causes make to class differences in total mortality. DESIGN: Comparison of cause of death in manual and non-manual classes, using data on mortality from national studies. SETTING: Eleven western European countries in the period 1980-9. SUBJECTS: Men aged 45-59 years at death. RESULTS: A north-south gradient was observed: mortality from ischaemic heart disease was strongly related to occupational class in England and Wales, Ireland, Finland, Sweden, Norway, and Denmark, but not in France, Switzerland, and Mediterranean countries. In the latter countries, cancers other than lung cancer and gastrointestinal diseases made a large contribution to class differences in total mortality. Inequalities in lung cancer, cerebrovascular disease, and external causes of death also varied greatly between countries. CONCLUSIONS: These variations in cause specific mortality indicate large differences between countries in the contribution that disease specific risk factors like smoking and alcohol consumption make to socioeconomic inequalities in mortality. The mortality advantage of people in higher occupational classes is independent of the precise diseases and risk factors involved.
Comment In: BMJ. 1998 Dec 12;317(7173):16599917158
Comment In: BMJ. 1998 May 30;316(7145):1620-19603740
BACKGROUND: Previous studies of variation in the magnitude of socioeconomic inequalities in health between countries have methodological drawbacks. We tried to overcome these difficulties in a large study that compared inequalities in morbidity and mortality between different countries in western Europe. METHODS: Data on four indicators of self-reported morbidity by level of education, occupational class, and/or level of income were obtained for 11 countries, and years ranging from 1985 to 1992. Data on total mortality by level of education and/or occupational class were obtained for nine countries for about 1980 to about 1990. We calculated odds ratios or rate ratios to compare a broad lower with a broad upper socioeconomic group. We also calculated an absolute measure for inequalities in mortality, a risk difference, which takes into account differences between countries in average rates of illhealth. FINDINGS: Inequalities in health were found in all countries. Odds ratios for morbidity ranged between about 1.5 and 2.5, and rate ratios for mortality between about 1.3 and 1.7. For men's perceived general health, for instance, inequalities by level of education in Norway were larger than in Switzerland or Spain (odds ratios [95% CI]: 2.57 [2.07-3.18], 1.60 [1.30-1.96], 1.65 [1.44-1.88], respectively). For mortality by occupational class, in men aged 30-44, the rate ratio was highest in Finland (1.76 [1.69-1.83]), although there was no large difference in the size of the inequality in those countries with data. For men aged 45-59, for whom France did have data, this country had the largest inequality (1.71 [1.66-1.77]). In the age-group 45-64, the absolute risk difference ranked Finland second after France (9.8% [9.1-10.4], 11.5% [10.7-12.4]), with Sweden and Norway coming out more favourably than on the basis of rate ratios. In a scatter-plot of average rank scores for morbidity versus mortality. Sweden and Norway had larger relative inequalities in health than most other countries for both measures; France fared badly for mortality but was average for morbidity. INTERPRETATION: Our results challenge conventional views on the between-country pattern of inequalities in health in western European countries.
Comment In: Lancet. 1997 Aug 16;350(9076):516-7; author reply 517-89274599
Comment In: Lancet. 1997 Aug 16;350(9076):516; author reply 517-89274598
BACKGROUND: Studies from most European countries have been able to demonstrate that lower socioeconomic groups have higher risks of disease, disability and premature death. Uncertain is, however, whether these studies have also been able to estimate the precise magnitude of these inequalities, their patterns and their trends over time. The purpose of this paper is to illustrate the extent to which results of descriptive studies can be biased due to problems with the data that are commonly available to European countries. METHODS: Three illustrations are presented from a project on socio-economic inequalities in premature morbidity and mortality in Europe. These illustrations concern three problems often encountered in data on social class differences in mortality among middle aged men: the numerator/denominator bias in cross-sectional studies (illustrated for France), the exclusion of economically inactive men (illustrated for 4 countries), and the use of approximate social class schemes (illustrated for Sweden). RESULTS: In each illustration, inequalities in mortality among middle aged men could be demonstrated, but data problems appeared to bias estimates of the precise magnitude of inequalities in mortality, their patterns by social class and cause of death, and their trends over time. The bias was substantial in most cases. Usually, it was difficult to predict in which ways and to what extent inequality estimates would have been biased. CONCLUSIONS: When the aim of a study is to determine the precise magnitude, patterns or time trends of health inequalities, the results should be evaluated carefully against a number of potential data problems. Investments are needed, e.g. in data sources and in the measurement of socio-economic status, to secure that future studies can describe socio-economic inequalities in health in Europe in more detail and with more reliability.