Social inequalities in health
Those with higher education levels and a good financial situation live longer and have fewer health problems than those who have lower education and poorer economy. These social inequalities can be studied at a country or county and municipal level.
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There are substantial social inequalities in health in Norway, especially between educational groups.
- Women and men with the highest education live 6-7 years longer and have better health than those with the lowest education.
- Among women, the differences in terms of both life expectancy and health are increasing.
- Within Oslo, life expectancy varies by up to nine years between districts.
- Inequalities in health in Norway are larger than in many other European countries.
- Smoking is probably a major cause of social inequalities in health.
About social inequalities
When comparing groups in society, we find systematic differences in health. The higher the education and income the group has, the higher the proportion of the group’s members have good health (Norwegian Directorate of Health, 2005; Huisman, 2005). These are known as social inequalities in health.
Health improves with every step on the socioeconomic ladder. A higher education is associated with better health. The same applies to income. Not only has the next poorest better health than the poorest, we see that the richest on average have slightly better health than the next richest.
Social inequalities in health apply to almost all diseases, injuries and ailments. We see differences among all age groups. These involve many lost days and years of good health and quality of life.
Social inequalities are unfair and represent a loss for individuals, families and society. The total health potential of the population is not fully utilised.
Here we describe specific examples of socioeconomic differences in health and life expectancy in Norway.
Health and life expectancy increases with increasing education
Men with university or college education have seven years longer life expectancy than men with primary education. For women, the difference is six years. This is shown by calculations for the period 2007-2013 (NIPH, 2016a).
Life expectancy differences exist in all counties and vary with 6-8 years for men and 4-7 years for women. Figure 1 shows the expected remaining life years at 35 years. The figures apply to the period from 1960 to 2009. Women to the left, men to the right (Steingrimsdottir, 2012).
Figure 1. Expected remaining life years from 35 years of age in Norway from 1960 to 2009, grouped by level of education. The top curve shows the group with the highest education. We see that this group has had as many expected remaining years of life for the entire period from 1960 to 2009, both for women (left) and men (right). Source: Steingrímsdóttir, 2012.
Developments from the 1960s show the following:
In the decade from 1960 to 1970 there was a decrease in expected remaining life years among men in the lowest educational groups. From 1970 to 2000, life expectancy increased significantly in all groups but most in the groups with the highest education. Until around 1980, women in all three educational groups had a higher life expectancy than men, see Figure 1, women to the left. This is no longer the case. Women with lower education are lagging behind and have had the poorest development (Steingrimsdottir, 2012).
New studies of mortality (see Figure 5b) show that women with low education still lag behind (Strand, 2014). For men, the differences in mortality have declined after year 2000.
Smoking is believed to be a major cause of the increasing difference in mortality between women who have low and high education. Women with higher education began to stop smoking first, see Figure 1. Therefore, the decline in mortality first began in this group. As women with lower education change their smoking habits, we expect that this group will have a better development, and that the gap between this group and the groups with medium and high education will decrease.
Besides life expectancy and mortality, we also see differences between educational groups in terms of health and disease. In groups with lower education there are:
- a much larger proportion who report poor health than in groups with higher education (Kurtz, 2013).
- more people with musculoskeletal disorders and mental health problems than in groups with higher education (Dahl, 2014; NIPH, 2007).
Inequalities in health among children and adolescents
There are differences in health at all ages, among children, adolescents, adults and the elderly.
- There is higher infant mortality, lower birth weight and a higher risk of premature birth in groups with lower education (Dahl, 2014).
- There is a higher proportion of children and adolescents who report poor health in families with lower socioeconomic status than higher socioeconomic status (Elstad, 2012).
Adolescents from homes with high socioeconomic status more frequently report a higher quality of life, better health and less psychological distress than children from homes with lower socioeconomic status (NOVA, 2016). The differences are particularly evident among girls, according to new figures from the Ungdata study in 2014 and 2015.
The Ungdata study is based on responses from 118,000 schoolchildren aged 13-19 in 183 Norwegian municipalities (NOVA, 2016). Socioeconomic factors were measured through questions about parental education, access to books and material resources in the home. The fifth of the adolescents with the highest score were defined as the group with high socioeconomic status (NOVA, 2016).
Health inequalities among the elderly
There are few Norwegian studies of socioeconomic differences in health among the elderly. Perhaps it was assumed that the strongest survive, regardless of socioeconomic background. Consequently, there would be small differences among those who have lived long lives. However, recent studies suggest that differences continue into old age. Among the eldest there are differences in expected remaining life years:
- Among 65-year-olds, the expected remaining lifetime is about 2 years longer for those who have a higher education than for those with lower education (Moe, 2012).
- 95-year-old men with university or college education can expect to live three months longer than men with primary education. For 90-year-olds, this difference is six months. This was shown in a large Norwegian study for the period 2000-2009 (Kinge, 2015a).
Statistically, elderly people with low socioeconomic status have more illnesses and health problems than those with high socioeconomic status. The "World Report on Ageing and Health" highlights that this group also has the least resources to take care of their own health (Beard, 2015).
Geographic differences in life expectancy
There are major differences in health and life expectancy between Norwegian municipalities and counties. Similar differences exist in other Western societies too (Sund, 2009).
Geographical differences in health are found among districts in the largest cities, in particular, within Oslo. According to figures for the period 2000-2014, there are about 9 years difference in life expectancy between the Sagene and Vestre Aker districts in Oslo, see Figures 2 and 3A.
In Bergen and Stavanger, the corresponding differences between districts are 3 to 3.5 years. In Trondheim, the difference between the neighbourhoods is under one year (see Figures 2 and 3B-3D).
Figure 2. The difference in life expectancy between districts with the lowest and highest life expectancy within Oslo, Stavanger, Bergen and Trondheim. The differences are largest in Oslo. Source: NIPH, 2016b.
Figure 3a. Life expectancy for men in districts with the lowest (Sagene) and the highest (Vestre Aker) life expectancy in Oslo in the period 1990-2014. Life expectancy is increasing in all districts but differences remain. All districts in Oslo. Source: NIPH, 2016b.
Figure 3b. Life expectancy for men in districts of Bergen in the period 1990-2014. Source: NIPH, 2016b.
Figure 3c. Life expectancy for men in districts of Stavanger during the period 1990-2014. Source: NIPH, 2016b.
Figure 3d. Life expectancy for men in districts of Trondheim during the period 1990-2014. The differences between districts in Trondheim are less than in other large towns in Norway. Source: NIPH, 2016b.
Why are there such large gaps within municipalities? 80 per cent of the variation in mortality can be explained by various socioeconomic factors according to a large study of all deaths among 60-89 year olds in the period 2000-2008 (Kravdal, 2015).
A similar study analysed differences between Norwegian municipalities in terms of obesity among young people (Kinge, 2015b). The results show that about half of the variation in obesity among the municipalities could be attributed to socioeconomic conditions. The analysis was based on weight and height for nearly 200,000 young people at 17 years of age in the period from 2011 to 2013. In addition, data included socioeconomic conditions in the municipalities, such as income, the proportion with higher education and the proportion who were employed in managerial positions.
Socioeconomic differences in lifestyle
Studies show that lifestyle habits such as smoking, diet and physical activity often follow educational and income levels. That means that those who have higher education and higher incomes have a more favourable lifestyle than those with lower education and income. For example, a study of 11-year-olds from the Oslo area shows that children's consumption of sugary drinks is related to parental educational levels. The same applies to the consumption of fruit and vegetables (NIPH, 2016c; Norwegian Directorate of Health, 2013, 2015).
In recent years, society has intensified the fight against smoking. In 1996, the age limit for buying tobacco was raised from 16 to 18 years. In 2004, a total ban on smoking in all public places was introduced. Several regulatory and legislative changes have followed, including a law on tobacco-free schools and kindergartens in 2013.
In parallel with public health initiatives aimed at smoking, there have been major changes in opinions of smoking since 2000, even among the young. Smoking was previously associated with a certain status, but today smoking gives little status and respect among young people (NOVA, 2015).
Smoking is closely related to education. The proportion of smokers falls steadily with increasing education (Norwegian Directorate of Health, 2013; NOVA, 2013). Since the mid-1990s, there has been a decline in the proportion of daily smokers in all education groups but the differences between groups are still large. In a comparison between 22 European countries, Norway is the country with the greatest difference between educational groups with regards to the proportion of daily smokers. This proportion is about four times higher among those with primary education than among those who have university or college education (Mackenbach, 2008).
New figures from 2015 show that only 6 per cent of 25-74-year-old men with college or university education are daily smokers, see Figure 4. In the group with primary education, the proportion is less than 27 per cent. These figures are compiled by NIPH based on data from Statistics Norway.
The differences are as great among women. Approximately one in four women with lower education smokes, compared with 7 per cent of women with higher education, see Figure 4. Smoking is an important cause of the mortality gap in Norway.
Figure 4. Percentage of daily smokers aged 25-74 years by educational period 1975-2015. The figures are adjusted for European standard populations in the ten-year age groups (25-34, 35-44, 65-74 ...). We see that there are major differences between educational groups. Among women (right), we also see that the proportion of daily smokers declined first in the group with the longest education (orange curve) and last in the group with lower education (purple curve with approximate peak in 1995). Source: Smoking Habits Survey by Statistics Norway.
Alcohol use increases in line with education and income levels. However, the proportion of people who are alcohol dependent is not highest among those with the highest socioeconomic status, but is highest among people with lower income and education (NIPH, 2009; Norwegian Directorate of Health, 2016).
Overweight and obesity
Obesity is less common among 40-year-olds with higher education than among 40-year-olds with lower education (Meyer, 2005). Social differences in overweight and obesity are also found among children (Biehl, 2013).
However, the pattern is different in rich and poor countries. In a large study of 70 countries, it was shown that in poor countries there is more obesity among those with higher education, while in rich countries there is more obesity among people with lower education (Kinge, 2015b)
Smoking-related diseases explain much of the differences
To explain social inequalities in health, mortality and life expectancy, we have to look at both disease patterns and lifestyle habits.
Around 2000, significantly more died prematurely from myocardial infarction (heart attacks) in the groups with lower education than in the groups with higher education. Here, premature death refers to death before 75 years of age. Calculations for all causes of death combined show that cardiovascular diseases explained about half of the differences between educational groups in terms of premature death (Strand, 2010). After 2000, the differences in mortality from cardiovascular diseases were significantly reduced (Strand, 2014), especially among men, see Figure 5A men. As a result, educational differences in mortality have also started to flatten out (Mackenbach, 2014; Mackenbach, 2016).
Among women, there has also been a decline in educational differences in mortality from cardiovascular diseases, see Figure 5B women. However, parallel with this decline there has been an increase in educational differences in terms of mortality from lung cancer and COPD. Overall, therefore, the social inequalities in mortality among women has increased in the period from 2000 to 2009 (Strand, 2014).
Figure 5a. Differences in premature death among men with low and high education. Differences are shown for seven causes and in five periods. The diagram applies to the age group 45-74 years (premature deaths), the number of deaths per 100 000 per year. Mortality rates are age-adjusted. The overall height of the columns represents the absolute difference in overall mortality. The figure is based on Figure 1 in (Strand, 2014).
Comments to Figure 5a: We see that the total difference between educational groups was highest in the 1990s. We also see that there are various diseases that create differences (see colour codes). In the 1960s there was no apparent major cause. In subsequent decades, mortality from cardiovascular diseases created ever greater differences between educational groups. In the 2000s, the differences in mortality from cardiovascular diseases were still significant but less than in the previous decade.
Figure 5b. The difference in mortality between women who have low and high education. Differences are shown for seven causes and in five periods. The diagram applies to the age group 45-74 years (premature deaths) during the period 1961-2009, the number of deaths per 100 000 per year. Mortality rates are age-adjusted. The total height of the columns represents absolute difference in overall mortality. The figure is based on Figure 1 in (Strand, 2014).
Comments to Figure 5b: We see that the total difference between educational groups is highest in the 2000s. We also see that there are various diseases that create differences (see colour codes). In all decades, mortality from cardiovascular diseases creates large differences between educational groups. In the 2000s, the significance of cardiovascular diseases has been somewhat reduced. The significance of lung cancer and COPD, however, has increased.
Heart disease, COPD and lung cancer are all smoking-related diseases. Different smoking habits in groups with lower and higher education are probably a particularly important cause of social inequalities in mortality in Norway (Mackenbach, 2008; Mackenbach, 2016; Strand, 2010; Strand, 2014). An important public health challenge is to combat smoking, especially in groups with lower education.
Health and social conditions interrelated
Health and lifestyle habits such as smoking, diet and physical activity are closely linked to social conditions, local communities, housing and living conditions (Dahl, 2014). Some causal relationships are probably influential throughout life (Blane, 2013) and the interaction between factors is important.
Different factors affect public health, including age, gender and genetics, environmental and psychosocial factors related to employment, housing and local environment.
Lifestyle habits are primarily a result of the environment and living conditions. Factors such as economy, education, and living and working conditions may therefore affect health and the risk of disease, both in a positive and negative way.
Facts about noise
Noise is an example of an environmental factor that affects health in various ways. A report published by Statistics Norway shows that children and adolescents (0-20 years) in families with lower education increasingly live in areas with high noise levels (Statistics Norway, 2012).
- About 20 per cent of children in households with secondary education as their highest education were exposed to noise problems. The corresponding figure for children in families with higher education was 8 per cent.
- In low-income families, 14 per cent of children lived in houses with noise problems compared to 9 per cent in families with the highest incomes.
Noise can affect behaviour, lead to sleep disturbances, reduce the possibility for concentration and learning, as well as causing stress disorders. Such reactions to noise can have a huge impact on well-being, relaxation and health (WHO, 2011). Road traffic is the major source of noise in the community, followed by railways.
Norway in an international perspective
In Norway, the differences in mortality between educational groups are large. The differences are among the largest in Europe (Mackenbach, 2016). This has surprised both researchers and politicians.
New European figures suggest that mortality is falling and that life expectancy is increasing in all education groups. The countries that have had the strongest equalisation in recent years are Spain, Scotland, England / Wales and Italy (Mackenbach, 2016). Since 2005, the decline in mortality was greatest among those with the lowest education, especially for men. This is a positive development.
The levelling out between educational groups in European countries is mainly due to fewer people dying from heart attacks and other smoking-related diseases. Lifestyle changes and treatment for high blood pressure and high cholesterol have been important contributing factors. Better medical care and higher survival rates from heart attacks have also been significant (Mackenbach, 2016).
Great opportunities to improve public health
Efforts to improve living conditions, such as employment, education and living environment can help to promote health. This will also reduce social inequalities in health and increase life expectancy in all groups. The large differences in health and lifestyle habits that we see in Norway are a social problem that can be changed (Dahl, 2014).
Reduced social inequalities in health is also an important goal in health promotion. Levelling of social inequalities in health has a great potential for improvement of public health.
The Norwegian version of this article is an update of the chapter about Social Inequalities of Health in the Public Health Report 2014. Translated to English in March 2017.
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