6 Eurohealth OBSERVER

7
Higgins ST, Washio Y, Heil SH, et al. Financial
incentives for smoking cessation among pregnant
THE PERSISTENCE OF
HEALTH INEQUALITIES
and newly postpartum women. Preventive Medicine
2012;55(Suppl): S33 – S40.
8
Merkur S, Sassi F, McDaid D. Promoting health,

IN MODERN WELFARE
preventing disease: is there an economic case?
Copenhagen: World Health Organization Regional
Office for Europe, 2013. Available at: http://www.
euro.who.int/_ _data/assets/pdf_file/0004/235966/
e96956.pdf
STATES: THE ROLE OF
HEALTH BEHAVIOURS
By: Johan P. Mackenbach

Summary: Despite the rise of the modern welfare state, health

inequalities by socioeconomic position are substantial in all European
countries with available data. One reason is that people with a higher
socioeconomic position often are the first to abandon behaviours
that are found to damage health, such as smoking and high-fat
diets, or to adopt behaviours that are found to promote health,
such as leisure-time physical activity. As a result, and as shown by
recent European studies, inequalities in smoking, excessive alcohol
consumption, diet, obesity and other factors are common, contributing
importantly to inequalities in morbidity and mortality. Tackling
inequalities in health-related behaviours therefore is key to success
in reducing health inequalities. Although some examples of effective
interventions are available, more research and development is
necessary to develop adequate countermeasures.

Keywords: Health Inequalities, Health Outcomes, Health Behaviours, Tobacco, Alcohol

Health inequalities are surprisingly suffering from illness or disability. 1 As

large Figure 1 indicates, the magnitude of these
inequalities varies considerably between
It is now widely known that people who
European populations, with smaller
have lower socioeconomic positions
inequalities in populations in Spain and
(indicated by their level of education,
Italy, and larger inequalities in central and
Johan P. Mackenbach is Professor occupation or income) have, on average,
eastern Europe. Nevertheless, inequalities
of Public Health and Chair of the shorter and less healthy lives than those
in mortality are substantial everywhere,
Department of Public Health, who are better off. Indeed, life expectancy
Erasmus University Medical Centre, even in countries with highly developed
at birth often varies by five to ten years,
Rotterdam, The Netherlands. Email: welfare states like the Nordic countries.
j.mackenbach@erasmusmc.nl with less educated and poorer people also
spending ten to twenty more years of life

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 Eurohealth OBSERVER 7

Figure 1: Relative inequalities in premature mortality, men 30–79 years, shrunk in size, but have also probably
19 selected European countries and regions, 2000s become more homogeneous in terms of
disadvantage. The reason for this is that
Relative Risk (age-adjusted, 30–79 years)
3.0
the more social mobility there is, the more
opportunities there are for selection into
higher social positions on the basis of
2.5
personal characteristics like mental health,
cognitive ability and personality. We
2.0 know that these personal characteristics
are important for health, e.g. because
1.5 they determine health-related behaviour,
and the increased importance of these
selection processes will therefore tend to
1.0
increase inequalities in health. 4 This may
be the case particularly in countries with
0.5
well-developed welfare policies such as the
Nordic countries, which usually also have
0.0 egalitarian education policies.
Finland

Sweden

Denmark

France

Barcelona

Estonia
Norway

England & Wales

The Netherlands

Belgium

Switzerland

Madrid

Turin

Tuscany

Hungary

Czech Republic

Poland
Aust ria

Basque Country

Third, people with a higher socioeconomic

position often are early adopters
of new behaviours, only later to be
followed by those with a lower social
Source: Unpublished data from EURO-GBD-SE project (http://www.euro-gbd-se.eu/). position. 5 This also applies to health-
Notes: A Relative Risk of, e.g., 2 indicates that the risk of premature mortality is twice as high among the low compared to the
related behaviours, and thus people with
high educated. Vertical lines indicate 95% confidence intervals.
a higher socioeconomic position often are
the first to abandon behaviours that are
In the nineteenth century, this would not policies, such as the Nordic countries, do found to damage health, such as smoking
have been surprising, given low average not have smaller health disparities than and high-fat diets. Over the past decades,
income, widespread poverty and lack of other western European countries. these behaviours have been pushed back in
social security. But it is surprising that many western European countries, partly
such large inequalities are commonly as a result of health promotion efforts,
The explanation of a paradox
found in high-income countries today, but during this dynamic phase large and
including those ranking high on indices Many researchers have struggled to widening inequalities in health behaviours
of human development. Since the end explain this paradox, and what emerges have emerged, which in their turn have
of World War II, many countries have from the scientific literature is that led to large and widening inequalities
tried to reduce socioeconomic inequality, the persistence of health inequalities in mortality.
or offset its consequences, through in modern welfare states results from
progressive taxation, social security a combination of three factors. 3 First,
Inequalities in health-related
programmes, and a wide range of and perhaps most importantly, despite
behaviours
collectively financed provisions, such as increases in average prosperity and some
public housing, education, health care and redistribution of income from higher Significant disparities in smoking,
cultural facilities. income earners to those with lower physical exercise, diet, alcohol
incomes, inequalities in access to material consumption, and several other health-
While there is no doubt that these resources have not been eliminated. The related behaviours now afflict many of
policies have reduced inequalities in welfare state does redistribute lifetime Western Europe’s welfare states. Their
some social and economic outcomes, income through taxation, cash transfers welfare arrangements, which were
including income, housing quality and and non-cash benefits, but what remains of created to combat poverty, obviously have
health care access, they have apparently inequalities in material living conditions been less effective against the causes of
been insufficient to eliminate health is still substantial, even where there are “diseases of affluence” like heart disease
inequalities. Long-term time-series data relatively small income inequalities as in and lung cancer, which are often linked to
indicate that the socioeconomic mortality the Nordic countries. modern consumption behaviour.
gap narrowed in the first half of the
twentieth century, but has grown again Second, social mobility, with children Among men, smoking nowadays is more
since the 1950s. 2 Even more puzzling is ending up in higher social positions than prevalent among the lower educated in
the fact that, as can be seen in Figure 1, their parents, has been widespread in all European countries, with inequalities
countries with more generous welfare all high income countries. Due to this being particularly large in some of the
process of upward social mobility, the Nordic countries. Among women, similar
lower socioeconomic groups have not only international patterns are seen, but in

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8 Eurohealth OBSERVER

southern Europe inequalities in smoking women, overweight and obesity are much in consumption behaviour. It follows
sometimes still have a “reverse” pattern, more prevalent in lower socioeconomic that a substantial reduction of health

‘‘
with smoking being more prevalent among groups in all countries with available inequalities can only be achieved by more
the higher educated. Studies have shown data, and inequalities in overweight and radical redistribution measures, and/or a
that inequalities in smoking explain up to a obesity are largest in southern Europe direct attack on the personal, psychosocial
third of inequalities in all-cause mortality, where they make a larger contribution to and cultural determinants of modern
particularly among men. 6 the explanation of inequalities in mortality health inequalities.
among women than smoking. 9
In the last few decades, social policy in

Equal The systematic nature of differences

in health-related behaviour clearly
most Western European countries has
moved away from redistribution. This is

access to health demonstrates that these are not a matter

of free choice, but must be determined
a mistake, given that the consequences
of this shift – rising income inequality,

care is certainly by conditions which are at least partly

beyond the control of the individual. The
weaker social safety nets and reduced
health care access – will aggravate health

not enough explanation of inequalities in smoking

has been studied in some detail and the
inequalities in the long run. In fact, more
and better-targeted redistributive policies
results of these studies point to a variety are likely to be crucial to improving
While smoking is clearly bad for of specific factors that work together to health outcomes in lower socioeconomic
health, alcohol is a more complex risk produce a higher prevalence of smoking groups. For example, income support
factor: both abstinence and excessive in lower socioeconomic groups. Because should be complemented by preventive
alcohol consumption are bad for health social norms in lower socioeconomic health programmes, while health literacy
(as compared to moderate drinking). groups are more pro-smoking, adolescents programmes could help to diminish the
Abstinence usually is more common in from these groups are more likely to start link between low cognitive ability and
the lower socioeconomic groups but the smoking than their better-off counterparts, bad health. Equal access to health care –
pattern for excessive alcohol consumption and they start at a younger age, leading still the main focus of health inequality
is more variable. The clearest evidence to more nicotine dependence. Smokers reduction in many countries – is certainly
comes from countries, such as some of from lower socioeconomic groups also not enough. Reducing inequalities
the Nordic countries and central and stop less often, and with less success. in health outcomes requires more
eastern European countries, where ‘binge Prevention of health problems at higher intensive health care for patients in lower
drinking’ is a major source of health ages has less priority for people from socioeconomic groups, tailored to their
problems. Binge drinking usually is more lower socioeconomic groups, because they specific needs and challenges.
common in lower socioeconomic groups, have more urgent problems to deal with –
and then makes an important contribution problems that are linked to their less Tackling inequalities in health-related
to the explanation of health inequalities, favourable living conditions and higher behaviours probably is the key to
e.g. through a higher rate of cardiovascular exposure to psychosocial stress. Finally, success in reducing health inequalities.
disease and injury mortality. 7 tobacco control policies, particularly those Unfortunately, we know very little about
relying on health education, have been less how to do this. Systematic reviews
Dietary behaviours also vary effective for smokers with a lower level of of smoking interventions covering
systematically by socioeconomic position. education or income. 10 price increases, access restrictions and
Men and women in lower socioeconomic smoking bans only found evidence
groups tend to eat fresh vegetables less Partly different but equally complex for an inequalities-reducing effect of
frequently, particularly in the north of explanations apply to inequalities in other price increases. Whereas raising excise
Europe. Differences in fresh vegetable health-related behaviours, and all of this taxes may be effective, its regressive
consumption are smallest in the south of highlights the need for creative solutions. impact on the poorest smokers who
Europe, probably because of the larger cannot stop should be counteracted by
availability and affordability of fruit and active promotion of the use of nicotine
What to do about
vegetables in Mediterranean countries. replacement therapy and other forms of
health inequalities?
A similar north-south gradient has been smoking cessation support. Revenues
found for inequalities in the consumption This article has shown that modern from tobacco taxation could be used to
of fruit. 8 European welfare states have been fund cessation-support programmes that
unable to stop the re-emergence of health target disadvantaged smokers. A national
Lack of leisure-time physical activity inequalities, partly because of a failure programme which created smoking
tends to be more common in the lower to implement more radical redistribution cessation services in disadvantaged
socioeconomic groups as well, as are measures, and partly because of areas in England has effectively reached
overweight and obesity. Interestingly, this concurrent developments which have disadvantaged smokers and has somewhat
is one of the very few aspects of health changed the composition of socioeconomic reduced the gap in smoking. 11
where patterns of social variation are groups and have made the reduction of
clearer for women than for men. Among health inequalities dependent on changes

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Eurohealth OBSERVER 9

Generally speaking, supply-side References 8

Prattala R, Berg MA, Puska P. Diminishing or
interventions are likely to be more 1
Mackenbach JP, Stirbu I, Roskam AJ, et al.
increasing contrasts? Social class variation in Finnish
food consumption patterns, 1979 – 1990. European
effective in reducing inequalities in Socioeconomic inequalities in health in 22 European
Journal of Clinical Nutrition 1992;46(4):279 – 87.
health-related behaviours than demand- countries. The New England Journal of Medicine
side interventions. For example, Finnish
9
2008;358(23):2468 – 81. Roskam AJ, Kunst AE, Van Oyen H, et al.
Comparative appraisal of educational inequalities in
nutrition policies have followed the Nordic 2
Pamuk ER. Social class inequality in mortality
overweight and obesity among adults in 19 European
welfare ideology where universalism from 1921 to 1972 in England and Wales. Population
countries. International Journal of Epidemiology
has been the general principle. School studies 1985;39(1):17 – 31.
2010;39(2):392 – 404.
children, students and employees in 3
Mackenbach JP. The persistence of health 10
Schaap MM, Kunst AE, Leinsalu M, et al.
Finland receive free or subsidised meals inequalities in modern welfare states:the explanation
Effect of nationwide tobacco control policies
at school or in the workplace, and special of a paradox. Social Science and Medicine
on smoking cessation in high and low educated
2012;75(4):761 – 9.
dietary guidelines have been implemented groups in 18 European countries. Tobacco Control
to ensure the use of low-fat food products. 4
Mackenbach JP. New trends in health 2008;17(4):248 – 55.
This has contributed to a favourable trend inequalities research:now it’s personal. The Lancet 11
Bauld L, Judge K, Platt S. Assessing the impact
2010;376(9744):854 – 5.
of narrowing socioeconomic inequalities of smoking cessation services on reducing health
in the use of butter and high-fat milk 5
Rogers EM. Diffusion of innovations. inequalities in England:observational study.
Tobacco Control 2007;16(6):400 – 4.
in Finland. 12 New York:Free Press, 1962.
12
6
Kulik MC, Menvielle G, Eikemo TA, et al. Mackenbach JP, Bakker MJ, European
As these examples show, tackling Educational inequalities in three smoking-related Network on Policies to Reduce Inequalities in
Health. Tackling socioeconomic inequalities in
inequalities in health-related behaviours causes of death in 18 European populations. Nicotine
and Tobacco Research 2013. doi: 10.1093/ntr/ntt175. health:analysis of European experiences. The Lancet
is possible, but it will require 2003;362(9393):1409 – 14.
sustained efforts underpinned by 7
Makela P, Valkonen T, Martelin T. Contribution
systematic evaluation. of deaths related to alcohol use to socioeconomic
variation in mortality:register based follow up study.
British Medical Journal 1997;315(7102):211 – 6.

New Policy Summary on Europe’s Health 2020 policy. However, large gaps are
apparent in both the numbers of professionals trained and
Addressing needs in the public the kind of training that exists. The discussion then turns to

health workplace in Europe the need to agree upon core and emerging competences for
a well-equipped workforce, including the important role of
employers in determining these
By: Vesna Bjegovic-Mikanovic, Katarzyna Czabanowska,
competences. In addition, public
Antoine Flahault, Robert Otok, Stephen Shortell,
health education needs to
Wendy Wisbaum and Ulrich Laaser
Y 10
POLICY SUMMAR

include a wider range of

s
Copenhagen: World Health Organization/European Addressing need health-related professionals,
alth
in the public he
Observatory on Health Systems and Policies, 2013 rope including managers, health
workforce in Eu

vic, promotion specialists, health

Number of pages: 48, ISSN: 2077-1584, Policy Summary 10
ikano
Vesna Bjegovic-M ska,
anow
Katarzyna Czab
Antoine Flahault,
Stephen Shor tell,
Robert Otok,
Wen dy Wisb aum, economists, lawyers
Ulrich Laaser
Available at: http://www.euro.who.int/__data/assets/pdf_ and pharmacists.
file/0003/248304/Addressing-needs-in-the-public-health-
Identified and agreed-upon
workforce-in-Europe.pdf?ua=1
competences can, in turn, be
One of the primary challenges facing European health translated into competency-
systems is the need for a multidisciplinary public health based training and education,
workforce supported by new skills and expertise. This necessary to equip current public health professionals
policy summary aims to outline these needs and to consider with the skills required in today’s competitive job market.
measures and options towards meeting them. New developments in public health training, include flexible
academic programmes, lifelong learning (LLL) which is vital
Starting off with a snapshot of the current workforce and
for employability, and accreditation. Seven case studies
training provisions in different European health systems,
present examples of current developments and practices.
the policy summary goes on to discuss positive efforts to
promote public health training and education such as the
Bologna Process and the WHO Regional Office for

Eurohealth incorporating Euro Observer — Vol.20 | No.2 | 2014