Mental disorders
4.7 Inequalities in Health Status
state of wellbeing essential for health as de-fined by WHO. Even such a “soft” indicator of health status was found to be predictive of long-term survival in cohort studies [58].
Health status, as determined by self-assess-ment, improved with increasing level of edu-cation in various countries of the Region. In Bulgaria, the proportion of the population reporting good or very good health was over 75 % among people with at least full elemen-tary education, but was scarcely 57 % among people with less [59]. In the Netherlands, good or very good health was reported by 87 % of university graduates and 62 % of people with elementary school education [26]. In an international comparison of self-reported health status of adults in Denmark, Finland, the Netherlands, Sweden and the United Kingdom, long-standing health prob-lems were found to be some 20 % less fre-quent in people with an average or better level of education than in those with fewer years at school [60].
A prospective study in Moscow and St Pe-tersburg examined the relationship between coronary heart disease mortality and edu-cational attainment [61]. In this study, only 22 % of the twofold excess in mortality as-sociated with low educational attainment was statistically attributable to the major risk factors: age, blood pressure, cholesterol, body mass index, smoking and alcohol in-take. Several studies reported mental dis-orders to be more frequent in populations with lower socioeconomic status [53]. In-creased mortality or morbidity in people with lower socioeconomic status was also seen even after allowing for personal habits such as tobacco smoking [62–64]. An example of issues related to lower socioeco-nomic class, and possibly linked to health status, is perception of excessive body weight. In a study of an urban population in Poland, overweight people with elementary education were significantly more likely to be unaware of their excessive body weight than those with more education [65].
The social status of mothers, as expressed by their level of education, was found to be an indicator of conditions affecting the
Inequalities in Health Status 123
health of their children. In Poland in 1987, infant mortality ranged from 10.6 deaths per 1000 live births for mothers with a university education, to 18.7 and 28.3 per 1000 for mothers with elementary and lower levels of education, respectively [66]. The corre-sponding rates for Hungary in 1987 were very similar: 10.3, 19.0 and 36.1 per 1000 [67]. This association was not present in Sweden, however, where adequate environ-mental conditions and efficient health care are accessible to all residents irrespective of their social status and associated educational attainment, and where infant mortality is very low [68].
Further, the distribution of personal in-come in countries was found to have an im-portant association with health. In a health and lifestyle survey conducted in Great Brit-ain in 1981, standards of health for three dif-ferent measures of morbidity improved rapidly as income increased from the low end towards the middle of the range; no further gains in health accompanied in-creases in income beyond this point [69]. In England, a study using a composite index showed that social deprivation was related to premature mortality (death before 65 years of age) throughout the range of affluence; it was not limited to the poorest areas [70].
Fig. 4.18: Percentage of the population in countries reporting health status as fair/average or better in the late 1980s
Comparable data are not available from the eastern countries of the Region, but an analysis based on grouped data for sub-national regions of Bulgaria, Poland and the USSR did not reveal any consistent relation-ship between higher levels of affluence and better health indicators [71].
In some eastern countries, mortality rates were still higher in rural than in urban popu-lations at the end of the 1980s. This was ob-served in all age groups in Bulgaria and the USSR. In Hungary, infant mortality rates de-creased more rapidly in cities than in rural areas. This can be explained not only by better access to health care in cities but also by less developed sanitary infrastructures and more difficult living conditions in rural areas. In Poland, the advantage of urban populations was reversed in 1987. The life ex-pectancy (at birth and at ages 45 and 60 years, and in both males and females) in rural areas exceeded that in urban lations. The excess mortality in urban popu-lations is related mostly to coronary heart disease and digestive diseases [57]. This may indicate that the unfavourable lifestyles and dietary factors prevalent in the cities have outweighed such advantages of urban living as better access to health care.
Great disparities in the distribution of health resources between regions have per-sisted virtually unchanged since the early 1970s. The increase in the effectiveness of health care is still much smaller in the east-ern than in the westeast-ern European countries, as illustrated by the slower decline in mortal-ity from causes that are considered to be amenable to medical care [72]. Neverthe-less, mortality from causes not amenable to care rose in the eastern countries in recent decades, in contrast to the declining trends observed elsewhere. This suggests that life-style factors and adequate living and environ-mental conditions may be even more import-ant in achieving an overall improvement in health status than the availability of curative services.
Among lifestyle factors affecting health, tobacco smoking and the excessive consump-tion of alcohol are particularly important. It
has been estimated that as much as 20 % of deaths in developed countries can be at-tributed to smoking [73]. Extensive litera-ture demonstrates that the incidence of cancer at various sites (lung, trachea, bron-chus, oesophagus, urinary bladder), cardiov-ascular diseases and chronic obstructive air-ways diseases are significantly higher in smokers than in nonsmokers, and maternal smoking was found to affect infant mortality in Sweden, for example [68]. Data from Po-land [74] and the USSR [51] show that ex-cessive alcohol drinking, even as represented by total alcohol sales, can be correlated with several indicators of ill health such as prema-ture mortality, cirrhosis of the liver and some cancers of the digestive tract.
This overview indicates vast differences in many aspects of health status between vari-ous parts of the population of the European Region. The most general conclusions, based on several indicators, are as follows.
The health of people in the western coun-tries has improved in recent decades while, according to the information available, health has not improved or has deteriorated in some populations in the CCEE and NIS.
These diverging trends are reflected in markedly higher mortality rates in the east-ern than in the westeast-ern parts of the Region.
The differences are greatest among young adults and people of middle age, particularly men. The most pronounced differences in premature mortality between the groups of countries are in mortality from cardiovascu-lar and respiratory diseases and, in males, in injury and cancer. These diseases contribute most to the difference in total mortality be-tween parts of the Region. The limited data on morbidity support the conclusions based on the evaluation of mortality patterns.
As to the impact on society, the most sig-nificant findings are the unfavourable trends in middle-aged people in the CCEE and NIS.
4.8 Conclusions
References 125 The impaired health of the most
economi-cally and socially active part of the popu-lation has a direct impact on the overall well-being of society. It is also important to stress the significance of even relatively mild dis-eases experienced in childhood or as a young adult. Besides their immediate effect on the individual’s life, these diseases may affect de-velopment and/or health status later in life.
Such diseases include common respiratory infections in childhood, which have a negative impact on pulmonary function, or viral hepatitis, which increases the risk of liver cancer.
Preventing disease, as well as trying to cure it, should be emphasized as the way to improve the health status of a population.
Lifestyle factors, particularly smoking, alco-hol and dietary habits, clearly need improve-ment. The elimination of tobacco smoking would result in significant reductions in cancer and in cardiovascular and respiratory diseases. The current patterns and trends in tobacco consumption correspond well to the overall patterns of health deficiencies in the Region. In addition, environmental factors may be important determinants of health for certain groups, including occupational groups (see Chapter 18).
Continuing or renewing effective immu-nization programmes will reduce infectious diseases and prevent a repetition of recent epidemics of, for example, diphtheria and poliomyelitis. This approach, based on the WHO strategy for health for all [11], should be adopted and efficiently implemented by all countries, particularly the CCEE and NIS. The experience of the western coun-tries shows that major improvement is poss-ible. No less important is the effort to ident-ify the reasons for deviations from the gen-eral pattern at national and subnational le-vels. Understanding the reasons for these dif-ferences can contribute to the improvement of the health of all people in the European Region.
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