The findings presented in this thesis have important policy implications and support a number of recommendations for future research. Two main recommendations for research may be drawn from this work. First, this thesis highlights a number of limitations regarding data harmonisation and data availability. Further improvements need to be made at the international level to carry out surveys with harmonised questions for the sake of international comparisons, and to make data available in a timely manner to researchers. Second, while researchers and experts already pay attention to measuring and monitoring health inequalities, more efforts need to be undertaken regarding the understanding of inequalities in order to design more effective policy instruments to tackle inequalities (e.g. identifying the causal impact of determinants on health inequalities).
Regarding policy implications, the findings presented in this thesis highlight possible policy levers to help reduce social inequalities in health-related behaviours, and more generally reduce social inequalities in health. First, this thesis provides some evidence that, in order to achieve effective policy measures, it is relevant to focus on the most at-risk population groups, in particular groups with lower education levels and lower socioeconomic status among which a higher prevalence of risk factors is concentrated, as well as lower income groups who experience higher barriers in access to care. Better-targeted redistributive policies (e.g. cash transfers, social safety nets) combined with health policy measures directed at the worst-off (e.g. health literacy or prevention programmes) could help to reduce inequalities in health-related behaviours.
Second, as shown in this thesis, health and health inequalities are related to a number of
a broader policy agenda. One can think for instance, of including objectives for health outcomes in other policy sectors (like education, employment, and social affairs). For example, in Japan, a chronic disease prevention programme at the workplace is being developed with the aim of maintaining people longer in work and in good health, and as a result, improving work productivity. Of course, such initiatives imply coordination across ministries, and in particular, discussion of financing arrangements (e.g. who pays? who gets the return?).
Third, the framework of this thesis assumes that tackling social inequalities in health can be achieved to some extent by addressing inequalities in health-related behaviours. In particular, unhealthy lifestyles such as smoking, heavy drinking and obesity are directly targetable by governments to favour better health outcomes. Governments can reduce behavioural risk factors by implementing policies to reduce unhealthy lifestyles, such as health promotion and regulatory policies. Regarding health promotion policies to tackle obesity, coordinated national programmes -including mass media campaigns and school-based interventions- are increasingly used by countries, such as the United States (Let’s ove), the United Kingdom (Change4Life), and also amongst EU member states with the 2014 European action plan targeting childhood obesity. Beyond the sole role of governments, the involvement of multi-stakeholders like the tobacco, alcohol and food industries, the community, and patient and doctor associations, appears a promising strategy in order to achieve the best outcomes. For instance, food manufacturers can play a role in the fight against obesity by reformulating the contents of products, this is the case for instance in Hungary after the fat tax implementation, and in the Netherlands after the compulsory food labelling implementation. Regarding regulatory policies, governments can employ taxation, advertising regulation, and location and time restrictions (for smoking and drinking). For example, to counter obesity, France, Hungary and Mexico have used taxation for sugar-sweetened beverages. One concern about taxation is its regressive effect on low income groups. However, some analyses show that low-socioeconomic groups benefit more from prevention policies in terms of health outcomes since they have a higher prevalence of risk factors (Sassi et al., 2009). Moreover, to counterbalance the side effects of taxation, redistributive measures can be used. For instance, financial gains raised from taxes could subsidize vouchers for healthy products or baskets of fruits and vegetables to the low-income groups adversely affected by the introduction of such taxes.
Research presented in this thesis highlights the need for possible extensions of the work and raises further questions that could be addressed in future investigations. Four possible avenues of work development are proposed here.
First, the analysis of the relationship between education and obesity sheds some light on the nature of the link and attempts to explore the causality. However, the investigation of the causal relationship was limited because -at the time of analysis- cross-sectional data were only accessible whereas longitudinal data would have allowed assessment of causality. In order to expand this analysis, it would be worth exploring the causal link using longitudinal data such as the British Household Panel Survey, or the Household, Income and Labour Dynamics in Australia survey.
Second, the study on inequalities in hazardous drinking highlights important weaknesses of survey data regarding the measurement of alcohol consumption. Alcohol consumption is highly underestimated in health surveys. A correction of survey data from underreporting was applied by using national alcohol sales data. This work could be extended by considering another correction technique which combines various types of questions (the usual quantity-frequency questions and the consumption in the day prior to the interview) (Meier et al., 2013; Stockwell et al., 2014). This would allow confirmation of the findings on the mis-estimation of social inequalities in hazardous drinking due to the underreporting bias in alcohol surveys.
Third, the work on health care services utilisation tries to inform the role of national policy settings on social inequalities, although this analysis is strongly limited by the small number of countries25 and so, by the lack of variability at the country level. More robust analyses (like multilevel modelling) could be undertaken in future work if access to adequate data sets to increase the number of countries was made possible.
Fourth, while the study on health care services utilisation highlights persistent income-related inequalities, it may be worth examining the effect of the 2008 economic crisis on health care utilisation and assessing to what extend the crisis has led to larger social inequalities in health care access. A recent study shows that the crisis has contributed to a deterioration in access to health care, although the effects may vary across European countries (Eurofound, 2013). Similarly, the latest European data (from EU-SILC 2012) indicates increased unmet care needs in the aftermath of
released, it will be possible to assess the impact of the crisis on the utilisation of health care services and on health outcomes by socioeconomic group.
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