Social and spatial inequalities in premature mortality across Europe
Authors: Fiona Bragg, Ben Lacey
Journal: The Lancet Public Health (2024)

Although some differences in health status between populations are inevitable, such as poorer health among older populations, differences in health linked with social and economic circumstances are not. These avoidable and unfair inequalities in health have been long recognised,1Marmot M Wilkinson R Social Determinants of Health. Oxford University Press, Oxford2005Crossref Google Scholar, 2Whitehead M A typology of actions to tackle social inequalities in health.J Epidemiol Community Health. 2007; 61: 473-478Crossref PubMed Scopus (236) Google Scholar but addressing them remains a major challenge throughout the world. According to the adage "if something cannot be measured, it cannot be improved".3Berenson RA If you can't measure performance, can you improve it?.JAMA. 2016; 315: 645-646Crossref PubMed Google Scholar If true, the article by José Chen-Xu and colleagues in The Lancet Public Health,4Chen-Xu J Varga O Mahrouseh N et al.Subnational inequalities in years of life lost and associations with socioeconomic factors in pre-pandemic Europe, 2009–19: an ecological study.Lancet Public Health. 2024; 9: e166-e177Summary Full Text Full Text PDF Google Scholar measuring subnational geographical differences in premature mortality in Europe, provides a potentially valuable contribution to addressing health inequalities across the continent. Chen-Xu and colleagues investigated estimated years of life lost (YLLs) due to all-cause mortality to assess the extent of differences in premature mortality within and between 32 European countries (including all countries of the European Economic Area). Their findings showed that in 2019, the highest sex-specific age-standardised rates of YLLs were predominantly in central and eastern European countries, but notable subnational differences in rates of YLLs were observed in all countries studied. Relative spatial inequalities were assessed by applying the Gini coefficient to YLL estimates for subnational administrative areas. Among women, Gini coefficient estimates ranged from 3% in Ireland to 11% in the UK, and among men from 2% in Ireland to 11% in Belgium. Sizeable absolute inequalities in YLLs were observed within some, most notably central and eastern European, countries, with slope index of inequality measures of up to approximately 30% in men and approximately 20% in women. Estimated YLLs declined modestly in almost all areas studied between 2009 and 2019, but no consistent changes were observed in measured spatial inequalities within the countries studied over the same period. Differences in rates of premature mortality between European countries are well documented, and subnational estimates have been available for some time for many of these countries.5Mackenbach JP Kulhánová I Menvielle G et al.Trends in inequalities in premature mortality: a study of 3.2 million deaths in 13 European countries.J Epidemiol Community Health. 2015; 69: 207-217Crossref PubMed Scopus (162) Google Scholar, 6GBD 2019 Demographics CollaboratorsGlobal age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019.Lancet. 2020; 396: 1160-1203Summary Full Text Full Text PDF PubMed Scopus (796) Google Scholar Nevertheless, Chen-Xu and colleagues' Europe-wide analysis of differences in YLLs at a relatively granular level, both within and between countries, provides a useful addition to the literature. However, the study has limitations. For example, among the numerous potential determinants of the observed differences, only age and sex were routinely accounted for in the study. Moreover, the relevance of the data sources used, including their quality and comparability across geographical areas and time periods,7Costa C Freitas Stefanik I et al.Evaluation of data availability on population health indicators at the regional level across the European Union.Popul Health Metr. 2019; 17: 11Crossref PubMed Scopus (19) Google Scholar is unclear. So too is the influence of population differences in social, economic, and cultural environments, living and working conditions, health systems and services, and other key determinants of health. Although investigation of all-cause mortality avoids uncertainties in the comparability of cause of death attribution between areas, it also limits understanding of the relevance of the observed disparities. Furthermore, as the authors acknowledge, the data presented do not capture the marked impacts of the COVID-19 pandemic and its consequences on health and health inequalities in Europe.8McGowan VJ Bambra C COVID-19 mortality and deprivation: pandemic, syndemic, and endemic health inequalities.Lancet Public Health. 2022; 7: e966-e975Summary Full Text Full Text PDF PubMed Scopus (54) Google Scholar Thus, while this study by Chen-Xu and colleagues provides detailed mapping of differences in premature mortality across Europe, the factors underlying these observed differences remain unclear. The study did explore the relevance of area-level indicators of socioeconomic position, showing higher YLLs, after controlling for age and sex, in areas with lower average educational attainment, lower household income, or with higher risk of poverty. The ecological study design precludes understanding of the association of socioeconomic position with premature mortality among individuals within the populations studied. However, the observed correlations are consistent with previously reported socioeconomic inequalities in health.1Marmot M Wilkinson R Social Determinants of Health. Oxford University Press, Oxford2005Crossref Google Scholar, 5Mackenbach JP Kulhánová I Menvielle G et al.Trends in inequalities in premature mortality: a study of 3.2 million deaths in 13 European countries.J Epidemiol Community Health. 2015; 69: 207-217Crossref PubMed Scopus (162) Google Scholar, 9Lewer D Jayatunga W Aldridge RW et al.Premature mortality attributable to socioeconomic inequality in England between 2003 and 2018: an observational study.Lancet Public Health. 2020; 5: e33-e41Summary Full Text Full Text PDF PubMed Scopus (100) Google Scholar Described by Whitehead as "systematic differences in health between different socioeconomic groups within a society",2Whitehead M A typology of actions to tackle social inequalities in health.J Epidemiol Community Health. 2007; 61: 473-478Crossref PubMed Scopus (236) Google Scholar social inequalities in health are "potentially avoidable and are widely considered unacceptable in a civilised society".2Whitehead M A typology of actions to tackle social inequalities in health.J Epidemiol Community Health. 2007; 61: 473-478Crossref PubMed Scopus (236) Google Scholar It is unclear to what extent the observed socioeconomic gradients contributed to the overall differences in YLLs between geographical areas in the study. However, there is a clear need to understand this, and to elucidate the environmental and individual factors underlying the reported inequalities at subnational, national, and Europe-wide levels (initiatives to enhance nationwide linkages of administrative data would support this work), informing multi-level actions for improved health equity and individual and population health.10Marmot M Allen J Boyce T Goldblatt P Morrison J Health equity in England: The Marmot Review 10 years on. Institute of Health Equity, London2020Google Scholar Inequalities in health are unfair and contribute substantially to preventable morbidity and mortality globally.1Marmot M Wilkinson R Social Determinants of Health. Oxford University Press, Oxford2005Crossref Google Scholar, 2Whitehead M A typology of actions to tackle social inequalities in health.J Epidemiol Community Health. 2007; 61: 473-478Crossref PubMed Scopus (236) Google Scholar The study by Chen-Xu and colleagues, through measuring and mapping disparities in premature mortality, provides a timely reminder of the marked health disparities in Europe, even before the COVID-19 pandemic. The study findings provide a valuable incentive for further investigation of the nature and causes of these avoidable inequalities in premature mortality, and for action to address the known social determinants of health both between and within countries in Europe. BL is a member of the UK Biobank Senior Team; UK Biobank has core funding from the Medical Research Council, Wellcome, British Heart Foundation, Cancer Research UK, and the National Institute for Health Research. FB declares no competing interests. Subnational inequalities in years of life lost and associations with socioeconomic factors in pre-pandemic Europe, 2009–19: an ecological studyDifferences in YLLs remain within, and between, EEA countries and are associated with socioeconomic factors. This evidence can assist stakeholders in addressing health inequities to improve overall disease burden within the EEA. Full-Text PDF Open Access