Social determinants of population health
to reduce inequalities in health
Some population groups are healthier than others. People with lower education, social class or income more often suffer ill health and die at a younger age. Socio-economic inequalities in health persist over time, and there is evidence for a widening of these health inequalities in the Netherlands and elsewhere in Europe. Other important disparities in health are those between men and women, between different ethnic groups, and between people with a different marital status. Our research aims to explain inequalities in health and support policies to reduce inequalities in health in both the Netherlands and abroad.
Since 1991 we have been conducting a longitudinal study (the GLOBE study) that aims to elucidate why disadvantaged people have poorer health and live shorter lives. A new wave of data collection was started in 2004, focussing on the role of environmental characteristics in the explanation of socio-economic inequalities in health-related behaviour. We also perform comparative studies of socio-economic inequalities in health between different European countries, to gain insight into the key factors involved in the explanation of these inequalities. The next challenge is to reduce these inequalities. Health interventions need to be targeted at disadvantaged groups, and tailored to their needs. However, it remains uncertain which policies and interventions are most effective in reducing inequalities, and how their effectiveness can be increased. Therefore we are involved in studies evaluating the effectiveness of a number of interventions and policies among disadvantaged groups.
Public Health Impact
The health situation of migrant groups became a key concern in public health policies in the Netherlands in the 1990s. Since that time, our group has completed a series of mortality studies on the four main minority groups in the Netherlands (Turkish, Moroccan, Surinamese, Antillean/Aruban) and of refugees from Iraq, Iran, Somalia and elsewhere. The results were presented in international journals, books, Dutch journals, at national congresses, and also received widespread attention in the Dutch media. Journalists of leading national newspapers (e.g. the NRC and Volkskrant) wrote extensive articles, which were often followed by public discussions. These publications helped to change the public’s view of migrants’ health into a less gloomy one. Low rates of mortality from cancer and cardiovascular disease showed that most migrant groups had been more successful in avoiding these fatal diseases than the native Dutch population. At the same time, specific problems were highlighted, such as a higher mortality from diabetes and homicide in most migrant groups. This has provided a better basis for public health policies, which now focus on the specific problems of migrant groups, while recognizing the fundamental role of socio-economic factors and policies.
Research Highlight: Educational inequalities in cause-specific mortality in 8 western-European populations
(Huisman et al., Lancet, 2005)
Socio-economic inequalities in health are known to exist in all countries for which data are available, and are of major concern for public health policy. Much effort has been put into identifying the underlying causes of these inequalities. Our approach was to study the contribution of several specific causes of death to inequalities in the level of overall mortality between groups with a different educational level in eight western-European populations.
Our results demonstrated that the excess mortality in lower educated men and women in Europe was largely due to cardiovascular diseases (for 39% in men, and 60% in women). All cancers combined contributed much less to the excess mortality (24% in men, and 11% in women). In European men, the ‘top five’ of specific causes of death that contributed most to excess mortality in the lower educated were: ischaemic heart disease (IHD), lung cancer, COPD, ‘other cardiovascular diseases’, and cerebrovascular disease. In women the ‘top five’ consisted of: IHD, ‘other cardiovascular diseases’, cerebrovascular disease, pneumonia, and COPD.
We also observed important differences between countries. For instance, the role of IHD in overall mortality inequalities was much larger in northern-European countries than in southern-European countries. It appeared that differences in overall mortality between educational groups existed in all the countries in our study, but that the mechanisms underlying these inequalities for a large part differ between countries.
Thus, countries can learn from each other about how to reduce inequalities in health; however, they also need to further develop their own evidence base for public-health policy on this important issue.
 | Social determinants of population health projects |