International Journal of Epidemiology 2003;32:830-837
© International Epidemiological Association 2003

Widening socioeconomic inequalities in mortality
in six Western European countries

Johan P Mackenbach1, Vivian Bos1, Otto Andersen2, Mario Cardano3,
Giuseppe Costa4, Seeromanie Harding5, Alison Reid5, Örjan Hemström6,
Tapani Valkonen7 and Anton E Kunst1

1 Department of Public Health, Erasmus MC, The Netherlands.
2 Statistics Denmark, Copenhagen, Denmark.
3 Department of Social Sciences, Turin University, Italy.
4 Department of Public health and Microbiology, Turin University, Italy.
5 Medical Statistics, Office for National Statistics, London, UK.
6 SU-KI Centre for Health Equity Studies, Stockholm University, Sweden.
7 Department of Sociology, University of Helsinki, Finland.

Prof. Dr JP Mackenbach, Erasmus MC, Department of Public Health, PO Box
1738, 3000 DR Rotterdam, The Netherlands. E-mail:
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Objectives During the past decades a widening of the relative gap in death
rates between upper and lower socioeconomic
groups has been reported for several European countries. Although
differential mortality decline for cardiovascular diseases has
been suggested as an important contributory factor, it is not known what
its quantitative contribution was, and to what extent
other causes of death have contributed to the widening gap in total
mortality.

Methods We collected data on mortality by educational level and
occupational class among men and women from national
longitudinal studies in Finland, Sweden, Norway, Denmark, England/Wales,
and Italy (Turin), and analysed age-standardized
death rates in two recent time periods (1981?1985 and 1991?1995), both
total mortality and by cause of death. For simplicity,
we report on inequalities in mortality between two broad socioeconomic
groups (high and low educational level, non-manual
and manual occupations).

Results Relative inequalities in total mortality have increased in all six
countries, but absolute differences in total mortality were
fairly stable, with the exception of Finland where an increase occurred. In
most countries, mortality from cardiovascular
diseases declined proportionally faster in the upper socioeconomic groups.
The exception is Italy (Turin) where the reverse
occurred. In all countries with the exception of Italy (Turin), changes in
cardiovascular disease mortality contributed about half
of the widening relative gap for total mortality. Other causes also made
important contributions to the widening gap in total
mortality. For these causes, widening inequalities were sometimes due to
increasing mortality rates in the lower socioeconomic
groups. We found rising rates of mortality from lung cancer, breast cancer,
respiratory disease, gastrointestinal disease, and
injuries among men and/or women in lower socioeconomic groups in several
countries.

Conclusions Reducing socioeconomic inequalities in mortality in Western
Europe critically depends upon speeding up mortality
declines from cardiovascular diseases in lower socioeconomic groups, and
countering mortality increases from several other
causes of death in lower socioeconomic groups.

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