DiVerences in self reported morbidity by educational level: A comparison of 11 Western European countries

Study objective—To assess whether there are variations between 11 Western European countries with respect to the size of diVerences in self reported morbidity between people with high and low educational levels. Design and methods—National representative data on morbidity by educational level were obtained from health interview surveys, level of living surveys or other similar surveys carried out between 1985 and 1993. Four morbidity indicators were included and a considerable eVort was made to maximise the comparability of these indicators. A standardised scheme of educational levels was applied to each survey. The study included men and women aged 25 to 69 years. The size of morbidity diVerences was measured by means of the regression based Relative Index of Inequality. Main results—The size of inequalities in health was found to vary between countries. In general, there was a tendency for inequalities to be relatively large in Sweden, Norway, and Denmark and to be relatively small in Spain, Switzerland, and West Germany. Intermediate positions were observed for Finland, Great Britain, France, and Italy. The position of the Netherlands strongly varied according to sex: relatively large inequalities were found for men whereas relatively small inequalities were found for women. The relative position of some countries, for example,West Germany, varied according to the morbidity indicator. Conclusions—Because of a number of unresolved problems with the precision and the international comparability of the data, the margins of uncertainty for the inequality estimates are somewhat wide. However, these problems are unlikely to explain the overall pattern. It is remarkable that health inequalities are not necessarily smaller in countries with more egalitarian policies such as the Netherlands and the Scandinavian countries. Possible explanations are discussed. (J Epidemiol Community Health 1998;52:219–227) Many studies throughout Europe have reported a higher level of morbidity and mortality for people with a lower educational level, occupational status or income level. An interesting question is whether the size of these health inequalities varies substantially between countries. One of the reasons for studying international variations in socioeconomic inequalities is that international comparison enables judgements to be made on the size of inequalities in health in diVerent country. In addition, comparative studies of health inequalities in societies that diVer with respect to the size of income inequalities, national living standards, and other potentially relevant aspects, may shed more light on the causes of socioeconomic inequalities in health. Several international comparisons have focused on socioeconomic inequalities in self reported morbidity. These studies suggested that the size of inequalities in health varies between countries. Comparative research has, however, until now lacked comprehensiveness and often suVered from problems with comparability of data. More specifically, previous international studies mainly concerned a few countries, especially the Scandinavian countries and Great Britain, and most of them included only one indicator of morbidity. In the few more comprehensive studies 14 15 the comparability of the morbidity indicators as well as the socioeconomic indicators was not always