title: The impact of increasing income inequalities on educational inequalities in mortality - An analysis of six European countries.
abstract: Over the past decades, both health inequalities and income inequalities have been increasing in many European countries, but it is unknown whether and how these trends are related. We test the hypothesis that trends in health inequalities and trends in income inequalities are related, i.e. that countries with a stronger increase in income inequalities have also experienced a stronger increase in health inequalities.
  
  
  
  We collected trend data on all-cause and cause-specific mortality, as well as on the household income of people aged 35-79, for Belgium, Denmark, England & Wales, France, Slovenia, and Switzerland. We calculated absolute and relative differences in mortality and income between low- and high-educated people for several time points in the 1990s and 2000s. We used fixed-effects panel regression models to see if changes in income inequality predicted changes in mortality inequality.
  
  
  
  The general trend in income inequality between high- and low-educated people in the six countries is increasing, while the mortality differences between educational groups show diverse trends, with absolute differences mostly decreasing and relative differences increasing in some countries but not in others. We found no association between trends in income inequalities and trends in inequalities in all-cause mortality, and trends in mortality inequalities did not improve when adjusted for rising income inequalities. This result held for absolute as well as for relative inequalities. A cause-specific analysis revealed some association between income inequality and mortality inequality for deaths from external causes, and to some extent also from cardiovascular diseases, but without statistical significance.
  
  
  
  We find no support for the hypothesis that increasing income inequality explains increasing health inequalities. Possible explanations are that other factors are more important mediators of the effect of education on health, or more simply that income is not an important determinant of mortality in this European context of high-income countries. This study contributes to the discussion on income inequality as entry point to tackle health inequalities. More research is needed to test the common and plausible assumption that increasing income inequality leads to more health inequality, and that one needs to act against the former to avoid the latter.
authors.affiliation: Department of Public Health, Erasmus Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, Netherlands. r.hoffmann@erasmusmc.nl.
authors.forename: Rasmus
authors.initials: R
authors.lastname: Hoffmann
authors.affiliation: Department of Public Health, Erasmus Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, Netherlands.
authors.forename: Yannan
authors.initials: Y
authors.lastname: Hu
authors.affiliation: Department of Public Health, Erasmus Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, Netherlands.
authors.forename: Rianne
authors.initials: R
authors.lastname: de Gelder
authors.affiliation: Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), F75012, Paris, France.
authors.forename: Gwenn
authors.initials: G
authors.lastname: Menvielle
authors.affiliation: Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
authors.forename: Matthias
authors.initials: M
authors.lastname: Bopp
authors.affiliation: Department of Public Health, Erasmus Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, Netherlands.
authors.forename: Johan P
authors.initials: JP
authors.lastname: Mackenbach
mesh_terms: D000328:Adult; D000368:Aged; D001530:Belgium; D002318:Cardiovascular Diseases / Q000453:epidemiology; D003718:Denmark; D004522:Educational Status; D004739:England; D005060:Europe; D005260:Female; D005602:France; D054624:Health Status Disparities; D006801:Humans; D007182:Income / Q000639:trends*; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends*; D009790:Occupations / Q000639:trends; D017524:Slovenia; D012959:Socioeconomic Factors; D013557:Switzerland; D014852:Wales
keywords: Europe; Fixed-effects; Health inequality; Income inequality; International comparison; Longitudinal analysis; Mortality