Nimmt die gesundheitliche Ungleichheit zu? Ergebnisse eines Literaturreviews und Empfehlungen für die weitere Forschung

Zusammenfassung

Einleitung:

Es ist häufig gezeigt worden, dass der sozio-ökonomische Status eng mit dem Gesundheitszustand zusammenhängt. Die weiterführende Frage, ob sich das Ausmaß dieser ‚gesundheitlichen Ungleichheit‘ mit der Zeit vergrößert hat, ist von großer gesundheitspolitischer Relevanz. Bisher wird darüber in Deutschland jedoch kaum diskutiert – es fehlt auch eine Überblicksarbeit zu den vorhandenen empirischen Arbeiten.

Methoden:

Die hier vorgestellten Ergebnisse einer systematischen Literaturrecherche beziehen sich auf 4 Themenbereiche: Zeitliche Veränderungen im Ausmaß der gesundheitlichen Ungleichheit bei Mortalität/Lebenserwartung, selbst-eingeschätztem Gesundheitszustand (Self-Rated Health), Rauchen, Adipositas. Eingeschlossen wurden alle Arbeiten aus Deutschland und Publikationen aus dem europäischen Ausland aus dem Zeitraum 2008 bis 2012. In einem mehrstufigen Verfahren wurden anhand vorher festgelegter Kriterien 44 Studien (davon 5 aus Deutschland) für die detailliertere Darstellung der Ergebnisse und Methoden ausgewählt.

Ergebnisse:

Die stark anwachsende Zahl der Publikationen zeigt deutlich, wie sehr das Interesse an zeitlichen Trends im Ausmaß dieser gesundheitlichen Ungleichheit in den letzten Jahren zugenommen hat. Die empirischen Ergebnisse der 44 Studien lassen sich wie folgt zusammenfassen: Insgesamt werden 184 einzelne Ergebnisse zu zeitlichen Veränderungen im Ausmaß der gesundheitlichen Ungleichheit berichtet – davon weisen 112 auf eine Zunahme und nur 13 auf eine Verringerung der gesundheitlichen Ungleichheit hin. Auch die aus Deutschland vorliegenden Studien zeigen in die gleiche Richtung. Deutlich wird auch eine große methodische Heterogenität: In einigen Studien werden Unterschiede nach individuellem Status untersucht (z. B. Schulbildung), in anderen nach regionaler Deprivation. Zum Teil fehlt eine explizite Berechnung der zeitlichen Veränderung im Ausmaß der gesundheitlichen Ungleichheit, manchmal wird nur die absolute oder nur die relative gesundheitliche Ungleichheit analysiert.

Schlussfolgerungen:

Die in Deutschland verfügbaren Datensätze sollten mehr als bisher für Analysen zu zeitlichen Veränderungen im Ausmaß der gesundheitlichen Ungleichheit verwendet werden. Die Studien sollten dabei nach Möglichkeit individuelle und regionale Ungleichheiten einbeziehen, absolute und relative gesundheitliche Ungleichheiten analysieren (getrennt für Männer und Frauen, mit Signifikanztests für die zeitlichen Veränderungen), möglichst viele Zeitpunkte betrachten und die Zusammenhänge mit gesellschaftlichen Veränderungen untersuchen.

Abstract

Objectives:

It has been shown that socio-economic status (SES) and health are closely linked to one another. Now we focus on further ques­tions, and one of the most important ones is whether these “health inequalities” increase with time. In Germany, there is little discussion about this question and no review summarising the empirical evidence is available.

Methods:

This review focuses on 4 dimen­sions: time trends of health inequalities concerning mortality (or, respectively, life expectancy), self-rated health, smoking and obesity. First we included all empirical analyses from Germany, and all analyses from other European countries published between 2008 and 2012. Then, step­wise, 44 studies (including 5 from Germany) were selected by predefined criteria for a detailed ­description of empirical results and methods.

Results:

The number of publications has strong­ly increased in recent years, illustrating the growing interest in time trends of health inequalities. The empirical results of the 44 studies could be summarised in the following way: All in all, 184 empirical results are reported about time trends in health inequalities and 112 of them show increasing inequalities; decreasing inequalities are shown in 13 reports. The studies from Germany point in the same direction (i. e., most results indicate increasing health inequalities). It is also important to stress that there is great ­heterogeneity concerning the methodical approaches. Some studies analyse health inequalities by individual socio-economic status (e. g., educa­tional level), others by regional deprivation. Sometimes changes in the extent of health inequalities over time are not calculated explicitly. Some papers do not include absolute and relative measures of inequalities, but just one of them.

Conclusions:

In Germany, there is a need for more empirical studies looking at time trends of health inequalities; the available datasets should be used more often for this type of analysis. If possible, further studies should include individual SES and regional deprivation, measures of absolute and relative inequality (stratified by sex, with significance tests for time trend), and they should cover as many points in time as possible. Also, it would be important to relate the chang­es in health inequalities to the other changes in the society.

Schlüsselwörter

gesundheitliche Ungleichheit - zeitliche Trends - Review

Key words

health inequalities - time trends - review

• Literatur

• 1 Commission on Social Determinants of Health . Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008
• 2 Mackenbach JP. Health Inequalities: Europe in Profile. An independent expert report commissioned by the UK presidency of the EU. London: COI for the Department of Health; 2006
• 3 Troschke Jv. Gesundheitsförderung und Prävention als zentrale Handlungsfelder einer New Public Health. In: Walter U, Paris W. Hrsg Public Health – Gesundheit im Mittelpunkt. Alfred&Söhne; Verleger: 1996: 159-167
• 4 Steinkamp G. Soziale Ungleichheit, Erkrankungsrisiko und Lebenserwartung. Kritik und Perspektiven sozialwissenschaftlicher Ungleichheitsforschung. Sozial- und Präventivmedizin 1993; 38: 111-122
• 5 Directorate-General for Health and Consumers . White Paper: Together for Health: a Strategic Approach for the EU 2008–2013. Brüssel: Commission of the European Communities; 2007
• 6 Kroll LE. Sozialer Wandel, soziale Ungleichheit und Gesundheit. Die Entwicklung sozialer und gesundheitlicher Ungleichheiten in Deutschland zwischen 1984 und 2006. Wiesbaden: VS Verlag für Sozialwissenschaften; 2010
• 7 Moor I, Pförtner TK, Lampert T et al. Sozioökonomische Ungleichheiten in der subjektiven Gesundheit bei 11- bis 15-Jährigen in Deutschland. Eine Trendanalyse von 2002–2010. Gesundheitswesen 2012; 74 (Suppl. 01) S49-S55
• 8 Kroll LE, Lampert T. Changing health inequalities in Germany from 1994 to 2008 between employed and unemployed adults. Int J Public Health 2011; 56: 329-339
• 9 Kroll LE, Lampert T. Zunehmende Unterschiede im subjektiven Gesundheitszustand zwischen den Einkommensschichten. Analysen zu einem Aspekt der gesundheitlichen Ungleichheit. Informationsdienst Soziale Indikatoren 2010; 43: 5-8
• 10 Lampert T, Kroll LE. Zeitliche Entwicklung der gesundheitlichen Ungleichheit in Deutschland und anderen europäischen Ländern. Forum Public Health 2008; 16: 1-3
• 11 Nolte E, McKee M. Changing health inequalities in east and west Germany since unification. Soc Sci Med 2004; 58: 119-136
• 12 Heinemann L, Helmert U, Classen E et al. Social gradient of CVD risk in Germany before/after unification. Rev Environ Health 1996; 11: 7-14
• 13 Heidemann C, Kroll L, Icks A et al. Prevalence of known diabetes in German adults aged 25–69 years: results from national health surveys over 15 years. Diabet Med 2009; 26: 655-658
• 14 Icks A, Moebus S, Feuersenger A et al. Diabetes prevalence and association with social status – widening of a social gradient? German national health surveys 1990–1992 and 1998. Diabetes Res Clin Pract 2007; 78: 293-297
• 15 Lampert T. Soziale Determinanten des Tabakkonsums bei Erwachsenen in Deutschland. Bundesgesundheitsbl 2010; 53: 108-116
• 16 Richter M, Leppin A. Trends in socio-economic differences in tobacco smoking among German schoolchildren, 1994–2002. Eur J Public Health 2007; 17: 565-571
• 17 Schulze A, Mons U. The evolution of educational inequalities in smoking: a changing relationship and a cross-over effect among German birth cohorts of 1921–70. Addiction 2006; 101: 1051-1056
• 18 Helmert U, Buitkamp M. Die Veränderung des Rauchverhaltens in Deutschland von 1985 bis 2002. Gesundheitswesen 2004; 66: 102-106
• 19 Rohrmann S, Becker N, Kroke A et al. Trends in cigarette smoking in the German centers of the European Prospective Investigation into Cancer and Nutrition (EPIC): the influence of the educational level. Prev Med 2003; 36: 448-454
• 20 Maziak W, Hense HW, Döring A et al. Ten-year trends in smoking behavior among adults in southern Germany. Int J Tuberc Lung Dis 2002; 6: 824-830
• 21 Härtel U, Stieber J, Keil U. Der Einfluss von Ausbildung und beruflicher Position auf Veränderungen im Zigarettenrauchen und Alkoholkonsum: Ergebnisse einer prospektiven Kohortenstudie. Soz Praventivmed 1993; 38: 133-141
• 22 Schulz R, Güther B, Mutert S et al. Adipositas bei bayerischen Jugendlichen: Prävalenz im Trend, soziodemographische Strukturmerkmale und subjektive Gesundheit. Gesundheitswesen 2010; 72: 88-98
• 23 Icks A, Moebus S, Feuersenger A et al. Widening of a social gradient in obesity risk? German national health surveys 1990 and 1998. Eur J Epidemiol 2007; 22: 685-690
• 24 Helmert U, Strube H. Die Entwicklung der Adipositas in Deutschland im Zeitraum von 1985 bis 2002. Gesundheitswesen 2004; 66: 409-415
• 25 Helmert U, Shea S, Maschewsky-Schneider U. Social class and cardiovascular disease risk factor change in West Germany 1984–1991. Eur J Public Health 1995; 5: 103-108
• 26 Helmert U, Mielck A, Classen E. Social inequities in cardiovascular disease risk factors in East and West Germany. Soc Sci Med 1992; 35: 1283-1292
• 27 Kibele EU, Jasilionis D, Shkolnikov VM. Widening socioeconomic differences in mortality among men aged 65 years and older in Germany. J Epidemiol Community Health 2013; 67: 453-457
• 28 Helmert U. Subjektive Einschätzung der Gesundheit und Mortalitätsentwicklung. Gesundheitswesen 2003; 65: 47-54
• 29 Delpierre C, Lauwers-Cances V, Datta GD et al. Using self-rated health for analysing social inequalities in health: a risk for underestimating the gap between socioeconomic groups?. J Epidemiol Community Health 2009; 63: 426-432
• 30 Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration 2011. Available from www.cochrane-handbook.org
• 31 Shkolnikov VM, Andreev EM, Jdanov DA et al. Increasing absolute mortality disparities by education in Finland, Norway and Sweden, 1971–2000. J Epidemiol Community Health 2012; 66: 372-378
• 32 Leinsalu M, Stirbu I, Vågerö D et al. Educational inequalities in mortality in four Eastern European countries: divergence in trends during the post-communist transition from 1990 to 2000. Int J Epidemiol 2009; 38: 512-525
• 33 Klotz J. Convergence or divergence of educational disparities in mortality and morbidity? The evolution of life expectancy and health expectancy by educational attainment in Austria in 1981–2006. Vienna Yearb Popul Res 2010; 8: 139-174
• 34 Windenberger F, Rican S, Jougla E et al. Spatiotemporal association between deprivation and mortality: trends in France during the nineties. Eur J Public Health 2012; 22: 347-353
• 35 Luy M. Differences in life expectancy by education and occupation in Italy, 1980–94: Indirect estimates from maternal and paternal orphanhood. Population Studies 2011; 65: 137-155
• 36 Deboosere P, Gadeyne S, Van Oyen H. The 1991–2004 Evolution in Life Expectancy by Educational Level in Belgium Based on Linked Census and Population Register Data. Eur J Popul 2009; 25: 175-196
• 37 Brønnum-Hansen H, Baadsgaard M. Widening social inequality in life expectancy in Denmark. A register-based study on social composition and mortality trends for the Danish population. BMC Public Health 2012; 12: 994
• 38 Asaria P, Fortunato L, Fecht D et al. Trends and inequalities in cardiovascular disease mortality across 7932 English electoral wards, 1982–2006: Bayesian spatial analysis. Int J Epidemiol 2012; 41: 1737-1749
• 39 Tarkiainen L, Martikainen P, Laaksonen M et al. Trends in life expectancy by income from 1988 to 2007: decomposition by age and cause of death. J Epidemiol Community Health 2012; 66: 573-578
• 40 Steingrímsdóttir OA, Næss Ø, Moe JO et al. Trends in life expectancy by education in Norway 1961–2009. Eur J Epidemiol 2012; 27: 163-171
• 41 Audureau E, Rican S, Coste J. Worsening trends and increasing disparities in health-related quality of life: evidence from two French population-based cross-sectional surveys, 1995–2003. Qual Life Res 2013; 22: 13-26
• 42 Daponte-Codina A, Bolívar-Muñoz J, Toro-Cárdenas S et al. Area deprivation and trends in inequalities in self-rated health in Spain, 1987–2001. Scand J Public Health 2008; 36: 504-515
• 43 Levin KA, Currie C, Muldoon J. Mental well-being and subjective health of 11- to 15-year-old boys and girls in Scotland, 1994–2006. Eur J Public Health 2009; 19: 605-610
• 44 Sulander T, Rahkonen O, Nummela O et al. Ten year trends in health inequalities among older people, 1993–2003. Age Ageing 2009; 38: 613-617
• 45 Helasoja V, Lahelma E, Prättälä R et al. Trends in the magnitude of educational inequalities in health in Estonia, Latvia, Lithuania and Finland during 1994–2004. Public Health 2006; 120: 841-853
• 46 Regidor E, Martínez D, Astasio P et al. Trends of socioeconomic inequalities and socioeconomic inequalities in self-perceived health in Spain. Gac Sanit 2006; 20: 178-182
• 47 Kunst AE, Bos V, Lahelma E et al. Trends in socioeconomic inequalities in self-assessed health in 10 European countries. Int J Epidemiol 2005; 34: 295-305
• 48 Gravelle H, Sutton M. Income related inequalities in self assessed health in Britain: 1979–1995. J Epidemiol Community Health 2003; 57: 125-129
• 49 Dalstra JA, Kunst AE, Geurts JJ et al. Trends in socioeconomic health inequalities in the Netherlands, 1981–1999. J Epidemiol Community Health 2002; 56: 927-934
• 50 Krokstad S, Kunst AE, Westin S. Trends in health inequalities by educational level in a Norwegian total population study. J Epidemiol Community Health 2002; 56: 375-380
• 51 Marques-Vidal P, Cerveira J, Paccaud F et al. Smoking trends in Switzerland, 1992–2007: a time for optimism?. J Epidemiol Community Health 2011; 65: 281-286
• 52 Peretti-Watel P, Constance J, Seror V et al. Cigarettes and social differentiation in France: is tobacco use increasingly concentrated among the poor?. Addiction 2009; 104: 1718-1728
• 53 Federico B, Costa G, Ricciardi W et al. Educational inequalities in smoking cessation trends in Italy, 1982–2002. Tob Control 2009; 18: 393-398
• 54 Charafeddine R, Demarest S, Van der Heyden J et al. Using multiple measures of inequalities to study the time trends in social inequalities in smoking. Eur J Public Health 2013; 23: 546-551
• 55 Daponte-Codina A, Bolívar-Muñoz J, Ocaña-Riola R et al. Patterns of smoking according to individual social position, and to socio-economic environment in municipal areas, Spain 1987–2001. Health Place 2009; 15: 679-686
• 56 Nagelhout GE, de Korte-de Boer D, Kunst AE et al. Trends in socioeconomic inequalities in smoking prevalence, consumption, initiation, and cessation between 2001 and 2008 in the Netherlands. Findings from a national population survey. BMC Public Health 2012; 12: 303
• 57 Rasmussen M, Due P, Damsgaard MT et al. Social inequality in adolescent daily smoking: has it changed over time?. Scand J Public Health 2009; 37: 287-294
• 58 Hotchkiss JW, Davies C, Gray L et al. Trends in adult cardiovascular disease risk factors and their socio-economic patterning in the Scottish population 1995–2008: cross-sectional surveys. BMJ Open 2011; 1: e000176
• 59 Doku D, Koivusilta L, Rainio S et al. Socioeconomic differences in smoking among Finnish adolescents from 1977 to 2007. J Adolesc Health 2010; 47: 479-487
• 60 Ernstsen L, Strand BH, Nilsen SM et al. Trends in absolute and relative educational inequalities in four modifiable ischaemic heart disease risk factors: repeated cross-sectional surveys from the Nord-Trøndelag Health Study (HUNT) 1984–2008. BMC Public Health 2012; 12: 266
• 61 Devaux M, Sassi F. Social inequalities in obesity and overweight in 11 OECD countries. Eur J Public Health 2013; 23: 464-469
• 62 Großschädl F, Stronegger WJ. Long-term trends in obesity among Austrian adults and its relation with the social gradient: 1973–2007. Eur J Public Health 2013; 23: 306-312
• 63 Faeh D, Braun J, Bopp M. Prevalence of obesity in Switzerland 1992–2007: the impact of education, income and occupational class. Obes Rev 2011; 12: 151-166
• 64 Singh-Manoux A, Gourmelen J, Lajnef M et al. Prevalence of educational inequalities in obesity between 1970 and 2003 in France. Obes Rev 2009; 10: 511-518
• 65 Tchicaya A, Lorentz N. Socioeconomic inequality and obesity prevalence trends in luxembourg, 1995–2007. BMC Res Notes 2012; 5: 467
• 66 Charafeddine R, Van Oyen H, Demarest S. Trends in social inequalities in obesity: Belgium, 1997–2004. Prev Med 2009; 48: 54-58
• 67 Marques-Vidal P, Paccaud F, Ravasco P. Ten-year trends in overweight and obesity in the adult Portuguese population, 1995–2005. BMC Public Health 2011; 11: 772
• 68 Scholes S, Bajekal M, Love H et al. Persistent socioeconomic inequalities in cardiovascular risk factors in England over 1994–2008: a time-trend analysis of repeated cross-sectional data. BMC Public Health 2012; 12: 129
• 69 Lahti-Koski M, Seppänen-Nuijten E, Männistö S et al. Twenty-year changes in the prevalence of obesity among Finnish adults. Obes Rev 2010; 11: 171-176
• 70 Neovius K, Johansson K, Kark M et al. Trends in self-reported BMI and prevalence of obesity 2002–2010 in Stockholm County, Sweden. Eur J Public Health 2013; 23: 312-315
• 71 Maier W, Fairburn J, Mielck A. Regionale Deprivation und Mortalität in Bayern. Entwicklung eines, Index Multipler Deprivation‘ auf Gemeindeebene. Gesundheitswesen 2012; 74: 416-425
• 72 Povall SL, Haigh FA, Abrahams D et al. Health equity impact assessment. Health Promot Int 2013; epub ahead of print; DOI: 10.1093/heapro/dat01271.