Studies on socioeconomic health disparities often suffer from a lack of uniform data and methodology. Using high quality, census-linked data and sensible inequality measures, this study documents the changes in absolute and relative mortality differences by education in Finland, Norway and Sweden over the period 1971 to 2000. The age-standardised mortality rates and the population exposures for three educational categories were computed from detailed data provided by the national statistical offices. Mortality disparities by education were assessed using two range measures (rate differences and rate ratios), and two Gini-like measures (the average inter-group difference (AID) and the Gini coefficient (G)). The formulae for the decomposition of the change in the AID into (1) the contribution of change in population composition by education, and (2) the contribution of mortality change were introduced. Mortality decreases were often greater for high than for medium and low education. Both relative and absolute mortality disparities tend to increase over time. The magnitude and timing of the increases in absolute disparities vary by country. The contributions of the changes in population composition to the total AID increase were substantial in all countries, and for both sexes. The mortality contributions were substantial for males in Norway and Sweden. The study reports increases in absolute mortality disparity, and its components.
Background In 2008, £30 million was invested by UK Government in the Healthy Towns (HT) Programme in England. Nine urban areas were selected to develop and implement interventions to tackle the obesogenic environment. These involved multi-sector approaches to promoting physical activity and improve diet through the use of environmental interventions. In this paper, we explore how stakeholders conceptualised and defined programme outcomes in relation to national and local priorities, and across multiple policy sectors.
Methods We undertook semi-structured, face-to-face interviews with 65 HT staff (programme leads, intervention managers and staff) in 2010–2011. Interviews lasted 50 to 110 minutes and were digitally recorded, anonymised and transcribed verbatim. Participants were asked about: the main outcomes and benefits of the HT programme, and links and synergies with other policy areas. Thematic analysis was undertaken; three authors developed and discussed the coding framework, coding outputs and agreed the resultant main themes.
Results Programme staff conceptualised outcomes as extending beyond obesity-related behaviours and identified multiple, complementary policy areas that they were attempting to address through the initiative. Four broad categories of outcomes were articulated:  direct obesity-related outcomes (healthy diet, physical activity);  indirect obesity-related outcomes (obesity awareness, infrastructure provision);  wider health-related outcomes (air quality, social capital);  non-health outcomes (environmental sustainability, monetary savings). Stakeholders emphasised the interrelatedness of these four categories of outcomes. For example, tackling obesity, improving transport planning and air quality could all be addressed using active travel interventions; tackling obesity, enhancing social capital and promoting environmental sustainability could be addressed using ‘growing food’ interventions. Furthermore, obesity and non-obesity agendas were seen as complementary in terms of delivery of their respective outcomes.
Discussion The range and number of outcomes identified may have been both a consequence of the multi-sector, holistic approach taken by HT programme and the ‘on the ground’ reality of implementing complex interventions, whose components touch a wide variety of policy sectors. When planning programmes and their evaluation, consideration of the impact on outcomes that extend beyond the focus of a particular programme could also be beneficial. In the HT programme, policy makers and practitioners believed that delivered interventions could address a range of complementary policy areas, which were all equally important. Taking such a ‘joined-up’ perspective could help increase the efficiency and acceptability of social, environmental, and health policies and interventions.
Background. Prior studies on spatial inequalities in mortality in Russia were restricted to the highest level of administrative division, ignoring variations within the regions. Using mortality data for 2239 districts, this study is the first analysis to capture the scale of the mortality divide at a more detailed level.
Methods. Age- standardised death rates are calculated using aggregated deaths for 2008–2012 and population exposures from the 2010 census. Inequality indices and decomposition are applied to quantify both the total mortality disparities across the districts and the contributions of the variations between and within regions.
Results. Regional variations in mortality mask one- third (males) and one- half (females) of the inequalities observed at the district level. A comparison of the 5% of individuals residing in the districts with the highest and the lowest mortality shows a gap of 15.5 years for males and 10.3 years for females. The lowest life expectancy levels are in the shrinking areas of the Far East and Northwest of Russia. The highest life expectancy clusters are in the intercity districts of Moscow and Saint Petersburg, and in several science cities. Life expectancy in these best- practice districts is close to the national averages of Poland and Estonia, but is still substantially below the averages in Western countries.
Conclusion. The large between- regional and within- regional disparities suggest that national- level mortality could be lowered if these disparities are reduced by improving health in the laggard areas. This can be achieved by introducing policies that promote health convergence both within and between the Russian regions.
Background. The Russian Federation has very high cardiovascular disease (CVD) mortality rates compared with countries of similar economic development. This cross-sectional study compares the characteristics of CVD-free participants with and without recent primary care contact to ascertain their CVD risk and health status.
Methods. A total of 2774 participants aged 40–69 years with no self-reported CVD history were selected from a population-based study conducted in Arkhangelsk and Novosibirsk, Russian Federation, 2015–2018. A range of co-variates related to socio-demographics, health and health behaviours were included. Recent primary care contact was defined as seeing primary care doctor in the past year or having attended a general health check under the 2013 Dispansarisation programme.
Results. The proportion with no recent primary care contact was 32.3% (95% CI 29.7% to 35.0%) in males, 16.3% (95% CI 14.6% to 18.2%) in females, and 23.1% (95% CI 21.6% to 24.7%) overall. In gender-specific age-adjusted analyses, no recent contact was also associated with low education, smoking, very good to excellent self-rated health, no chest pain, CVD 10-year SCORE risk 5+%, absence of hypertension control, absence of hypertension awareness and absence of care-intensive conditions. Among those with no contact: 37% current smokers, 34% with 5+% 10-year CVD risk, 32% untreated hypertension, 20% non-anginal chest pain, 18% problem drinkers, 14% uncontrolled hypertension and 9% Grade 1–2 angina. The proportion without general health check attendance was 54.6%.
Conclusion. Primary care and community interventions would be required to proactively reach sections of 40–69 year olds currently not in contact with primary care services to reduce their CVD risk through diagnosis, treatment, lifestyle recommendations and active follow-up.
Background Although estimates of socioeconomic mortality disparities in Germany exist, the trends in these disparities since the 1990s are still unknown. This study examines mortality trends across socioeconomic groups since the late 1990s among retired German men aged 65 and above.
Methods Large administrative data sets were used to estimate mortality among retired German men, grouped according to their working-life biographies. The data covered the years 1997–2016 and included more than 84.1 million person-years and 4.3 million deaths. Individual pension entitlements served as a measure of lifetime income. Changes in total life expectancy at age 65 over time were decomposed into effects of group-specific mortality improvements and effects of compositional change.
Results Over the two decades studied, male mortality declined in all income groups in both German regions. As mortality improved more rapidly among higher status groups, the social gradient in mortality widened. Since 1997, the distribution of pension entitlements of retired East German men has shifted substantially downwards. As a result, the impact of the most disadvantaged group on total mortality has increased and has partly attenuated the overall improvement.
Conclusion Our results demonstrate that socioeconomic deprivation has substantial effects on levels of mortality in postreunification Germany. While East German retirees initially profited from the transition to the West German pension system, subsequent cohorts had to face challenges associated with the transition to the market economy. The results suggest that postreunification unemployment and status decline had delayed effects on old-age mortality in East Germany.
In 2008, the Healthy Community Challenge Fund commissioned nine 'healthy towns' in England to implement and evaluate community-based environmental interventions to prevent obesity. This paper examines the role of evidence in informing intervention development, innovation and the potential for programmes to contribute to the evidence base on the effectiveness of interventions that tackle population obesity.
Twenty qualitative interviews with local programme stakeholders and national policy actors were conducted. Interview transcripts were coded and thematically analysed. Initial analyses were guided by research questions regarding the nature and role of evidence in the development and implementation of the healthy towns programme and the capacity for evidence generation to inform future intervention design, policy and practice.
Stakeholders relied on local anecdotal and observational evidence to guide programme development. While the programme was considered an opportunity to trial new and innovative approaches, the requirement to predict likely health impacts and adopt evidence-based practice was viewed contradictory to this aim. Stakeholders believed there were missed opportunities to add to the existing empirical evidence base due to a lack of clarity and planning, particularly around timing, in local and national evaluations.
A strong emphasis on relying on existing evidence-based practice and producing positive impacts and outcomes may have impeded the opportunity to implement truly innovative programmes because of fear of failure. Building more time for development, implementation and evaluation into future initiatives would maximise the use and generation of robust and relevant evidence for public health policy and practice.