Reducing inequalities in life expectancy: what works?

Social inequalities in life expectancy are a major issue for governments – and they have increased over time. But they have done so at different rates in different countries, and there is a need for greater understanding of how and why this has happened. In this blog, Daniel Zazueta-Borboa describes a new study which uses the ONS-LS to look in detail at how policy and social change is linked to reductions or increases in these inequalities.

We know that in modern welfare states, people with higher socio-economic status live longer than those with lower status. And efforts to reduce these gaps have not always been successful.

It’s crucial for policymakers to understand the dynamics of these phenomena if they are to tackle the issues. Yet most studies of the subject either cover only short periods of time or they take longer periods but look only at their start and end dates. This means they are unable to pinpoint accurately the key points at which different phases or changes in trends have occurred. So they have not been able to verify whether social events or policy changes have had a sudden or a gradual effect: for example, how did ‘lifestyle epidemics’ such as increases in the number of deaths due to smoking relate to the life expectancy of different social groups? How did improvements in key medical interventions such as cardiovascular care play out across societies?

Using Census data from England and Wales, register data from Finland and survey data from Turin in Italy, we were able to look at mortality from 1971 onwards. Using a standard measure of educational attainment to indicate socioeconomic status, we compared the life expectancy of those with no more than lower secondary schooling with that of those who continued to study after school leaving age.

For England and Wales, we used data from people in the ONS Longitudinal Study who were aged 20 and older at the time of the 1971, 1981, 1991, 2001 and 2011 censuses. For Finland we were able to check on census respondents aged 25 and older every five years from 1970 to 2015. For Italy, we looked at respondents in Turin who were aged 20 or older in censuses from 1971 to 2011 and who were also included in the Turin Longitudinal Study from 1972–2019.

Trends in inequalities

By looking at trends in the gaps in life expectancy between the lowest and highest socio-economic groups over time, we could map changes in these inequalities and when they happened. We found that over 47 years the inequalities grew more among men in Italy and among both men and women in Finland, but grew less among British men and remained stable among British women. Among Italian women, they were roughly the same at the end of the period.

When we looked in more detail at what happened during different time periods, we could see different phases and breaks in these overall trends.

In England and Wales, there was a clear break in the mid-1970s as women began to gain better educational qualifications, though for men this was reversed in 2008. In Finland, there was a break in the 1980s as educational inequalities increased – again, reversed among Finnish men in 2008. In  Turin, there was a clear break in the mid-1970s indicating increased inequality among men, while among women this happened later, in 2003.

 

Figure 1: Time trends in educational differences in life expectancy at age 30 (high minus low educated – in years-), by sex and country. Dashed lines represent the start of increasing educational differences in life expectancy.  Solid lines represent the start of reducing educational inequalities.

Where there were long-term increases in educational inequalities, the more highly educated improved their life expectancy at better pace when compared with those who had lower levels of education. Conversely, where there were decreases in inequalities those with lower levels of education gained more years of life expectancy. This was particularly the case for young men in Finland and Italy.

Health and behaviour changes

What triggered the marked changes in the trends? A key factor is likely to be the revolution in cardiovascular care, which began in the early 1970s and involved both medical advances and changes in health behaviours such as smoking: we know those in more highly educated groups gained greater health benefits from these changes. Similarly, those with higher levels of education benefited more from decreases in mortality linked to alcohol.

For Italian women, reforms which made healthcare more universally accessible in the early 1980s are likely to have been important in improving life expectancy and reducing disparities in life expectancy. There were negative social factors too – in Italy there was a large increase in deaths from AIDS in the 1980s which was linked to drug use among younger men, particularly those in lower social groups, and that might be behind the increase of educational inequalities in life expectancy among Italian men.

So, reversals and breaks in these life expectancy gaps can be set in train by gradual social changes, and they can be set in train by more immediate policy decisions. For example in Finland, a reduction in alcohol tax and prices in 2004 was accompanied by a rise in alcohol-related deaths among deprived men, and this was reversed when the tax was increased from 2008. In England and Wales, austerity measures from 2010 have been linked to slower improvements in life expectancy, particularly due to higher mortality among younger age groups in areas of high social deprivation.

What can be done?

There are hopeful messages here for policymakers: inequalities in life expectancy can be shaped by public policy decisions. These may be short-term, such as changes in taxation, or they may be longer-term, such as initiatives to effect behavioural changes. Policies aimed at improving the health of younger people in lower-educated groups could be particularly effective.

Reversals in past long-term trends in educational inequalities in life expectancy for selected European countries, by Daniel Zazueta-Borboa, Pekka Martikainen, Jose Manuel Aburto, Guiseppe Costa, Riina Peltonen, Nicholas Zengarini, Alison  Sizer, Anton Kunst and Fanny Janssen, is published in the Journal of Epidemiology and Community Health, July 2023, 77(7):421-429, https://doi.org/10.1136/jech-2023-220385