Definition of health inequalities

Health inequalities are defined as 'differences in health status or in the distribution of health determinants between different population groups' ( WHO Social determinants of health key concepts   ; WHO 2014a). When avoidable, health inequalities are generally referred to as health inequities ( WHO Social determinants of health key concepts  ). In this Brief, the term 'health inequalities' will be used in its broader sense, which includes (but is not limited to) health inequities.

Health tends to be inversely associated with socioeconomic status, phenomenon known as "social gradient in health", and this exacerbates inequalities ( WHO Social determinants of health key concepts  ). Gender inequities can also have a deteriorating effect on health inequalities, e.g. through violence against women, discriminatory feeding patterns, less employment opportunities for women, etc (WHO 2008). 

Social determinants of health in European countries

The social gradient of health within countries, as well as the health inequalities between countries, largely depend on the unequal distribution of power, income, goods and services both at a global and a national level (WHO 2008). Consequently, the conditions in which people are born, grow and flourish, such as their access to education and to healthcare, their employment status, their homes, communities, and environment are generally defined as "social determinants of health" (WHO 2014a, WHO 2008, WHO Social determinants of health). 

Table 1 includes population data provided by Eurostat and European Core Health Indicators (ECHI) for most EU countries for a set of relevant indicators. The available data can be summarised as follows:

• Among over 447 million people in the EU in 2021, around 31 million were unemployed (almost one third of which were long-term unemployed), and at least 111 million people had a low education level (ISCED 0,1 or 2, year 2021).
• Around 75 million people lived in poverty or at risk of poverty (mainly women, children, young people, people living in single-parent households, lower educated people and migrants (Eurostat, 2015).
• There were more than 37 million resident non-EU citizens (which does not include illegal migrants nor migrants with an already acquired EU citizenship, year 2021).

Table 1: Population size and social determinants of health in the EU 

Social determinants of health are also closely connected with other health determinants, such as access and use of healthcare services. For example, preventive measures such as breast and cervical cancer screening have been shown effective in reducing cancer mortality (EC 2017). However, there are socioeconomic inequalities in participation in screening that exacerbate health inequalities (EC European Cancer Inequalities Registry -ECIR-; Available statistics on breast cancer screening by income and by education, and of cervical cancer screening by income and by education). 

Health inequalities in European countries

Common indicators of health status are Life expectancy at birth, Healthy life expectancy , Infant mortality rate and cause-specific mortality rates (ECHI). Table 2 and the maps below show the measure of these indicators in EU member states. They illustrate several differences between countries such as:

• Life expectancy at birth - ( OECD 2016 )  In 2023, life expectancy at birth differed by almost 10 years between countries in the EU (ECHI Data tool, Eurostat 2023). Similar inequalities (gaps of 10 years and more, e.g. 69 vs 80.6) can be seen within some countries between people with different education levels (ECHI Data tool).
• Healthy life expectancy - in 2021, healthy life expectancy at birth in both men and women, ranged from approximately 52 to 69 years, meaning that depending on their country of birth EU citizens could expect to have 17 more (or less) years of healthy life (ECHI Data tool, Eurostat 2023). Moreover, the mismatch between life expectancy at birth and healthy life expectancy varied across the EU, from the lowest difference of 11 years to the highest one of 27 years.
• Infant mortality rate per 1 000 ranged from 1.2 to 5.7 in 2022, indicating a threefold variation across EU countries (Eurostat 2023).
• In 2019, mortality rates for ischemic heart disease, the leading cause of death in the EU, ranged from below 80/100 000 deaths in some Northern and Southern European countries to over 300/100 000 deaths in some Eastern European countries ( OECD 2022 ).

Table 2: Life expectancy at birth, infant mortality and standardised mortality rates

Life expectancy at birth in EU Member States in 2023 (both sexes) map 

Life expectancy at birth in EU Member States in 2023 (both sexes) chart 

Healthy life expectancy at birth in men in EU Member States in 2021 map 

Healthy life expectancy at birth in women in EU Member States in 2021 map 

Healthy life expectancy at birth by sex in EU Member States in 2021 chart 

Dietary and physical activity-related determinants as drivers of health inequalities

Differences in various health determinants, such as in smoking, alcohol consumption, diet and physical activity, underlie health inequalities in EU member states.

Table 3 presents an example of data on fruit and vegetable intake and physical activity levels, stratified by educational level. Self-reported daily consumption of fruit and vegetables is higher in groups with higher education levels in northern and central European countries, but not necessarily in southern ones (Eurostat 2019). In most countries, the self-reported absence of health-enhancing aerobic physical activity was highest in people with a low level of education (Eurostat 2019).

Table 3: Proportion of people reporting daily consumption of vegetables and fruit and reporting no time in health enhancing aerobic physical activity stratified by ISCED education level

Table 4 summarises the evidence reported so far on nutrition and PA-related health determinants and their relation to health inequalities.

Table 4: Nutrition- and Physical activity-related health behaviours and inequalities 

An analysis by UNICEF ( UNICEF 2016 (pdf) ) explored how inequality trends changed over time in the period 2002-2014 in children and adolescents of various countries, including EU countries. It reports that inequality in unhealthy eating (based on self-reported consumption data of 'sweets' (candy or chocolate) and 'coke or other soft drinks that contain sugar' was reduced in most EU countries (with the exception of Hungary, Poland, Estonia and Lithuania with no change, and Romania, Slovakia and Belgium, with increased inequalities). This reduction appears to be driven by improvements on the eating behaviours of the lower SES population groups. Similarly, inequality in physical activity decreased in the majority of countries, where the lower SES improved more than other groups (with the exception of Poland and Romania with no change, and Italy with increased inequalities).

Among various minority groups living in the EU, it appears that dietary and PA habits have been recorded systematically only for Roma (EC 2014 ). The data indicate that Roma minorities tend to have a diet characterized by fewer vegetables and more fats and to do less physical activity, compared to the general population.

Inequalities in obesity and in other conditions associated with dietary and physical activity-related determinants

Obesity is the most described health outcome associated with health inequalities related to diets and physical activity. The prevalence of self-reported adult obesity in the EU varies from 10% in Romania to 26% in Malta ( OECD 2020 ). In the EU, self-reported overweight (including obesity) among 15-year-olds is about 23% in boys and 15% in girls. Moreover, overweight and obesity rates vary if the adolescents belong to more or less affluent households, being the average rate 17% or 26%, respectively ( OECD 2020 ).  

Many socio-economic variables are associated with obesity and these are summarised in Table 5.

Table 5: Proposed relations between overweight/obesity, and socioeconomic status, educational level and ethnicity. 

Obesity and the condition of being overweight are distributed unevenly between women and men. In particular, in EU Member States men are more likely to suffer from overweight (67% of men versus 52% of women) and obesity (22% of men versus 24% of women) than women (WHO 2022).  In most countries, obesity rates have grown more rapidly in low SES groups than in high SES groups (OECD 2019; WHO 2022), thus widening health inequalities. The link between obesity and socio-economic disadvantage appears to be perpetuated in a vicious cycle (ENHR 2009), and, over the life course, different inequality dimensions can contribute to worsen the nutritional and PA status, thus maintaining the cycle. For instance, obesity in women, especially during pregnancy and breastfeeding, contributes to the health risks of their children, amplifying health inequities across generations. Impacts can be long-lasting; for example the association between the BMIs of parents and their children has been shown to persist from birth up to 45 years of age. And again, it was found that the impact of living in a low- or very low-income neighbourhood on excessive childhood body weight was even greater than the family’s socioeconomic status (WHO 2022). Furthermore, there is evidence that childhood obesity is significantly associated with poor academic performance (OECD 2019) with the consequent risk of exacerbating pre-existing unequal conditions.

A SES gradient on health was also seen in conditions other than obesity (EU 2012 (pdf)). National data from across Europe show an inverse association between the level of education and the proportion of population reporting any long-standing chronic illness or long-standing health problem (i.e. the higher the education level, the fewer the reported long-standing health concerns). In fact, obesity itself often clusters with metabolic risk factors, such as high blood pressure, high fasting glucose and dyslipidaemia in the so-called metabolic syndrome, and acts as a risk factor for the development of other non-communicable diseases (NCDs). 

Data on reported BMI and reported recent diagnosis of diabetes and high blood pressure, stratified by education level, are presented in Table 6. BMI and education level data is also presented in the map below.

Table 6: Proportion of people reporting BMI above 30, new diagnosis of diabetes or high blood pressure stratified by ISCED educational level

Proportion of people reporting BMI above 30 stratified by ISCED education level in EU Member States in 2019 chart 

Proportion of people reporting BMI above 30 stratified by ISCED education level, class 0-2, in EU Member States in 2019 map 

Proportion of people reporting BMI above 30 stratified by ISCED education level, class 3-4, in EU Member States in 2019 map 

Proportion of people reporting BMI above 30 stratified by ISCED education level, class 5-8, in EU Member States in 2019 map 

Policy recommendations to reduce dietary and physical activity-related inequalities

The European Commission considers health inequalities as a challenge to the EU's commitment to solidarity, social and economic cohesion, human rights and equal opportunities (EU 2010, EU 2023). Reducing health inequalities is still one of the greatest public health challenges in Europe ( EPRS 2020  ). 

Many are the policies that can be put in place to reduce both  absolute and relative inequalities. Whereas policies that aim to improve income distribution and raise income of the poorest groups (e.g. social protection, minimum wage, equal pay legislation, and redistributive taxation) are of great relevance to decreasing the inequality gap, the discussion that follows is focused on diet and physical activity-related policies that health inequalities. In the current European context, where baseline levels of obesity are greater in low SES compared to high SES groups, member states may wish to directly those more vulnerable. 

Table 7 summarises policy recommendations to address inequalities related to diet and physical activity.

Table 7: Examples of policy recommendations addressing inequalities in diet and physical activity 

Implemented policies to address health inequalities and in particular inequalities in diet and physical activity

Many of the implemented policies reviewed in other chapters that diets, nutrients or specific food and drink products have the potential to reduce health inequalities related to these. As highlighted in the recommendations above (Table 7), certain policies can, for example, be delivered specifically to more vulnerable groups to reduce the inequality gap. Some examples of policies implemented or designed by the European Commission that potentially might contribute reducing inequalities are presented below (Table 8). 

Implemented policies to alleviate inequalities

At the EU level, the European Commission, but also Council and Parliament have implemented policies and initiatives with the aim of alleviating health inequalities. These include Council conclusions, European Commission communications, the EU health programme and joint actions ( EPRS 2020 ). EU institutions also granted financial support through EU funds, notably the Fund for European Aid to the Most Deprived (FEAD) and the European Social Fund (ESF). Moreover, the EU promoted research focused on finding mechanisms to reduce health inequalities thanks to the Horizon 2020 programme for research and innovation ( EPRS 2020 ).

Table 8 describes implemented policies that aim at reducing health inequalities through diet and physical activity. 

Table 8: Implemented policies related to inequalities in nutrition and physical activity     

References

Overview of the references