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Health and social inequities in Sweden
0?77-9536;90 $3.00 + 0.00 Copyright c 1990 Pergamon Press plc
Sot. Si. .Med. Vol. 31, No. 3. pp. 359-367. 1990 Printed m Great Britain. All rights reserved
HEALTH
AND SOCIAL INEQUITIES
IN SWEDEN
FINN DIDER~CHSEN Department
of Social
Medicine, Karolinska Institute, Kronan Health Centre, S-172 82 Sundbyberg, Sweden
Abstract-Sweden is one of Europe’s most egalitarian countries. The social inequities in living conditions have been gradually reduced to a level that is more equal than in most countries in Europe. Even if general health development has been positive during recent years, data reviewed here indicate that there may be adverse effects for some groups which may increase inequities. This article presents results on inequities in health from the Public Health Report of Sweden 1987 and discusses causal mechanisms and implications for health policy. Key ~rords--+ccupation,
social position,
mortality,
health,
health
selection
INTRODUCTION
INFANT MORTALITY
The political question of social inequities has for many years held a unique position in Sweden because
One of the social inequities often discussed and on which we have long time series is the mortality of infants. Mortality has for many years been higher
it has been a major goal of the Social Democratic party which has dominated political life and government for more than half a century. Historically this question has become more important as political democracy has given underprivileged groups more influence and as industrial development has made it possible to distribute the surplus more equally. In postwar Sweden the equity-goal in politics has been institutionalized in the sense that more or less all social changes and political reforms are confronted and tested against this goal. Health policy is no exception. However, as biomedical science has grown stronger and professional dominance over healthpolicy initiatives has increased, the equity perspective has been discussed and analysed less frequently. Maybe the most revealing piece of evidence is that most Swedish medical registers of mortality and morbidity, well known for their high coverage and for the validity of their medical information, all lack any information on the patient’s social position, i.e. occupation, tenancy, education, etc. However, the fact that it is possible to write this report is due partly to record linkages between the national census conducted each fifth year including a number of social variables and the medical registers and partly to the national household surveys carried out by the National Bureau of Statistics. Some of this material has been published earlier in reports to the government [I], in WHO reports [24] and in other forms [S]. The emphasis in this report will therefore be put on the recent findings and trends recently presented to the Swedish parliament [13]. The social indicators that will be used are the following: -occupational class, -region/urbanization. The health indicators are the following: -mortality, -self-reported illness, -in-patient care. 359
among infants born to unmarried mothers than among those born to married mothers, but the differential has varied from time to time. During the first and third quarters of this century, inequities in infant mortality decreased, although they increased between 1925 and 1950. When legal regulations relating to hygiene were introduced at the end of the nineteenth and the beginning of the twentieth century, they probably had more effect on children living under vulnerable conditions, whereas the more affluent groups had already acquired the resources to achieve hygiene, clean water, etc. In this period there was public recognition of state responsibility for health regulations from which all strata in the population benefited, but the underprivileged benefited more than those who had resources to achieve health protection by private means. In 1933 the infant mortality rate between different income groups of Stockholm varied from 14 to 49. Analysis of the data by the national authorities brought the conclusion that “there is no reason to accept an infant mortality for any social class of society that is higher than the average among the wealthiest quartile of the nation. What one social group can buy for money society must provide for others.” In following years the Swedish parliament decided on a broad range of legislation to improve the low birth rate and the health conditions of mothers and children. This legislation included a number of economic allowances for families with children-for housing, a certain allowance for each child, maintenance support to divorced mothers, etc. Unmarried mothers were given priority for housing, nursing care and employment opportunities. Similar reforms were introduced after the war in Norway and Denmark. This improved the economic conditions of families in general and single parent families in particular. Swedish legislation in 1937 also introduced a comprehensive free mother and child health care
FINN DIDERICHSEN
360 Table I. Infant
mortality
rate
197681.
Infant
mortality
Perinatal
and
rate
mortality
other
National
rate
measures
of
register
(per
birth
birth
weight
(< 2500 g)
Serious
malformations
Source:
Ref.
IN CHILDREN
2. Infant
mortality
mothers
and
cohabiting.
C
7.4
7.6
7.2
1976;77
7.9
10.4
10.7
10.2
other
birth
7.1
7.5
10.9
7.6
1976/81
35
45
60
45
1976181
24
24
24
24
[6].
AND YOUNG
Sweden
Total
B
5.9
outcomes
1976-81
(per
recent studies which describe or measure health conditions in relation to parents’ occupations. Some differences in mortality related to parents’ occupational status persist. Boys in families employed in agriculture and services (cleaning, restaurants, etc.) seem to have a higher death rate. Sons of parents in service occupations in contrast to all other groups have an increasing mortality rate (Table 3). These differences have not yet been studied in relation to causes of death, citizenship, family structure, etc. It is possible that an increasing number of immigrants within service jobs, together with other selective forces may be responsible. This and following tables on mortality in different occupational groups are based on two registers where all certified deaths in Sweden in 1961-70 and 1971-80 have been linked to the 1960 and 1970 censuses respectively. This register was produced in 1981-83 by the National Bureau of Statistics in Stockholm but has only been analysed to a very limited extent. Deaths during the 1980s have not yet been linked. The occupational classification used here is based on the Nordic classification which roughly follows the International Classification of Occupations from 1958. The raw output published tables give mortalility in relation to occupation on a two-digit level. On the basis of these tables we have not been able to classify occupations according to the social classes regularly used in Sweden (i.e. in the household surveys, see Table 13), but we have grouped them into rather homogeneous groups of major occupational categories (technical, administrative, manufacturing industry, transportation, service, agriculture, etc.). Differences and tendencies might be different if social classes were used. That would, however, demand a regrouping of occupations on at least a three-digit level. Whilst that is fully possible it has not been available for this report. ADULT MORTALITY
PERSONS
Mortality among children is very low in Sweden compared with other countries. We have very few
Table
in Sweden
A
service. The programme included screening for somatic and psychological conditions, individual and group advice and health education, free drugs and vaccinations. The coverage of this programme for pregnant women and children under five expanded gradually and has been virtually 100% for the last 20 years. Mothers who do not attend are visited by a nurse who encourages them to come. In 1950 when 35% of the mothers and 10% of the children were still not covered by this programme, surveys showed that children not covered by the programme had very high rates of anaemia, rickets and respiratory disease. The excess mortality of infants of unmarried mothers decreased considerably during the first three quarters of this century from a level that was nearly double that of children born to married mothers. Recently published data analysed by Zetterberg et al. has, however, shown that Sweden still has a social differential in infant mortality rates. This study includes all births in Sweden 1976/77 and 1980/81 (n = 378,651) linked to the censuses of 197.5and 1980 respectively. Two marginal groups have been constructed. Group A (IO%) includes mothers with Swedish citizenship who are cohabiting, highly educated and living in owner-occupied houses or flats. Group C (7%) consists of mothers who are living as single persons, are tenants and have a low level of education. Group B are the rest (83%). Table I shows considerable differences between these three groups. Most pronounced is the differential in the rate of low birth weight. The incidence of malformations is an interesting exception. Single living seems to be the most important variable in the combination of variables distinguishing the three groups (Table 2). The differences persist in spite of an overall decreasing level of infant and perinatal mortality rates. In a longer perspective, however, the infants of single mothers had much higher relative risk. MORTALITY
outcome
1000)
1976~81 1980’81
Low
birth
in relation 1000)
to
RELATED TO OCCUPATION
There are many significant differences in mortality from all causes between different occupational groups Table
3. Mortality
1971-80
in
among
Sweden
in
persons
aged
relation
to
(per
100,000)
Single living Infant
mortality
Perinatal
mortality
rate rate
1976177
9.1
7.5
I980/8
7.4
6.3
I I.2
9.9
5-8
Industry,
9.5
7.3
4
Agriculture, Service
I
1976i77 198018 I
Low
birth
Source:
weight
Ref.
161.
Cohabiting
C&3 Techn.,
1976177
56
40
9
1980,81
61
40
Total Source:
Ref.
commerc.,
adminstr.,
manufact. (domestic,
171.
transport
forestry hotel,
rest.)
care
O-19
parents
years
1961-70
occupational
and status
1961-70
1971-80
M
F
M
F
51
33
48
29
66
35
59
32
72
37
71
34
72
45
93
44
68
37
60
32
Health Table
4. Age standardized
death rate ratios (SRR)
and social inequities
197G30
and 1966-70
in Sweden some
among
361
occupational
groups
(one- or two-digit
Female
Male Occupational
0 Tech”.. human. 05 Pedagogical
4564
25-w
group
I Administrative
25-U
Male 254
454
Female 45-64
2541
45-64 a7
86
91
90
77
97
79
-
78
67
80
61
95
68
-
89
103
88
102 II3
70
care
level) in Sweden
196670
1976-80
-
77 I09
-
2 Clerical
96
103
97
100
94
3 Commercial
89
IO1
103
96
IO1
121
100
96
4 Agriculture. forestry 5 Mining. stoneworks
106
82 129
-
86 -
98 I.26
81 II0
II9 -
6 Transportation 61 Seamen
I IO 266
I08 159
100
IO0 -
107 294
II2 I61
-
102 99 92 91
96 -
7 Manufacturing
106
104
107
I04
97
98
I08
97
8 -(mostly unqualif.) 88 Packing. dock work
131 I57
II7 I23
I35 -
II0 II3
I24 133
109 119
129 -
IO1
9 Service 93 Cleaning
II8 I62
II? II2
I08 -
106 I I4
II3
II7 I08
121 -
109
100
100
100
100
100
100
IO0
100
All
occupied
in Sweden. These differences are, however, smaller than in the other Nordic countries (Table 4) [2]. Among men in certain occupations exposed to high risks in their working environment and lifestyles (seamen) and some unqualified occupations such as cleaning, packing, etc. the death rates are close to twice the level in technical, scientific or humanistic and administrative occupations. When we compare rates in the two periods we find an increased mortality ratio in persons occupied in manufacturing (occupational group 7-8) in the recent period. The differences in SRR between the two periods could, however, be influenced by changes in age structure within each occupational group between the censuses of 1960 and 1970. We have therefore compared the major occupational groups (Table 5) and some smaller groups (Table 6) by computing direct age-standardized death rates using all those employed in 1970 as the standard population for all occupational groups in both periods. Between 1965 and 1979 Sweden had an experience unique in its recent national history-an increase in mortality among men aged 4&60 years. This increase was most pronounced among divorced persons and in the Stockholm area (where the number of divorced men was rising and is higher than elsewhere). But the figures in Table 5 seem also to indicate that the trends in mortality during this period were diverging across the different occupational groups. Those men working in manufacturing industry, or not employed in 1970, had a higher mortality in the following years compared to those in similar groups in 1960. At the same time mortality decreased in other occupational
Table
5. Trends
in mortality
1966-80 45-64.
in Sweden Age
among
standardized
some major (per
occupational
care.
adminstr..
commerc.
5. 7, 8
Manufacturing
6. 9
Transport.
4
Agricull..
Not All
employed years
45-64
service forest
groups
at ages
100,000) Female % Change
Technical.
106
groups. Among middle-aged women the trends are also diverging, although the overall trend is one of decreasing mortality. Selective forces probably play an important role here. The number of people (especially women) occupied in the first group (O-3) increased by nearly one-third during the 1960s mainly due to the expansion of public health and the social services. This labour force was recruited mainly from the group of not-employed women (housewives) and from new generations of well educated young people. Women entering these groups were probably positively selected in respect of health. Increasing mortality among the fast diminishing group of notemployed women supports this hypothesis. The young people entering the labour market may also have been positively selected too, since the educational system probably tends to be selective (no Swedish studies on this question have, however, been done). The total size of the labour force in manufacturing decreased less than 1% during the 1960s and the same is true for the total of transport and service workers. The number in agricultural and forestry decreased by more than-one-third. In these groups, during this period, however, substantial health-selective mobility occurred. The number of persons each year leaving the labour force with a medicallycertified early retirement pension doubled from 1960 to 1970. This was mainly a way of solving the problem of long term unemployment in occupations and industries experiencing fast structural change. The medical criteria for receiving an early retirement pension were gradually lowered. The number of not-employed men thus increased between 1960 and
Male
&3
IO1
% Change
197680
1966-70
I97680
995
l%6-70
clerical. - 15.4
455
II82
+3.7
505
II89
-6.3
500
-
403
-20.4
790
-
12.3
2791
i-6.5
668
1203
+ I.6
557
-15.6 -8.3 16.4 + 1.7 -
10.6
FINN DIDERICHSEN
362 Table
6.
Age
expressed
standardized
death
as an index of mortality
rates
among
among
men
all employed
age
men.
45-64
1966-70
as IO0 1966-70 00
Engineers.
30 Medical 05
techn.
staff
doctors.
Teachers.
dentists
professors
IO Administrative
staff
32 Salesmen 61 Seamcn 63
Bwtrain
drivers
73 Steelworks 75
Manufacturing
79 Construction 82
Food
metal-industry
74
94
76
85
82
134
94
I64
I58
107
106
loo
I08 106
97
103
I IO
103
83 Chemical,
cellulosa
X6 Unskilled
101
II5
work
108
121
& restaurant
I43
163
91
Hotel
All
employed
Not
82
loo
105
industry
industry
1976-80
96
industry
employed
100
97
235
250
MORTALITY
1970 by one-half, while the official unemployment rate remained low (1.5%). This process had a strong impact on agriculture and forestry and the pension rate was also rising among those employed in the ‘old’ manufacturing industries, i.e. mining, the steel industry and unskilled work in general. When those who are relatively disabled leave the labour force, the mortality rate of the remainder tends to go down. In spite of this it increased among those employed in manufacturing industry. This seems to indicate an increased environmental risk and/or lifestyle influence. In Table 6 this process is illustrated for some occupational groups and it confirms the tendency described above. When the medical criteria for early retirement pensions were relaxed we would expect an improving level of health among the growing number of notemployed men. Household surveys on reported health status seems to bear out this expectation. Nevertheless, mortality increased. Whether this is a result of selection (i.e. new groups of high risk individuals such as alcohol abusers getting early retirement) or is an effect of long term unemployment we do not know. Table 7 shows however that the Table
7. Mortality
254
in
196&70
among and
employed 197680. (oer
and Age
not-employed standardized
Not
All
All
employed:
men
causes
1976-80
641
620
Cardiovascular
280
285
Cancers
I56
I58
Injuries
106
All
aged rates
lOO.ooO~
1966-70 Employed:
men death
causes
increase in mortality among the not-employed is found in all three main causes of death. It is most pronounced in ‘injuries’ which in this age group of men consists mainly of alcohol-related deaths and suicides. The changes in mortality from all causes are, however. mainly due to changes in cardiovascular deaths (see Table 8). During the 1980s mortality in Sweden has been decreasing unusually fast. We cannot yet say how particular occupational groups have performed since no linkage has yet been carried out with the 1980s mortality-register and the recent census. These changes can only be shown at the regional level.
Table
9. Infant
I620 631
Cancers
199
229
Germany
Injuries
223
282
Great
680
691
Sweden
in cardiovascular
rate in Germany, 1840-1980
588
8. Changes
mortality
89
1543
Table
TO
mortality
Britain
1966-80
among
men
(per
589
514 590
o-3
Techn..
5. 7. 8
Manufacturing
538
6. 9
Transport.
619
593
4
Agncult..
423
408
NOI All
service forest
employed men 45-64
commerc.
197680
II20 years
566
I207 596
Britain
and Sweden
1840s
1880s
1920s
1970s
298 I53
228
II2
142
72
23 17
I54
II2
60
IO
aged
45-64.
Age
% Change I96670
Great IOOO)
standardized
adminstr.,
REGION
Historically, inequities in health have probably diminished greatly between and within European nations. It is often thought that trends of decreasing mortality and of inequities in health are a more or less automatic outcome of economic growth. This view has dominated Swedish health policies for many increased productivity greater years: through economic growth is achieved and, with a relatively equitable distribution of the surplus, social inequities in living conditions and health can be diminished. From the figures in Table 9 it seems that the differences in infant mortality rates between European countries have been reduced somewhat during the last century. The most interesting feature of Table 9, however, is that long before the adoption of modern postwar welfare policies, Sweden already had a comparatively low infant mortality rate. It would therefore be premature to draw conclusions about the beneficial effects of social policy on inequities in health. But, even in Sweden, the regional differences in mortality have been quite substantial (see Table IO). Stockholm city was industrialized late (but very fast) compared with other cities of northern Europe. Stockholm had a high infant mortality rate in the early decades of industrialization when housing was scarce and of bad quality. But by 1920 increasing living standards and sanitary legislation had brought the infant mortality rate down to a low level. Stockholm county, the rural area surrounding the city, is now a mainly middle class suburban area with
Cardiovascular
25-64
RELATED
1966-70 -
12.7 +9.7 -4.2 -3.5 + 7.8 + 5.3
Health Table
IO. Mortality
1880-I985
and social inequities among
Stockholm
I I. Mortality
141.7
117.1
53.3
56.8
55.2
94.5
58.2
I960
16.9
16.1
15.8
17.3
16.5
1970
9.9
IO.1
II.1
12.3
I I.3
1985 Age: 40-49
7.9
7.2
4.2
6.3
6.7
I880
19.7
10.9
10.7
13.3
10.3
1920
8.4
7.2
7.3
9.1
7. I
I960
3.2
2.8
2.3
2.9
2.7
I970
4.0
3.4
2.4
2.8
2.9
I985
3.0
2.0
2.0
2.2
2.2
I880
96.0
85.2
84.3
100.2
83.0
I920
73.5
69.4
61.4
71.5
66.4
I960
56.3
54.8
51.0
59.4
55.0
1985
40.6
39.0
39.5
46.3
42.1
disease
Suicide
as potential
years life lost (PYLL)
of death
(men
in different
per
counties
of
197483) Halland
city
Norrbotten
county
county
21.3
17.2
27.8
4.5
2.6
2.6
4.2
7.8
6.8
I I.2
IO.1
10.4
Alcohol-related 14.9
5.0
8.7
All
95.9
76.6
94.2
underlying
and diagnosis
contributing
causes
(see Table
of
death
in
four
15).
a long record of low mortality, like the Halland county, a rural area in the south of Sweden with flourishing agriculture and small industries. (Sweden is divided into 24 counties with an average 250,000 inhabitants each.) Norrbotten county, the most northern part of Sweden, has always suffered from poverty and high unemployment. Heavy work in mining, forestry and the steel industry dominates employment. Adequate health care and especially antenatal care came late to this part of the country. Mortality among middle aged persons, today as at earlier periods, shows significant regional differences. The high mortality rate in Stockholm is mainly due to an excess of deaths in alcohol-related diseases, suicide and lung cancer (Table II). The high mortality in the northern regions is mainly due to a higher mortality in cardiovascular diseases. Recently a close positive ecological correlation has been shown between levels of cardiovascular mortality in the 24 counties of Sweden and levels of unemployment, consumption* of salt, milk products and coffee as well as the prevalence of hypertension, diabetes Table
12. Life
expectancy
at birth
and obesity. The correlation with smoking is negative [ 1I]. In summary, there has during the postwar period existed a regional pattern of mortality in Sweden with high levels of mortality in most age groups in the big cities and in the northern counties, while the rural areas in the south have had the lowest mortality. This pattern has changed little in the 1980s. However, Stockholm, compared to other areas, has shown a bigger fall in mortality during recent years (Table 12). It is tempting to relate this to economic expansion and to the decreasing and very low unemployment rate-l-2% compared to 336% in the rest of the country. We have very scant historical data on social inequalities in health but in an historical perspective these regional differences may serve as a proxy for social inequities. What is found here, as in the case of infants born to unmarried women, is a very substantial reduction of inequities during the twentieth century. Today regional differences between counties is not an adequate proxy for social inequities. The differences between small areas within the big cities, reflecting a segregated housing market, are probably a better measure. They show very pronounced inequalities in mortality and morbidity. Overall adult mortality under age 65 in housing areas dominated by local authority tenants is nearly twice the level of areas dominated by owner-occupied houses. These differences are mainly due to differences in mortality in alcohol-related diseases, cardiovascular diseases and suicide. Ecological analysis of these differences has been carried out in some Swedish cities and has shown that the differences are highly correlated with tenancy, household structure, occupational structure and unemployment rate. in some counties
of Sweden
Male
Increase since
since 1981-85
Halland Norbotten SWden
SSM ,I,?-,
county county county
and city
197685 Female
Increase
Stockholm
112.7
years
deaths* causes
I 18.1
years
7C-79
calculated
accidents
alcohol-related
Sweden
195.7
cancer
*Includes
Norrbotten
(infants)
and county
Motor
IOtXl)
I920
Stockholm
Lung
(per
1880
age 75 in some cuses
heart
in Sweden
Halland
Sweden
lschaemic
and regions
Stockholm county
0 years
Age:
1000 before
age groups
363
city Age:
Table
different
in Sweden
I97680
1981-85
1976-80
73.0
1.7
79.5
I.2
74.8
I.2
80.3
0.8
72.6
1.0
79.0
I.2
73.6
I.1
79.5
1.0
364
FINN
Table
13. Self-reported
capacity. hearing
reduced ability
long-standing
ability
to move
by social
class
illness
(cannot
1975-85.
percentage
(age
with
run
reduced
and
reduced
illness
working
Manual
Low
sex standardized
workers
level
Reduced
Reduced
Source:
Ref.
3.9 -
+0.2
I.5
9.0
15.4
8.6
- 2.8
-2.1
-
1.4
to hear:
1984/85 Change
level
to move:
1975 85
ability
high
6.7
Il.5 -0.8
1984,85 Change
and
capacity:
1975 85
ability
employees Intermediate
with
I984;85 Change
reduced
16-74) Salaried
Long-standing
and from this population we present data on self-reported illness and disability in the population aged 16-74. We note in Table 13 that there are considerable class differences in self-reported morbidity and that these differences are both consistent and persistent. The only major change occurred in workers aged 55-74 who clearly improved their ability to move from 30% in 1975 with reduced ability to 23% in 1985. Improvement can also be observed among early retirement pensioners (cf. above). Changes in individual perception may, of course, influence these figures. The data of reduced working capacity may, of course, be influenced not only by changes in morbidity but also by changes in labour market demand. Lowering of the pension age can also influence these figures, at least for persons older than 54 years, of whom an increasing number now get pensions and for whom working capacity is less relevant.
working
100 m) and
Age
DIDERICHSEN
1975 85
10.4
6.5
+ 2.2
+ I.1
6.8 +2.1
[S].
While the inter-regional differences between counties seems to be partly explained by socioeconomic factors like unemployment, and partly by historically determined food habits, the intra-regional differences within the cities is probably mainly due to selective forces in the housing market creating a segregation based not only on class, income and single living, but also on health directly. SELF-REPORTED
USE
Regular household surveys of living conditions have been conducted each year since 1975 in Sweden. During 1975-85 93,000 interviews have been done 14. Cancer
incidence and
1961-79
region.
in relation
SMR
Manual
IN-PATIENT
CARE
Since 1960 all hospitals in Sweden have reported all cases of malignant neoplasms to a central cancer register at the National Board of Health. This register has been linked to the 1960 census and the social class incidence has recently been studied by Vagerii and Persson [ 131. Workers have a high incidence of cancer of the lung and the stomach, while employees have a high incidence of breast and colon cancer. These are some
ILLNESS
Table
OF
where
to social class. Adjusted
all occupied
workers
for age
= 100
Employees
Farmers
Cancer location
Male
Breast
-
Prostate
134
-
106
-
IO1
84
98
120
102
78
109
97
92
41
Stomach
I08
II2
78
88
109
All
100
IO5
102
87
bronchus
cancer
Source:
15. Rate
class. Age
-
Male
Female
-
110
Lung,
Table
86 97
Colon
Male
Female
Ref.
ratio
[IO].
of in-patient
standardized
97
15-64
care years.
1981 for certain SRR
= where
diagnosis
whole
(ICD8)
population
in relation
to region
male + female
and social
= 100 (I5
Swedish
counties) A
Cities (Slockholm, Manual
workers
Male
level salaried
employees
37
Male
170
Female
I3
Some Manual Low
workers
level salaried
Intermediate salaried Whole
employees
and high level
employees population
A: acute
myocardial
C:
liver cirrosis
D: psychosis E: attempted F:
traffic
infarction diseases
+ alcohol
except suicide
accidents
216
68
46 ;:
79 I08
87
170
I08
I41
72
50
II5
72
58
26
62
II
32 44
67 III
II3
73
51
96
29
86
44
46
59
74
I50
96
Female Male Female
30 I58 32
53 II2 53
26 42 I5
Male
108
99
8
50
100
100
II8
51
82
I55
76
63
I09
69
%
35 51
41 70
98 51
58 82
22
24
20
149
43
8
47
38
69
66
100
100
loo
100
100
(410). alcohol
psychosis
(E950-959.
(E8l&829).
Total
(430-438).
psychosis,
alcohol
F
Gothenburg) I28
Male
incl. not employed
E
other regions
Female
B: cerebrovascular
D
60
II8
Female
C
II5
21
Male
Intermediate and high level salaried employees
Malmo, I80
Female Low
B
intoxication
(290-299
E980-989).
ext.
and chronic
291).
alcoholism
(571 + 291 +980+
3031.
Health and social inequities in Sweden of the few common diseases that are more prevalent among higher social classes. Farmers have a generally low cancer incidence with the exception of cancer of the stomach. Except for cancer there is no nationwide register of all admissions to in-patient care. A preliminary decision to create one from 1984 onwards is still subject to government discussion on confidentiality problems. In 1981, however, IS county councils (including more than 70% of the Swedish population) submitted registers covering all cases of in-patient care. The coverage of the register is more than 97% of all cases of in-patient care in the 15 counties. For those diagnoses where most cases are hospitalized, the number of persons cared for during a year is very close to the incidence. While geographical variations may be a result of differences in resources and routines, the social differences may reflect differences in morbidity since we have studies showing that no major social factors influence access to in-patient care-except psychiatry where working class patients more frequently receive in-patient care than outpatient treatment (Table 15). Levels of in-patient care are generally somewhat higher and social gradients considerably steeper in the cities than in other parts of the country. This picture gives overall confirmation of the rather large social differences in morbidity shown in the household interviews. It is worth noticing the class differences in suicide attempts since many earlier studies have shown no differences.
LIVING
365
CONDITIONS
AND RISK FACTORS
In order to understand the present, and to raise hypotheses about future inequities in health, the distribution of certain living conditions and risk factors revealed by the general household surveys conducted since 1975 may be of some interest. The class differences in income, home ownership and other possessions are now smaller than ever before during the postwar period (Table 16). In an international perspective Sweden seems to have smaller differences in income (after income tax) than other countries. Calculated as a Gini coefficient, Sweden has a value of 0.203 compared to 0.273 for Great Britain, 0.326 for U.S.A. and 0.355 for F.R.G. (Table 17). In respect of certain living conditions with special significance for health we do not find decreasing inequalities. Rather the opposite seems to be the case. The household survey includes data on some important health risk factors. Hectic and monotonous work, unemployment and smoking are three risk factors shown to have aetiological importance for early death in cardiovascular diseases, mental disease and cancer. Class trends seem to be diverging rather than converging (Table 18). Other studies have recently shown that the class distribution of risk factors such as smoking, high alcohol consumption and high fat consumption has now been reversed in comparison with the
Table 16. Income level in ditT.erentsocioeconomic groups 1975-84. Index where 100 = poverty limit (standardized for family size) 1975
I980
1984
181 212
183 209
173 200
229 100
232 100
216 100
Manual workers Low level salaried employees High and intermediate level salaried employees Poverty limit Source: Ref. [8].
Table 17. Living standard in certain material aspects for socioeconomic groups in Sweden 1975-85. Age and sex standardized 16-74 years (%) Manual workers
Does Does Does Does
not not not not
High level salaried employees
1984185
Change 1975-85
1984185
Change 1975-85
39.7 5.4 22.3 1.8
-9.7 -11.7 - 5.8 -4.9
30.8 2.8 13.9 0.5
-5.1 -0.0 -0.6 - 1.2
own house or flat live in acceptable housing own car own telephone
Source: Ref. [8].
Table 18. Some risk factors in living conditions and life style in Sweden 1975-85 among workers compared to senior employees. Age and xx standardized 16-74 years (%.) Manual workers
Hectic and monotonous work Unemployed at least once in the last 5 years Daily smoking Source: Ref. [S].
High level salaried employees Change 1975-85
1984185
Change 197-5
1984185
20.1
+4.9
2.7
0.0
19.3 36.9
+6.1 - 5.2
9.3 20.3
+ 1.9 -9.9
FINN DIDERICHSEN
366
distribution of 20-30 years ago. These risk factors are now concentrated in young working class persons. As an example it can be mentioned that among single mothers in manual occupations the proportion of smokers is two-thirds compared with one-sixth among cohabiting men in non-manual occupations. These changes in risk factors may play a major role in the above mentioned changes in social inequities in health. They may, however, also be an indication that the trend towards increased social inequities in mortality observed during the 1970s may continue into the future. CONCLUSIONS
Social inequities in health in Sweden have probably been reduced substantially during this century. In the 1960s inequities in mortality between occupations were very small. During the 1970s there was a small increase in mortality among men in most manual occupations in manufacturing industry and a strong decrease among non-manual occupations. Recently several studies of self-reported illness and of in-patient care related to cardiovascular diseases, mental problems and accidents are showing increased inequities between social classes with a level for manual workers at least 50% higher than that for senior salaried employees. Cancers of the breast and colon show a different pattern with a higher risk among the highly-educated. Infants of single mothers are more frequently of low birth weight and have a slightly higher mortality. Divorced men, the unemployed and certain groups of immigrants (men from Finland and women from Mediterranean countries) are also reported to have a higher mortality and morbidity and, together with certain manual occupations. are referred to as risk groups in official documents of national health policy [5]. The causal links in this distribution have not yet been studied systematically. Sweden is a society where upward intergenerational mobility from working class to professional status is increasing and is already more common than in other European nations, i.e. France and Great Britain [S]. This may make healthrelated selective mechanisms of increasing importance in interpreting trends in social inequality in morbidity and mortality. The rapidly decreasing mortality in many non-manual occupations may be influenced by this. Intragenerational mobility between social classes is much less frequent and the most important factor in health selection here is probably the high number leaving employment for early retirement. This has been increasingly common during the last 20 years, especially among manual workers aged 55-64. It tends to reduce health differences among those still employed. The social distribution of some important risk factors like smoking, alcohol consumption and maybe also dietary habits has also changed during the last 20-30 years and this may contribute to some present and future trends towards increased social inequities in mortality. The mechanisms behind these behavioural changes are not well understood. Since change in cardiovascular mortality is the main contributor to changes in overall mortality,
parallel changes in the psychosocial work environment and in unemployment have been discussed as possible causes. During the 1950s and 1960s a fast technical rationalization of Swedish industry occurred with an increase in piecerate wages and in hectic and monotonous machine-controlled industrial work. An increasing number of workers left the labour market for long term unemployment and early retirement. This led to strong reactions from labour in the late 1960s resulting in new legislation on the work environment. At the same time greater resources were put into research on working conditions. Some of these scientific studies showed that this type of monotonous industrial work has adverse effects on health with an increased risk of cardiovascular disease. During the 1970s a number of improvements in the psychosocial work environment have taken place. It is an interesting hypothesis that the trends in mortality among industrial workers during the 1970s may have been partly caused by the changes in the industrial working environment during previous years. The only possible method of continuously monitoring inequities in health is provided by the household surveys of self-reported illness. The other data reported above come from ad hoc studies which link census and medical registers. Each such study must be approved by a political board and the attitude towards this type of study has been increasingly restrictive during recent years. One alternative is to record occupation together with routine clinical notification of diagnosis. Hitherto this has been regarded as a cumbersome way of achieving social data of good quality. A problem with the record linkages, however, is that the quality of self-reported data on occupation in the census is not good. This, however, may be a minor problem when analysis is carried out on broad occupational groups. Sweden has a long tradition of intersectoral action to combat inequities in health. Action against inequities in infant mortality within the Social Democratic postwar programme was mentioned above. Regulation of safety at the workplace got a strong momentum during the 1970s. It also had an explicit equity perspective focused upon the high risk jobs in big industries. Small enterprises, however, still lag behind, although they often have the worst conditions. In the 1980s the ergonomic and psychosocial environment in the workplace has received more attention. This is relevant because they probably play a major role in present inequities between occupational groups. Recogniton of the ‘new’ inequities related to lifestyle factors has for the first time led to collaborative efforts between the national health authorities and the federation of trade unions to deal with the interrelationship between working conditions and risk factors in lifestyle on a broad scale throughout the country. A national programme for accident prevention has recently been launched having explicitly formulated equity targets. Regional data on mortality, sicknessabsence from work and early retirement pensions have been used from 1987 onwards as indicators for resource allocation to health care within county councils.
Health
and social inequities
REFERENCES I 2.
3.
4. 5.
6. 7.
The Swedish Health Services in 1990s (HS90). National Board of Health and Welfare. Stockholm, 1985. Inequalities in Healrh and Health Care. Nordic School of Public Health & WHO-Euro., Report 1985. p. 5. Gothenburg, 1985. The Health Burden of Social Inequities (Edited by Illsley R. and Svensson P. G.). WHO-Euro., Copenhagen, 1986. Dahlgren G. Strategies for combatting inequities in health. mimeo. WHO, Geneva, 1987. Dahlgren G. and Diderichsen F. Strategies for equity in health: report from Sweden. Int. J. Hlrh Serv. 16, 517-537, 1987. Zetterberg R. and Eriksson M. H&a och social klass. Socialmedicinsk Tidsskri/t i, 33-36, 1987. Halsopolitiska mal och behlvsbaserad planering. HS90. SOU 1984, pp. 40-41. Stockholm 1984.
in Sweden
367
8. Del scenska klassamhiiller. Levnadsfijrhallanden 1975-85. SCB ULF Rapport 50. Stockholm. 1987. 9. Navarro V. The determinants of social policy. A case study: regulating the safety at the workplace in Sweden. Inr. 2. Hirh Se&. 13, 517-561, 1983. _ IO. Vaaerd D. and Persson G. Sociala skillnader i cancerflirekomst? Socialmedicinsk Tidsskrift 10. 436-442. 1985. Il. Rosen M. Epidemiology in planning for health. UmeH University Medical Dissertation. New Series No. 188. Stockholm, 1987. M. The Healrh Divide: Inequalities in Health 12. Whitehead in 1980’s. The Health Education Council, London. 1987. 13. Public Health Report of Sweden I987 (Edited by Diderichsen F.). National Board of Health and Welfare 1988. (Short version in English of Folkhiilsorapport 198% Socialstyrelsen Redovisar 1987: 15. Almmanna Forlaget, Stockholm, 1987.)
Sot. Si. .Med. Vol. 31, No. 3. pp. 359-367. 1990 Printed m Great Britain. All rights reserved
HEALTH
AND SOCIAL INEQUITIES
IN SWEDEN
FINN DIDER~CHSEN Department
of Social
Medicine, Karolinska Institute, Kronan Health Centre, S-172 82 Sundbyberg, Sweden
Abstract-Sweden is one of Europe’s most egalitarian countries. The social inequities in living conditions have been gradually reduced to a level that is more equal than in most countries in Europe. Even if general health development has been positive during recent years, data reviewed here indicate that there may be adverse effects for some groups which may increase inequities. This article presents results on inequities in health from the Public Health Report of Sweden 1987 and discusses causal mechanisms and implications for health policy. Key ~rords--+ccupation,
social position,
mortality,
health,
health
selection
INTRODUCTION
INFANT MORTALITY
The political question of social inequities has for many years held a unique position in Sweden because
One of the social inequities often discussed and on which we have long time series is the mortality of infants. Mortality has for many years been higher
it has been a major goal of the Social Democratic party which has dominated political life and government for more than half a century. Historically this question has become more important as political democracy has given underprivileged groups more influence and as industrial development has made it possible to distribute the surplus more equally. In postwar Sweden the equity-goal in politics has been institutionalized in the sense that more or less all social changes and political reforms are confronted and tested against this goal. Health policy is no exception. However, as biomedical science has grown stronger and professional dominance over healthpolicy initiatives has increased, the equity perspective has been discussed and analysed less frequently. Maybe the most revealing piece of evidence is that most Swedish medical registers of mortality and morbidity, well known for their high coverage and for the validity of their medical information, all lack any information on the patient’s social position, i.e. occupation, tenancy, education, etc. However, the fact that it is possible to write this report is due partly to record linkages between the national census conducted each fifth year including a number of social variables and the medical registers and partly to the national household surveys carried out by the National Bureau of Statistics. Some of this material has been published earlier in reports to the government [I], in WHO reports [24] and in other forms [S]. The emphasis in this report will therefore be put on the recent findings and trends recently presented to the Swedish parliament [13]. The social indicators that will be used are the following: -occupational class, -region/urbanization. The health indicators are the following: -mortality, -self-reported illness, -in-patient care. 359
among infants born to unmarried mothers than among those born to married mothers, but the differential has varied from time to time. During the first and third quarters of this century, inequities in infant mortality decreased, although they increased between 1925 and 1950. When legal regulations relating to hygiene were introduced at the end of the nineteenth and the beginning of the twentieth century, they probably had more effect on children living under vulnerable conditions, whereas the more affluent groups had already acquired the resources to achieve hygiene, clean water, etc. In this period there was public recognition of state responsibility for health regulations from which all strata in the population benefited, but the underprivileged benefited more than those who had resources to achieve health protection by private means. In 1933 the infant mortality rate between different income groups of Stockholm varied from 14 to 49. Analysis of the data by the national authorities brought the conclusion that “there is no reason to accept an infant mortality for any social class of society that is higher than the average among the wealthiest quartile of the nation. What one social group can buy for money society must provide for others.” In following years the Swedish parliament decided on a broad range of legislation to improve the low birth rate and the health conditions of mothers and children. This legislation included a number of economic allowances for families with children-for housing, a certain allowance for each child, maintenance support to divorced mothers, etc. Unmarried mothers were given priority for housing, nursing care and employment opportunities. Similar reforms were introduced after the war in Norway and Denmark. This improved the economic conditions of families in general and single parent families in particular. Swedish legislation in 1937 also introduced a comprehensive free mother and child health care
FINN DIDERICHSEN
360 Table I. Infant
mortality
rate
197681.
Infant
mortality
Perinatal
and
rate
mortality
other
National
rate
measures
of
register
(per
birth
birth
weight
(< 2500 g)
Serious
malformations
Source:
Ref.
IN CHILDREN
2. Infant
mortality
mothers
and
cohabiting.
C
7.4
7.6
7.2
1976;77
7.9
10.4
10.7
10.2
other
birth
7.1
7.5
10.9
7.6
1976/81
35
45
60
45
1976181
24
24
24
24
[6].
AND YOUNG
Sweden
Total
B
5.9
outcomes
1976-81
(per
recent studies which describe or measure health conditions in relation to parents’ occupations. Some differences in mortality related to parents’ occupational status persist. Boys in families employed in agriculture and services (cleaning, restaurants, etc.) seem to have a higher death rate. Sons of parents in service occupations in contrast to all other groups have an increasing mortality rate (Table 3). These differences have not yet been studied in relation to causes of death, citizenship, family structure, etc. It is possible that an increasing number of immigrants within service jobs, together with other selective forces may be responsible. This and following tables on mortality in different occupational groups are based on two registers where all certified deaths in Sweden in 1961-70 and 1971-80 have been linked to the 1960 and 1970 censuses respectively. This register was produced in 1981-83 by the National Bureau of Statistics in Stockholm but has only been analysed to a very limited extent. Deaths during the 1980s have not yet been linked. The occupational classification used here is based on the Nordic classification which roughly follows the International Classification of Occupations from 1958. The raw output published tables give mortalility in relation to occupation on a two-digit level. On the basis of these tables we have not been able to classify occupations according to the social classes regularly used in Sweden (i.e. in the household surveys, see Table 13), but we have grouped them into rather homogeneous groups of major occupational categories (technical, administrative, manufacturing industry, transportation, service, agriculture, etc.). Differences and tendencies might be different if social classes were used. That would, however, demand a regrouping of occupations on at least a three-digit level. Whilst that is fully possible it has not been available for this report. ADULT MORTALITY
PERSONS
Mortality among children is very low in Sweden compared with other countries. We have very few
Table
in Sweden
A
service. The programme included screening for somatic and psychological conditions, individual and group advice and health education, free drugs and vaccinations. The coverage of this programme for pregnant women and children under five expanded gradually and has been virtually 100% for the last 20 years. Mothers who do not attend are visited by a nurse who encourages them to come. In 1950 when 35% of the mothers and 10% of the children were still not covered by this programme, surveys showed that children not covered by the programme had very high rates of anaemia, rickets and respiratory disease. The excess mortality of infants of unmarried mothers decreased considerably during the first three quarters of this century from a level that was nearly double that of children born to married mothers. Recently published data analysed by Zetterberg et al. has, however, shown that Sweden still has a social differential in infant mortality rates. This study includes all births in Sweden 1976/77 and 1980/81 (n = 378,651) linked to the censuses of 197.5and 1980 respectively. Two marginal groups have been constructed. Group A (IO%) includes mothers with Swedish citizenship who are cohabiting, highly educated and living in owner-occupied houses or flats. Group C (7%) consists of mothers who are living as single persons, are tenants and have a low level of education. Group B are the rest (83%). Table I shows considerable differences between these three groups. Most pronounced is the differential in the rate of low birth weight. The incidence of malformations is an interesting exception. Single living seems to be the most important variable in the combination of variables distinguishing the three groups (Table 2). The differences persist in spite of an overall decreasing level of infant and perinatal mortality rates. In a longer perspective, however, the infants of single mothers had much higher relative risk. MORTALITY
outcome
1000)
1976~81 1980’81
Low
birth
in relation 1000)
to
RELATED TO OCCUPATION
There are many significant differences in mortality from all causes between different occupational groups Table
3. Mortality
1971-80
in
among
Sweden
in
persons
aged
relation
to
(per
100,000)
Single living Infant
mortality
Perinatal
mortality
rate rate
1976177
9.1
7.5
I980/8
7.4
6.3
I I.2
9.9
5-8
Industry,
9.5
7.3
4
Agriculture, Service
I
1976i77 198018 I
Low
birth
Source:
weight
Ref.
161.
Cohabiting
C&3 Techn.,
1976177
56
40
9
1980,81
61
40
Total Source:
Ref.
commerc.,
adminstr.,
manufact. (domestic,
171.
transport
forestry hotel,
rest.)
care
O-19
parents
years
1961-70
occupational
and status
1961-70
1971-80
M
F
M
F
51
33
48
29
66
35
59
32
72
37
71
34
72
45
93
44
68
37
60
32
Health Table
4. Age standardized
death rate ratios (SRR)
and social inequities
197G30
and 1966-70
in Sweden some
among
361
occupational
groups
(one- or two-digit
Female
Male Occupational
0 Tech”.. human. 05 Pedagogical
4564
25-w
group
I Administrative
25-U
Male 254
454
Female 45-64
2541
45-64 a7
86
91
90
77
97
79
-
78
67
80
61
95
68
-
89
103
88
102 II3
70
care
level) in Sweden
196670
1976-80
-
77 I09
-
2 Clerical
96
103
97
100
94
3 Commercial
89
IO1
103
96
IO1
121
100
96
4 Agriculture. forestry 5 Mining. stoneworks
106
82 129
-
86 -
98 I.26
81 II0
II9 -
6 Transportation 61 Seamen
I IO 266
I08 159
100
IO0 -
107 294
II2 I61
-
102 99 92 91
96 -
7 Manufacturing
106
104
107
I04
97
98
I08
97
8 -(mostly unqualif.) 88 Packing. dock work
131 I57
II7 I23
I35 -
II0 II3
I24 133
109 119
129 -
IO1
9 Service 93 Cleaning
II8 I62
II? II2
I08 -
106 I I4
II3
II7 I08
121 -
109
100
100
100
100
100
100
IO0
100
All
occupied
in Sweden. These differences are, however, smaller than in the other Nordic countries (Table 4) [2]. Among men in certain occupations exposed to high risks in their working environment and lifestyles (seamen) and some unqualified occupations such as cleaning, packing, etc. the death rates are close to twice the level in technical, scientific or humanistic and administrative occupations. When we compare rates in the two periods we find an increased mortality ratio in persons occupied in manufacturing (occupational group 7-8) in the recent period. The differences in SRR between the two periods could, however, be influenced by changes in age structure within each occupational group between the censuses of 1960 and 1970. We have therefore compared the major occupational groups (Table 5) and some smaller groups (Table 6) by computing direct age-standardized death rates using all those employed in 1970 as the standard population for all occupational groups in both periods. Between 1965 and 1979 Sweden had an experience unique in its recent national history-an increase in mortality among men aged 4&60 years. This increase was most pronounced among divorced persons and in the Stockholm area (where the number of divorced men was rising and is higher than elsewhere). But the figures in Table 5 seem also to indicate that the trends in mortality during this period were diverging across the different occupational groups. Those men working in manufacturing industry, or not employed in 1970, had a higher mortality in the following years compared to those in similar groups in 1960. At the same time mortality decreased in other occupational
Table
5. Trends
in mortality
1966-80 45-64.
in Sweden Age
among
standardized
some major (per
occupational
care.
adminstr..
commerc.
5. 7, 8
Manufacturing
6. 9
Transport.
4
Agricull..
Not All
employed years
45-64
service forest
groups
at ages
100,000) Female % Change
Technical.
106
groups. Among middle-aged women the trends are also diverging, although the overall trend is one of decreasing mortality. Selective forces probably play an important role here. The number of people (especially women) occupied in the first group (O-3) increased by nearly one-third during the 1960s mainly due to the expansion of public health and the social services. This labour force was recruited mainly from the group of not-employed women (housewives) and from new generations of well educated young people. Women entering these groups were probably positively selected in respect of health. Increasing mortality among the fast diminishing group of notemployed women supports this hypothesis. The young people entering the labour market may also have been positively selected too, since the educational system probably tends to be selective (no Swedish studies on this question have, however, been done). The total size of the labour force in manufacturing decreased less than 1% during the 1960s and the same is true for the total of transport and service workers. The number in agricultural and forestry decreased by more than-one-third. In these groups, during this period, however, substantial health-selective mobility occurred. The number of persons each year leaving the labour force with a medicallycertified early retirement pension doubled from 1960 to 1970. This was mainly a way of solving the problem of long term unemployment in occupations and industries experiencing fast structural change. The medical criteria for receiving an early retirement pension were gradually lowered. The number of not-employed men thus increased between 1960 and
Male
&3
IO1
% Change
197680
1966-70
I97680
995
l%6-70
clerical. - 15.4
455
II82
+3.7
505
II89
-6.3
500
-
403
-20.4
790
-
12.3
2791
i-6.5
668
1203
+ I.6
557
-15.6 -8.3 16.4 + 1.7 -
10.6
FINN DIDERICHSEN
362 Table
6.
Age
expressed
standardized
death
as an index of mortality
rates
among
among
men
all employed
age
men.
45-64
1966-70
as IO0 1966-70 00
Engineers.
30 Medical 05
techn.
staff
doctors.
Teachers.
dentists
professors
IO Administrative
staff
32 Salesmen 61 Seamcn 63
Bwtrain
drivers
73 Steelworks 75
Manufacturing
79 Construction 82
Food
metal-industry
74
94
76
85
82
134
94
I64
I58
107
106
loo
I08 106
97
103
I IO
103
83 Chemical,
cellulosa
X6 Unskilled
101
II5
work
108
121
& restaurant
I43
163
91
Hotel
All
employed
Not
82
loo
105
industry
industry
1976-80
96
industry
employed
100
97
235
250
MORTALITY
1970 by one-half, while the official unemployment rate remained low (1.5%). This process had a strong impact on agriculture and forestry and the pension rate was also rising among those employed in the ‘old’ manufacturing industries, i.e. mining, the steel industry and unskilled work in general. When those who are relatively disabled leave the labour force, the mortality rate of the remainder tends to go down. In spite of this it increased among those employed in manufacturing industry. This seems to indicate an increased environmental risk and/or lifestyle influence. In Table 6 this process is illustrated for some occupational groups and it confirms the tendency described above. When the medical criteria for early retirement pensions were relaxed we would expect an improving level of health among the growing number of notemployed men. Household surveys on reported health status seems to bear out this expectation. Nevertheless, mortality increased. Whether this is a result of selection (i.e. new groups of high risk individuals such as alcohol abusers getting early retirement) or is an effect of long term unemployment we do not know. Table 7 shows however that the Table
7. Mortality
254
in
196&70
among and
employed 197680. (oer
and Age
not-employed standardized
Not
All
All
employed:
men
causes
1976-80
641
620
Cardiovascular
280
285
Cancers
I56
I58
Injuries
106
All
aged rates
lOO.ooO~
1966-70 Employed:
men death
causes
increase in mortality among the not-employed is found in all three main causes of death. It is most pronounced in ‘injuries’ which in this age group of men consists mainly of alcohol-related deaths and suicides. The changes in mortality from all causes are, however. mainly due to changes in cardiovascular deaths (see Table 8). During the 1980s mortality in Sweden has been decreasing unusually fast. We cannot yet say how particular occupational groups have performed since no linkage has yet been carried out with the 1980s mortality-register and the recent census. These changes can only be shown at the regional level.
Table
9. Infant
I620 631
Cancers
199
229
Germany
Injuries
223
282
Great
680
691
Sweden
in cardiovascular
rate in Germany, 1840-1980
588
8. Changes
mortality
89
1543
Table
TO
mortality
Britain
1966-80
among
men
(per
589
514 590
o-3
Techn..
5. 7. 8
Manufacturing
538
6. 9
Transport.
619
593
4
Agncult..
423
408
NOI All
service forest
employed men 45-64
commerc.
197680
II20 years
566
I207 596
Britain
and Sweden
1840s
1880s
1920s
1970s
298 I53
228
II2
142
72
23 17
I54
II2
60
IO
aged
45-64.
Age
% Change I96670
Great IOOO)
standardized
adminstr.,
REGION
Historically, inequities in health have probably diminished greatly between and within European nations. It is often thought that trends of decreasing mortality and of inequities in health are a more or less automatic outcome of economic growth. This view has dominated Swedish health policies for many increased productivity greater years: through economic growth is achieved and, with a relatively equitable distribution of the surplus, social inequities in living conditions and health can be diminished. From the figures in Table 9 it seems that the differences in infant mortality rates between European countries have been reduced somewhat during the last century. The most interesting feature of Table 9, however, is that long before the adoption of modern postwar welfare policies, Sweden already had a comparatively low infant mortality rate. It would therefore be premature to draw conclusions about the beneficial effects of social policy on inequities in health. But, even in Sweden, the regional differences in mortality have been quite substantial (see Table IO). Stockholm city was industrialized late (but very fast) compared with other cities of northern Europe. Stockholm had a high infant mortality rate in the early decades of industrialization when housing was scarce and of bad quality. But by 1920 increasing living standards and sanitary legislation had brought the infant mortality rate down to a low level. Stockholm county, the rural area surrounding the city, is now a mainly middle class suburban area with
Cardiovascular
25-64
RELATED
1966-70 -
12.7 +9.7 -4.2 -3.5 + 7.8 + 5.3
Health Table
IO. Mortality
1880-I985
and social inequities among
Stockholm
I I. Mortality
141.7
117.1
53.3
56.8
55.2
94.5
58.2
I960
16.9
16.1
15.8
17.3
16.5
1970
9.9
IO.1
II.1
12.3
I I.3
1985 Age: 40-49
7.9
7.2
4.2
6.3
6.7
I880
19.7
10.9
10.7
13.3
10.3
1920
8.4
7.2
7.3
9.1
7. I
I960
3.2
2.8
2.3
2.9
2.7
I970
4.0
3.4
2.4
2.8
2.9
I985
3.0
2.0
2.0
2.2
2.2
I880
96.0
85.2
84.3
100.2
83.0
I920
73.5
69.4
61.4
71.5
66.4
I960
56.3
54.8
51.0
59.4
55.0
1985
40.6
39.0
39.5
46.3
42.1
disease
Suicide
as potential
years life lost (PYLL)
of death
(men
in different
per
counties
of
197483) Halland
city
Norrbotten
county
county
21.3
17.2
27.8
4.5
2.6
2.6
4.2
7.8
6.8
I I.2
IO.1
10.4
Alcohol-related 14.9
5.0
8.7
All
95.9
76.6
94.2
underlying
and diagnosis
contributing
causes
(see Table
of
death
in
four
15).
a long record of low mortality, like the Halland county, a rural area in the south of Sweden with flourishing agriculture and small industries. (Sweden is divided into 24 counties with an average 250,000 inhabitants each.) Norrbotten county, the most northern part of Sweden, has always suffered from poverty and high unemployment. Heavy work in mining, forestry and the steel industry dominates employment. Adequate health care and especially antenatal care came late to this part of the country. Mortality among middle aged persons, today as at earlier periods, shows significant regional differences. The high mortality rate in Stockholm is mainly due to an excess of deaths in alcohol-related diseases, suicide and lung cancer (Table II). The high mortality in the northern regions is mainly due to a higher mortality in cardiovascular diseases. Recently a close positive ecological correlation has been shown between levels of cardiovascular mortality in the 24 counties of Sweden and levels of unemployment, consumption* of salt, milk products and coffee as well as the prevalence of hypertension, diabetes Table
12. Life
expectancy
at birth
and obesity. The correlation with smoking is negative [ 1I]. In summary, there has during the postwar period existed a regional pattern of mortality in Sweden with high levels of mortality in most age groups in the big cities and in the northern counties, while the rural areas in the south have had the lowest mortality. This pattern has changed little in the 1980s. However, Stockholm, compared to other areas, has shown a bigger fall in mortality during recent years (Table 12). It is tempting to relate this to economic expansion and to the decreasing and very low unemployment rate-l-2% compared to 336% in the rest of the country. We have very scant historical data on social inequalities in health but in an historical perspective these regional differences may serve as a proxy for social inequities. What is found here, as in the case of infants born to unmarried women, is a very substantial reduction of inequities during the twentieth century. Today regional differences between counties is not an adequate proxy for social inequities. The differences between small areas within the big cities, reflecting a segregated housing market, are probably a better measure. They show very pronounced inequalities in mortality and morbidity. Overall adult mortality under age 65 in housing areas dominated by local authority tenants is nearly twice the level of areas dominated by owner-occupied houses. These differences are mainly due to differences in mortality in alcohol-related diseases, cardiovascular diseases and suicide. Ecological analysis of these differences has been carried out in some Swedish cities and has shown that the differences are highly correlated with tenancy, household structure, occupational structure and unemployment rate. in some counties
of Sweden
Male
Increase since
since 1981-85
Halland Norbotten SWden
SSM ,I,?-,
county county county
and city
197685 Female
Increase
Stockholm
112.7
years
deaths* causes
I 18.1
years
7C-79
calculated
accidents
alcohol-related
Sweden
195.7
cancer
*Includes
Norrbotten
(infants)
and county
Motor
IOtXl)
I920
Stockholm
Lung
(per
1880
age 75 in some cuses
heart
in Sweden
Halland
Sweden
lschaemic
and regions
Stockholm county
0 years
Age:
1000 before
age groups
363
city Age:
Table
different
in Sweden
I97680
1981-85
1976-80
73.0
1.7
79.5
I.2
74.8
I.2
80.3
0.8
72.6
1.0
79.0
I.2
73.6
I.1
79.5
1.0
364
FINN
Table
13. Self-reported
capacity. hearing
reduced ability
long-standing
ability
to move
by social
class
illness
(cannot
1975-85.
percentage
(age
with
run
reduced
and
reduced
illness
working
Manual
Low
sex standardized
workers
level
Reduced
Reduced
Source:
Ref.
3.9 -
+0.2
I.5
9.0
15.4
8.6
- 2.8
-2.1
-
1.4
to hear:
1984/85 Change
level
to move:
1975 85
ability
high
6.7
Il.5 -0.8
1984,85 Change
and
capacity:
1975 85
ability
employees Intermediate
with
I984;85 Change
reduced
16-74) Salaried
Long-standing
and from this population we present data on self-reported illness and disability in the population aged 16-74. We note in Table 13 that there are considerable class differences in self-reported morbidity and that these differences are both consistent and persistent. The only major change occurred in workers aged 55-74 who clearly improved their ability to move from 30% in 1975 with reduced ability to 23% in 1985. Improvement can also be observed among early retirement pensioners (cf. above). Changes in individual perception may, of course, influence these figures. The data of reduced working capacity may, of course, be influenced not only by changes in morbidity but also by changes in labour market demand. Lowering of the pension age can also influence these figures, at least for persons older than 54 years, of whom an increasing number now get pensions and for whom working capacity is less relevant.
working
100 m) and
Age
DIDERICHSEN
1975 85
10.4
6.5
+ 2.2
+ I.1
6.8 +2.1
[S].
While the inter-regional differences between counties seems to be partly explained by socioeconomic factors like unemployment, and partly by historically determined food habits, the intra-regional differences within the cities is probably mainly due to selective forces in the housing market creating a segregation based not only on class, income and single living, but also on health directly. SELF-REPORTED
USE
Regular household surveys of living conditions have been conducted each year since 1975 in Sweden. During 1975-85 93,000 interviews have been done 14. Cancer
incidence and
1961-79
region.
in relation
SMR
Manual
IN-PATIENT
CARE
Since 1960 all hospitals in Sweden have reported all cases of malignant neoplasms to a central cancer register at the National Board of Health. This register has been linked to the 1960 census and the social class incidence has recently been studied by Vagerii and Persson [ 131. Workers have a high incidence of cancer of the lung and the stomach, while employees have a high incidence of breast and colon cancer. These are some
ILLNESS
Table
OF
where
to social class. Adjusted
all occupied
workers
for age
= 100
Employees
Farmers
Cancer location
Male
Breast
-
Prostate
134
-
106
-
IO1
84
98
120
102
78
109
97
92
41
Stomach
I08
II2
78
88
109
All
100
IO5
102
87
bronchus
cancer
Source:
15. Rate
class. Age
-
Male
Female
-
110
Lung,
Table
86 97
Colon
Male
Female
Ref.
ratio
[IO].
of in-patient
standardized
97
15-64
care years.
1981 for certain SRR
= where
diagnosis
whole
(ICD8)
population
in relation
to region
male + female
and social
= 100 (I5
Swedish
counties) A
Cities (Slockholm, Manual
workers
Male
level salaried
employees
37
Male
170
Female
I3
Some Manual Low
workers
level salaried
Intermediate salaried Whole
employees
and high level
employees population
A: acute
myocardial
C:
liver cirrosis
D: psychosis E: attempted F:
traffic
infarction diseases
+ alcohol
except suicide
accidents
216
68
46 ;:
79 I08
87
170
I08
I41
72
50
II5
72
58
26
62
II
32 44
67 III
II3
73
51
96
29
86
44
46
59
74
I50
96
Female Male Female
30 I58 32
53 II2 53
26 42 I5
Male
108
99
8
50
100
100
II8
51
82
I55
76
63
I09
69
%
35 51
41 70
98 51
58 82
22
24
20
149
43
8
47
38
69
66
100
100
loo
100
100
(410). alcohol
psychosis
(E950-959.
(E8l&829).
Total
(430-438).
psychosis,
alcohol
F
Gothenburg) I28
Male
incl. not employed
E
other regions
Female
B: cerebrovascular
D
60
II8
Female
C
II5
21
Male
Intermediate and high level salaried employees
Malmo, I80
Female Low
B
intoxication
(290-299
E980-989).
ext.
and chronic
291).
alcoholism
(571 + 291 +980+
3031.
Health and social inequities in Sweden of the few common diseases that are more prevalent among higher social classes. Farmers have a generally low cancer incidence with the exception of cancer of the stomach. Except for cancer there is no nationwide register of all admissions to in-patient care. A preliminary decision to create one from 1984 onwards is still subject to government discussion on confidentiality problems. In 1981, however, IS county councils (including more than 70% of the Swedish population) submitted registers covering all cases of in-patient care. The coverage of the register is more than 97% of all cases of in-patient care in the 15 counties. For those diagnoses where most cases are hospitalized, the number of persons cared for during a year is very close to the incidence. While geographical variations may be a result of differences in resources and routines, the social differences may reflect differences in morbidity since we have studies showing that no major social factors influence access to in-patient care-except psychiatry where working class patients more frequently receive in-patient care than outpatient treatment (Table 15). Levels of in-patient care are generally somewhat higher and social gradients considerably steeper in the cities than in other parts of the country. This picture gives overall confirmation of the rather large social differences in morbidity shown in the household interviews. It is worth noticing the class differences in suicide attempts since many earlier studies have shown no differences.
LIVING
365
CONDITIONS
AND RISK FACTORS
In order to understand the present, and to raise hypotheses about future inequities in health, the distribution of certain living conditions and risk factors revealed by the general household surveys conducted since 1975 may be of some interest. The class differences in income, home ownership and other possessions are now smaller than ever before during the postwar period (Table 16). In an international perspective Sweden seems to have smaller differences in income (after income tax) than other countries. Calculated as a Gini coefficient, Sweden has a value of 0.203 compared to 0.273 for Great Britain, 0.326 for U.S.A. and 0.355 for F.R.G. (Table 17). In respect of certain living conditions with special significance for health we do not find decreasing inequalities. Rather the opposite seems to be the case. The household survey includes data on some important health risk factors. Hectic and monotonous work, unemployment and smoking are three risk factors shown to have aetiological importance for early death in cardiovascular diseases, mental disease and cancer. Class trends seem to be diverging rather than converging (Table 18). Other studies have recently shown that the class distribution of risk factors such as smoking, high alcohol consumption and high fat consumption has now been reversed in comparison with the
Table 16. Income level in ditT.erentsocioeconomic groups 1975-84. Index where 100 = poverty limit (standardized for family size) 1975
I980
1984
181 212
183 209
173 200
229 100
232 100
216 100
Manual workers Low level salaried employees High and intermediate level salaried employees Poverty limit Source: Ref. [8].
Table 17. Living standard in certain material aspects for socioeconomic groups in Sweden 1975-85. Age and sex standardized 16-74 years (%) Manual workers
Does Does Does Does
not not not not
High level salaried employees
1984185
Change 1975-85
1984185
Change 1975-85
39.7 5.4 22.3 1.8
-9.7 -11.7 - 5.8 -4.9
30.8 2.8 13.9 0.5
-5.1 -0.0 -0.6 - 1.2
own house or flat live in acceptable housing own car own telephone
Source: Ref. [8].
Table 18. Some risk factors in living conditions and life style in Sweden 1975-85 among workers compared to senior employees. Age and xx standardized 16-74 years (%.) Manual workers
Hectic and monotonous work Unemployed at least once in the last 5 years Daily smoking Source: Ref. [S].
High level salaried employees Change 1975-85
1984185
Change 197-5
1984185
20.1
+4.9
2.7
0.0
19.3 36.9
+6.1 - 5.2
9.3 20.3
+ 1.9 -9.9
FINN DIDERICHSEN
366
distribution of 20-30 years ago. These risk factors are now concentrated in young working class persons. As an example it can be mentioned that among single mothers in manual occupations the proportion of smokers is two-thirds compared with one-sixth among cohabiting men in non-manual occupations. These changes in risk factors may play a major role in the above mentioned changes in social inequities in health. They may, however, also be an indication that the trend towards increased social inequities in mortality observed during the 1970s may continue into the future. CONCLUSIONS
Social inequities in health in Sweden have probably been reduced substantially during this century. In the 1960s inequities in mortality between occupations were very small. During the 1970s there was a small increase in mortality among men in most manual occupations in manufacturing industry and a strong decrease among non-manual occupations. Recently several studies of self-reported illness and of in-patient care related to cardiovascular diseases, mental problems and accidents are showing increased inequities between social classes with a level for manual workers at least 50% higher than that for senior salaried employees. Cancers of the breast and colon show a different pattern with a higher risk among the highly-educated. Infants of single mothers are more frequently of low birth weight and have a slightly higher mortality. Divorced men, the unemployed and certain groups of immigrants (men from Finland and women from Mediterranean countries) are also reported to have a higher mortality and morbidity and, together with certain manual occupations. are referred to as risk groups in official documents of national health policy [5]. The causal links in this distribution have not yet been studied systematically. Sweden is a society where upward intergenerational mobility from working class to professional status is increasing and is already more common than in other European nations, i.e. France and Great Britain [S]. This may make healthrelated selective mechanisms of increasing importance in interpreting trends in social inequality in morbidity and mortality. The rapidly decreasing mortality in many non-manual occupations may be influenced by this. Intragenerational mobility between social classes is much less frequent and the most important factor in health selection here is probably the high number leaving employment for early retirement. This has been increasingly common during the last 20 years, especially among manual workers aged 55-64. It tends to reduce health differences among those still employed. The social distribution of some important risk factors like smoking, alcohol consumption and maybe also dietary habits has also changed during the last 20-30 years and this may contribute to some present and future trends towards increased social inequities in mortality. The mechanisms behind these behavioural changes are not well understood. Since change in cardiovascular mortality is the main contributor to changes in overall mortality,
parallel changes in the psychosocial work environment and in unemployment have been discussed as possible causes. During the 1950s and 1960s a fast technical rationalization of Swedish industry occurred with an increase in piecerate wages and in hectic and monotonous machine-controlled industrial work. An increasing number of workers left the labour market for long term unemployment and early retirement. This led to strong reactions from labour in the late 1960s resulting in new legislation on the work environment. At the same time greater resources were put into research on working conditions. Some of these scientific studies showed that this type of monotonous industrial work has adverse effects on health with an increased risk of cardiovascular disease. During the 1970s a number of improvements in the psychosocial work environment have taken place. It is an interesting hypothesis that the trends in mortality among industrial workers during the 1970s may have been partly caused by the changes in the industrial working environment during previous years. The only possible method of continuously monitoring inequities in health is provided by the household surveys of self-reported illness. The other data reported above come from ad hoc studies which link census and medical registers. Each such study must be approved by a political board and the attitude towards this type of study has been increasingly restrictive during recent years. One alternative is to record occupation together with routine clinical notification of diagnosis. Hitherto this has been regarded as a cumbersome way of achieving social data of good quality. A problem with the record linkages, however, is that the quality of self-reported data on occupation in the census is not good. This, however, may be a minor problem when analysis is carried out on broad occupational groups. Sweden has a long tradition of intersectoral action to combat inequities in health. Action against inequities in infant mortality within the Social Democratic postwar programme was mentioned above. Regulation of safety at the workplace got a strong momentum during the 1970s. It also had an explicit equity perspective focused upon the high risk jobs in big industries. Small enterprises, however, still lag behind, although they often have the worst conditions. In the 1980s the ergonomic and psychosocial environment in the workplace has received more attention. This is relevant because they probably play a major role in present inequities between occupational groups. Recogniton of the ‘new’ inequities related to lifestyle factors has for the first time led to collaborative efforts between the national health authorities and the federation of trade unions to deal with the interrelationship between working conditions and risk factors in lifestyle on a broad scale throughout the country. A national programme for accident prevention has recently been launched having explicitly formulated equity targets. Regional data on mortality, sicknessabsence from work and early retirement pensions have been used from 1987 onwards as indicators for resource allocation to health care within county councils.
Health
and social inequities
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3.
4. 5.
6. 7.
The Swedish Health Services in 1990s (HS90). National Board of Health and Welfare. Stockholm, 1985. Inequalities in Healrh and Health Care. Nordic School of Public Health & WHO-Euro., Report 1985. p. 5. Gothenburg, 1985. The Health Burden of Social Inequities (Edited by Illsley R. and Svensson P. G.). WHO-Euro., Copenhagen, 1986. Dahlgren G. Strategies for combatting inequities in health. mimeo. WHO, Geneva, 1987. Dahlgren G. and Diderichsen F. Strategies for equity in health: report from Sweden. Int. J. Hlrh Serv. 16, 517-537, 1987. Zetterberg R. and Eriksson M. H&a och social klass. Socialmedicinsk Tidsskri/t i, 33-36, 1987. Halsopolitiska mal och behlvsbaserad planering. HS90. SOU 1984, pp. 40-41. Stockholm 1984.
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8. Del scenska klassamhiiller. Levnadsfijrhallanden 1975-85. SCB ULF Rapport 50. Stockholm. 1987. 9. Navarro V. The determinants of social policy. A case study: regulating the safety at the workplace in Sweden. Inr. 2. Hirh Se&. 13, 517-561, 1983. _ IO. Vaaerd D. and Persson G. Sociala skillnader i cancerflirekomst? Socialmedicinsk Tidsskrift 10. 436-442. 1985. Il. Rosen M. Epidemiology in planning for health. UmeH University Medical Dissertation. New Series No. 188. Stockholm, 1987. M. The Healrh Divide: Inequalities in Health 12. Whitehead in 1980’s. The Health Education Council, London. 1987. 13. Public Health Report of Sweden I987 (Edited by Diderichsen F.). National Board of Health and Welfare 1988. (Short version in English of Folkhiilsorapport 198% Socialstyrelsen Redovisar 1987: 15. Almmanna Forlaget, Stockholm, 1987.)