Published 21st October 2019

By Alastair Leyland and Ruth Dundas, Inequalities programme

Deaths from cardiovascular disease are declining in many European countries, but they remain socially patterned i.e. faster declines are seen among the better off.

A recent paper investigates how inequalities in cardiovascular mortality have changed in 12 European countries since the 1990s. The paper raises an interesting (and old) question: which are more important, relative or absolute inequalities?

Unfortunately, it is not possible to summarise the distribution of mortality across social groups in a single number. In Scotland, for example, the long term monitoring of health inequalities includes publication of the relative index of inequality (detailing the size of the inequality gradient), the absolute gap (the difference between groups at the extremes of the social spectrum), and the scale (indicating the magnitude of the problem).

Future cardiovascular disease mortality

To gauge the extent to which current trends should be regarded as favourable, we can examine future mortality. Di Girolamo et al project cardiovascular disease mortality rates by occupation class - upper non-manual employees and manual workers.

Firstly, assuming that mortality rates continue with the absolute declines experienced between 1990-1994 and 2010-2014, the mortality rate in upper non-manual employees will fall to zero in most countries between 4 and 16 years.

Potentially more realistically, we can assume that the relative declines in mortality experienced between 1990-1994 and 2010-2014 will continue. By 2020-2024 absolute inequalities (the difference between the two groups) will have decreased in every country apart from Lithuania. Relative inequalities, however, will increase in just about every country. In Finland, for example, the mortality rate in manual workers will be more than three times that in upper non-manual employees.

This means that the inequalities that will be seen in the future are in general worse than at present. If the current trends continue, without any additional interventions in the more disadvantaged groups, it will take between 8 and 28 years in most countries for cardiovascular disease mortality among manual workers to fall to the levels currently experienced by upper non-manual employees.

So it is clear that we cannot continue down the same path; something needs to change if relative inequalities are to decrease.

In Scotland, recent declines in mortality from coronary heart disease are almost equally attributable to improvements in medical treatment and reductions in risk factors such as high blood pressure. But to see inequalities fall, future declines in mortality must be more pronounced among the more disadvantaged.

Reducing lifestyle risk factors

We know that population level policy interventions are the most effective way to reduce inequalities. As well as encouraging more disadvantaged groups to seek healthcare earlier in the progress of the disease, the greatest opportunity lies in changing lifestyle risk factors including smoking, alcohol consumption, diet and physical activity.

For example, it was known for many years that smoking was detrimental to health but, despite many individual behaviour change interventions delivered through the health service, smoking prevalence remained high, and higher still among more disadvantaged groups. It was not until smoking bans in public places were introduced, which impacted at a population level and on everyone in the population equally, that larger reductions in smoking prevalence and subsequent mortality from smoking-related causes were seen.

But even risk factor reductions have the potential to disappoint. We have seen, for example, levels of alcohol-related harms are greater in more disadvantaged groups at given levels of alcohol consumption. This means that an even greater reduction in risk factors in the more disadvantaged groups is needed to achieve the larger reduction in mortality rate needed to decrease inequalities.

This blog is based on an editorial published in Heart: Declining cardiovascular mortality masks unpalatable inequalities

First published: 21 October 2019

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Alastair Leyland

Ruth Dundas