Inequalities in life expectancy and quality of life

1. Key messages

People with a higher socio-economic status (SES) live longer. The gap in life expectancy at birth between the highest and lowest SE group (defined as quartiles of a multidimensional SE score) was 9.3 years for men and 6.3 years for women in 2020. The gaps have increased until 2011 then fluctuated at a higher level afterwards.
People with a higher SES also live longer in good health. The gap in health expectancy without disability at 25 years (Healthy Life Years) between the highest and lowest educational levels (EL) was 10.5 years for men and 13.4 years for women in the decennia 2011. The gaps in health expectancy have increased between the decennia 2001 and 2011.
The percentage of people rating their health as less than good shows large inequalities: people in the low educational level rate their health 2.2 times more often as less than good (35%) than the high educated people (16%), after age-adjustment. The inequalities in self-rated health have increased until 2013 then stabilized at a higher level than before.

2. Background

Socio-economic (SE) health inequalities refer to systematic disparities in health between SE groups, most often in disfavour of less advantaged social groups. SE health inequalities have been consistently observed throughout industrialized societies for the whole scope of health topics, ranging from health determinants to mortality [1,2]. Tackling health inequalities is a priority for the WHO [3], the European Union [4], and for Belgium [5–7]. In order to assess progress towards reducing health inequalities, it is important to measure and monitor them [8,9].

This section reports inequalities in health outcomes related to the duration and quality of life. Several recent studies have been used to provide the results shown here [10–14]. They use different SE markers. The methodological details can be found in this annexe

  • Recent inequalities in life expectancy at birth (LE_0) are based on the works of Aerden et al. [14] and Bourguignon et al. [10]. As a marker of SE position, they used a multidimensional score, afterwards grouped in quartiles.
  • Life expectancy and disability-free life expectancy at 25 years (LE_25, DFLY_25) are based on the work of Renard et al. [12] with the educational level (EL) grouped in 3 classes (Low, Mid, High) as marker of SE position. Life expectancies at 25 years with other SE markers are based on the work of Eggerickx et al. [11].
  • Inequalities in self-rated health were derived from the Health Interview Survey (HIS) and used educational level in 3 classes as marker of SE position.

Beside the outcomes broken down by SE level, we also calculated the magnitude of the inequalities by computing four inequality indices:

  • Absolute and relative difference between the low and the high SE groups;
  • Composite Inequality Index (CII), i.e. the number of years gained in life/health expectancy expected for the whole population if all groups experienced the life/health expectancy of the high SE group;
  • Population Attributable Fraction (PAF), i.e. the percentage of gain in health expected in the whole population if all groups experienced the health of the high educated group.

3. Results

Current situation (last available results)

Socio-economic inequalities in life expectancy, health expectancies and self-perceived health

In Belgium, in 2020, the gaps in LE_0 between the first and the fourth quartile of the multi-dimensional score were 9 years among men and 6 years among women [10], a slight increase compared to 2019. Moreover, a social gradient is observed, with LE_0 increasing from one quartile to the other. If there were no inequalities and the whole population experienced the LE_0 of the high SE group, the gain in LE_0 in the population would reach 4.2 years in men and 2.7 years in women (Composite inequality index CII, own calculations).

In 2011 (with 5 years follow-up), the gaps in LE_25 between people with a low EL and those with a high EL were 6.1 years for men and 4.6 years for women (EL grouped in 3). The LE_25 gain would reach 3.4 years for men and 2.4 years for women if there were no inequalities. For HE_25 the educational gap was even higher, reaching 10.5 years for men and 13.4 years for women [12]. The HLE_25 gain would reach 6.0 years for men and 7.2 years for women if there were no inequalities.

For self-rated health, large inequalities were also observed. In 2018, absolute inequalities reached 19 percentage-points; low educated people were 2.2 times more likely to rate their health as less than good compared to high educated people The PAF reaches 30%, meaning that if the whole population rated their health as the high EL group then the prevalence of poor self-rated health would decrease by 30%.

Socio-economic inequalities in life expectancy, health expectancies and self-rated health, Health Interview Survey, Belgium, 2018
Sources: (a) Bourguignon et al. [10]; (b) Renard et al. calculations based on census 2011 linked with a 5-years' mortality follow-up, and educational level (EL) grouped in 3 categories [12]; (c) own calculations based on the Health Interview Survey, with EL grouped in three categories, Sciensano [15] 

Socio-economic indicator Year Sex Value for the low SE group Value for the high SE group Absolute difference
Relative difference
CIIabs PAF
Life expectancy at birth(a) Multidimensional score (quartiles) 2020 Men 73.5 82.8 -9.3 - 4.2(d) -
Women 79.7 86 -6.3 - 2.7(d) -
Life expectancy at 25 b) Educational levels (3) 2011-2015 Men 51.7 57.8 -6.1 - 3.4 -
Women 57.3 61.9 -4.6 - 2.4 -
Disability-free life expectancy at 25(b) Educational levels (3) 2011-2015 Men 37 47.5 -10.5 - 6.0 -
Women 35.5 49 -13.4 - 7.2 -
Poor self-rated health (% people ≥ 15 yr)(c) Educational levels (3) 2018 Both 34.7% 15.8% 18.9% 2.2 - 30.0%
 
Socio-economic gaps in life expectancy based on different socio-economic markers
Large SE gaps in life expectancy are observed whatever the SE marker choosen. Depending on the SE marker, the gaps in LE_25 between the extreme SE positions ranged in 2011 (with 5 years FU) between 5.6 and 8.7 years for men and between 3.1 and 6.4 years for women.
 
Difference in life expectancy at 25 years old according to different socio-economic variables, Belgium, census 2011 with 5 years mortality follow up 
Sources: (a) Eggerickx et al. [11] + (b) Renard et al. [12]
 

Trends

Trends in life expectancy inequality

Absolute differences in LE_0 have increased between 1992-1996 and 2011-2015. Then, we observe a slight decline in 2019 and again a slight increase in 2020. A similar evolution is observed for the CII.

  • Absolute gaps in LE
  • CIIabs in LE

Evolution of the gaps in life expectancy at birth between the first and last quartiles of the multidimensional socio-economic score, by sex, Belgium, 1992-2020
Source: (a) Aerden et al. + (b) Bourguignon et al. [10,14]

Evolution of the population-level measure of absolute inequality in life expectancy at birth (CIIabs), by sex, Belgium, 1992-2020
Source: Own calculations from (a) Aerden et al. + (b) Bourguignon et al. [10,14]

Trends in health expectancy inequality

The evolution between 2001 and 2011 reveals a large increase in the gaps in years of HE_25 (+ 4.0 years for men and + 4.1 years for women). Using the CII, the inequality index weighting for the differences in the composition of the populations, we observe a strong increase in inequality for health expectancy CII among both men (+73%) and women (+20%). All inequality indices show an increase of inequality in health expectancy.

  • Absolute gaps in HE
  • CIIabs in HE

Evolution of the gaps between low and high educational levels for disability-free life expectancy, by sex, Belgium, 2001 and 2011
Source: Own calculations from censuses 2001 and 2011 linked with mortality

Evolution of population-level measure of absolute educational inequality in disability-free life expectancy, Belgium 2001 and 2011
Source: Own calculations based on censuses 2001 and 2011 linked with mortality, and HIS 2001 to 2013

Trends in self-rated health

Inequalities in self-rated health have increased until 2013 then stabilized: the relative and absolute differences follow the same pattern and have increased until 2013, they stayed constant at a higher level between 2013 and 2018. The PAF has increased since 1997 but this increase is not significant.

Rate difference and rate ratio in reporting less than good self-rated health, Belgium, 1997-2018
Source: Own calculation based on Health Interview Survey, Sciensano [15]

4. Read more

View the metadata for this indicator

HISIA: Interactive Analysis of the Belgian Health Interview Survey

References

  1. Mackenbach J. Health inequalities: Europe in profile. Expert Report commissioned by the EU. Department of Health Publications; 2006.
  2. Feinstein JS. The relationship between socioeconomic status and health : A review of the literature. The Milkbank Quarterly. 1993.
  3. WHO Commission on Social Determinants on Health. Closing the gap in a generation: health equity through action on the social determinants of health. WHO; 2008.
  4. Executive Agency for Health and Consumer. Second Programme of Community Action in the Field of Health 2008-2013. European Commission; 2007.
  5. Vlaamse overheid. Vlaamse Actieplan Geestelijke Gezondheid, Strategisch plan 2017-2019. 2017.
  6. Gouvernement wallon. Plan prévention et promotion de la santé en Wallonie. Partie 1: définition des priorités en santé. Namur; 2017. 
  7. Arrêté royal du 18 juillet 2013 portant fixation de la vision stratégique fédérale à long terme de développement durable: http://www.etaamb.be/fr/arrete-royal-du-18-juillet-2013_n2013011468.html. Moniteur Belge. 2013 Oct 8;
  8. Braveman PA. Monitoring equity in health and healthcare: a conceptual framework. JHealth PopulNutr. 2003.
  9. Maeseneer JD, Willems S. Terugdringen Sociale Gezondheidskloof: van concept naar politieke implementatie. Gent: Ghent University; 2021.
  10. Bourguignon M, Damiens J, Doignon Y, Eggerickx T, Fontaine S, Lusyne P, et al. Variations spatiales et sociodémographiques de mortalité de 2020-2021 en Belgique. L’effet de la pandémie Covid-19, Document de travail 27. Louvain-la-Neuve: Centre de recherche en démographie; 2021.
  11. Eggerickx T, Sanderson JP, Vanderschrick C. Les inégalités sociales et spatiales de mortalité en Belgique : 1991-2016; Espace Population et Société. 2018;
  12. Renard F, Devleesschauwer B, Van Oyen H, Gadeyne S, Deboosere P. Evolution of educational inequalities in life and health expectancies at 25 years in Belgium between 2001 and 2011: a census-based study. Arch Public Health. 2019.
  13. Tafforeau J, Drieskens S, Charafeddine R, Van der Heyden J. Enquête de santé 2018 : Santé subjective. Bruxelles, Belgique: Sciensano; Report No.: D/2019/14.440/26.
  14. Aerden KV, Damiens J, Moortel DD, Eggerickx T, Gourbin C, Huegaerts K, et al. Causes of health and mortality inequalities in Belgium: multiple dimensions, multiple causes. 
  15. Health Interview Survey, Sciensano, 1997-2018. https://www.sciensano.be/en/projects/health-interview-survey