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8. Changes in environmental health inequalities over time
Firmino Machado, Matthias Braubach
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This chapter provides an analysis of the changes in environmental health inequalities for countries in the WHO European Region, comparing information from this report (mainly based on data collected in 2016) and the 2012 report (mainly based on data collected in 2008/2009, see WHO Regional Office for Europe, 2012). The comparison looks at the changes in inequality gaps and shows whether the difference in environmental exposure across population subgroups – between rich and poor or rural and urban populations, for example – has increased or decreased over time.
Three change patterns were identified in the variations observed for the environmental health inequality indicators: • success stories – a reduction in inequalities in most countries; • mixed evidence – no clear pattern of increasing or decreasing inequalities across countries; • challenges – an increase in inequalities in most countries.
These patterns are presented below, illustrated by example figures showing the absolute changes in inequality gaps between two reporting years. Box 3 outlines the method applied to calculate the change in inequalities.
Box 3. Calculation of inequality changes over time
The arrow base represents the inequality gap determined in the first year of reporting and the arrowhead the inequality gap quantified in the second.
Green arrows represent a decrease and blue arrows an increase in inequalities. If the data are available for only one year it is not possible to compute the difference over time, so the inequalities are represented by a grey circle.
While the green and blue arrows indicate whether inequalities have decreased or increased between the reporting years, they do not provide further insight into the dynamics of inequalities and why the change has occurred. To provide this information, vertical arrow symbols (↑ and ↓) are inserted next to the blue and green arrows for each country to represent the increase or decrease over time for the population groups compared (such as lowest versus highest income quintile, rural versus urban or female versus male). The first arrow shows whether the exposure prevalence (or mortality rate) has gone up or down for the first group (for example, the lowest income quintile); the second arrow whether it has gone up or down for the second group (for example, the highest income quintile), thereby facilitating greater understanding of the dynamics of the inequalities and the causes of their changes between the groups over time. This is especially important when the data suggest a decrease of inequality between two population groups, but the reduction is caused not by lower prevalence or mortality in the disadvantaged group but by higher prevalence or mortality in the advantaged group. Statistically speaking, this leads to a decrease of inequality between the groups, but it is certainly not something to be celebrated. Therefore, a full assessment of the inequality trends should look not only at the overall decrease or increase in inequality gaps (represented by the green and blue arrows) but also at the change dynamics for the groups compared.
In some cases the inequalities may be reversed, which means that for a specific indicator, in one reporting year, the difference between the population groups is negative (for example, in one reporting year the highest income quintile might be more affected or exposed than the lowest). Such reversed inequality is reflected by † when it applies to the first reporting year and by ‡ when it applies to the second reporting year; inclusion of both symbols († and ‡) represents reversed inequalities in both reporting years. If just one year has reversed inequality, the magnitude of change in inequality cannot easily be quantified by the length of the blue or green arrow alone.
