Examining Health Inequalities in Slovenia During the Financial Crisis – Key Takeaway Messages

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The inequalities we see in health are only the tip of the iceberg.

Jasminka Dedić, Government Office for Development and European Cohesion Policy of the Republic of Slovenia Striving for equality in health is a dynamic

process, dependent on many factors.

Magda Zupančič, Ministry of Labour, Family and Social Affairs of the Republic of Slovenia

A systems approach and inclusion of key target groups are the main building blocks leading to better health as a fundamental value.

Lea Javornik Novak, Ministry of Labour, Family and Social Affairs

of the Republic of Slovenia Societal changes can shift our

attitudes to health and make specific elements of health more relevant.

Andreja Barle Lakota, Ministry of Education, Science and Sport

of the Republic of Slovenia

Agricultural policy is an additional tool for reducing health inequalities.

Tanja Polak Benkič, Ministry of Agriculture, Forestry and Food of the Republic of Slovenia Vlasta Nussdorfer,

Human Rights Ombudsman of the Republic of Slovenia

National Institute of Public Health Trubarjeva 2, 1000 Ljubljana Telephone: + 386 1 2441 400 E-mail: info@nijz.si

Publications and other materials available at:

http://www.nijz.si

EXAMINING HEALTH INEQUALITIES

IN SLOVENIA DURING THE

FINANCIAL CRISIS

Key takeaway

messages

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The publication “Examining Health Inequalities in Slovenia During the Financial Crisis – Key Takeaway Messages” is a shorter version of the report in Slovene bearing the same title and published by the National Institute of Public Health Slovenia (NIJZ) in 2018. The report is available free of charge online (https://www.nijz.si/sl/publikacije/

neenakosti-v-zdravju-v-sloveniji-v-casu-ekonomske-krize), printed copies can be ordered at info@nijz.si. This publication came about in the framework of the Slovene Resolution on the National Health Care Plan 2016–2025 “Together for a Healthy Society”, which lists better health and less health inequalities among the Slovene population as one of its key objectives. This brief, yet concise version of the publication aims to provide readers with our key findings and takeaway messages on health inequalities in Slovenia in a clear, easy to understand format, which is nonetheless scientific and evidence-based.

We are aware of the fact that (in)equalities in health are a reflection of complex real-life situations, mainly dependent on the wider societal context of the places where we are born, live, work…Health inequalities do not adhere to the principles of social justice, since these inequalities are avoidable. Health inequalities do not occur at random. They are determined by contexts outside the direct control of the individual.

These factors limit individuals of their potential to live longer, healthier lives.

This publication shares the same main conclusion as our first report on inequalities in Slovenia, published in 2011 – namely, that just as in other countries health inequalities in Slovenia do exist. As a general rule, better health is connected to higher socioeconomic status, whereas lower socioeconomic status is linked to worse health. Individuals are therefore unable to acheive the highest possible standard of mental and physical health that is within their rights. The main goal of this report and publication is therefore to raise awareness amongst key stakeholders that can contribute to a reduction of inequalities. The publication puts forth the key findings and analyses of experts in the field of public health employed at NIJZ and the Institute of Macroeconomic Analysis and Development of the Republic of Slovenia, while also including cross-sectoral approaches. This publication reflects the current state of affairs in society and explores the effects of the financial crisis on health. As also stated in the foreword to the full report, it is difficult to

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accurate picture using the full arsenal of tools and knowledge at our disposal. We have demonstrated that health inequalities based on socioeconomic status have not increased in Slovenia during the financial crisis.

An individual's educational attainment is the main indicator of socioeconomic status as illustrated in this publication; in Slovenia, education is currently correlated with income levels. The field of health inequalities is complex and we have done our best to illustrate inequalities through a prism of differing perspectives and throughout different life stages – spanning a comparison of Slovenia with other EU countries, a display of inequalities in various health conditions and health determinants in different life stages, inequalities of particularly vulnerable groups, inequalities based on financial access to healthcare services and examples of good practices that reduce inequalities. We have used all the available data produced by various institutions during our analyses.

Our wish is that this publication will serve as a building block and foundation for future decisions that may reduce inequalities and create a more just environment and life for the entire population.

In-depth analyses, descriptions of vulnerable groups, examples of good practice and further information on methodology and references are available in the full version of the report.

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How Healthy are Slovenes in the Context of the EU?

Figure 1: Selected health indicators, comparison of Slovenia (horizontal bars) and the EU28 average (vertical line), for 2007 and 2014

Slovenia has managed to maintain its traditionally good ranking in regards to certain health indicators (such as infant mortality rate), whilst also ranking amongst the worst countries in the EU in others (such as suicide rate); numerous other health indicators place Slovenia roughly in the middle of the EU ranking (such as life expectancy).

Life expectancy at birth is somewhat above the EU28 average, while Slovenia lags behind the EU28 when it comes to life expectancy at 65 years of age.

-100 -80 -60 -40 -20 0 20 40 60 80 100

Life expectancy at birth (T) Life expectancy at birth (M) Life expectancy at birth (W) Healthy life years at birth (M) Healthy life years at birth (W) Infant mortality per 1000 live birhts Child mortality aged 1 to 14, per 100,000 children Malignant neoplasm, age standardised mortality rate Cardiovascular disease, age standardised mortality rate Suicide, age standardised mortality rate Self-perceived health (“good” or “very good”) (M) % Self-perceived health (“good” or “very good”) (W) % Long-term disease or health problem (M) % Long-term disease or health problem (W) % Individuals over 65 with influenca vaccination % Health expenditure – % GDP BMI over 25 (aged 15 onwards) % Fruit consumption at least once per day (15 years and more) % Vegetables consumption at least once per day (15 years and more) % Smoking (aged 15 and up) % At least one heavy drinking episode over the past 12 months (M)%

At least one heavy drinking episode over the past 12 months (W)%

Slovenia in comparison to the EU28 average (vertical axis)

2007 2014

-100 -80 -60 -40 -20 0 20 40 60 80 100

Pričakovano trajanje življenja ob rojstvu (skupaj) Pričakovano trajanje življenja ob rojstvu (M) Pričakovano trajanje življenja ob rojstvu (Ž) Zdrava leta življenja ob rojstvu (M) Zdrava leta življenja ob rojstvu (Ž) Umrljivost dojenčkov na 1000 živorojenih Umrljivost otrok 1‒14 let na 100.000 otrok Starostno standardizirana stopnja umrljivosti zaradi malignih neoplazem Starostno standardizirana stopnja umrljivosti zaradi srčno-žilnih bolezni Starostno standardizirana stopnja umrljivosti zaradi samomora Samoocena zdravja (delež moških z samooceno dobro ali zelo dobro) Samoocena zdravja (delež žensk s samooceno dobro ali zelo dobro) Delež moških z dolgotrajno boleznijo ali zdravstveno težavo Delež žensk z dolgotrajno boleznijo ali zdravstveno težavo Delež cepljenih proti gripi, starih nad 65 let Zdravstveni izdatki‒delež BDP (%) Delež oseb z indeksom telesne mase nad 25 (15 let in več) Delež oseb, ki vsaj enkrat na dan uživajo sadje (15 let in več) Delež oseb, ki vsaj enkrat na dan uživajo zelenjavo (15 let in več) Delež kadilcev (15 let in več) Delež moških, ki so se vsaj enkrat tvegano opili v zadnjih 12 mesecih Delež žensk, ki so se vsaj enkrat tvegano opile v zadnjih 12 mesecih

2007 2014

Legend:

Shade of orange indicates a deviation of the indicator that is NEGATIVE from a public health perspective.

Shade of green indicates a deviation of the indicator that are POSITIVE from a public health perspective.

-100 -80 -60 -40 -20 0 20 40 60 80 100

2007 2014

-100 -80 -60 -40 -20 0 20 40 60 80 100

2007 2014

-100 -80 -60 -40 -20 0 20 40 60 80 100

Kazalnik Slovenije v primerjavi s povprečjem EU28 (navpičina os)

2007 2014

-100 -80 -60 -40 -20 0 20 40 60 80 100

Kazalnik Slovenije v primerjavi s povprečjem EU28 (navpičina os)

2007 2014

Slovenia in comparison to the EU28 average (vertical axis)

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Figure 2: Life expectancy based on health expenditure per capita, European countries, 2014

Slovenia has been fortunate in maintaining the relatively good health of the population throughout the financial crisis despite relatively low health expenditure in comparison to other EU Member States.

Austria Belgium

Bulgaria Croatia

Cyprus

Czech republik

Denmark

Estonia

Finland

France

Germany Greece

Hungary

Ireland Italy

Latvia Lithuania

Luxemburg The Netherlands

Poland Portugal

Romania

Slovakia Slovenia

Spain Sweden

UK

70 72 74 76 78 80 82 84

0 500 1.000 1.500 2.000 2.500 3.000 3.500 4.000 4.500

Life expectacy

Purchasing power standard (PPS) per inhabitant

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Life Expectancy and Healthy Life Years

Figure 4: Life expectancy at 30 years of age according to educational attainment in men and women in Slovenia, average in period 2012–2014

Figure 5: Expected healthy life years at 30 years of age, according to education and sex, 2005 and 2014

Figure 3: Life expectancy in men and women with lower/higher educational attainment in Slovenia in the periods 2006–2008 and 2012–2014

Low education Middle education High education

• Highly educated Slovenes live longer and are in better health than individuals with lower attained levels of education.

• The gap in life expectancy for individuals aged 30 based on educational attainment decreased in the period 2012–2014 compared to the period 2006–2008, in both sexes.

• The gap in life expectancy at 30 years between individuals with high vs. low educational levels decreased in both sexes in the period 2012–2014 in comparison to the period 2006–2008. There was a greater reduction of inequality for the life expectancy of men than for women, due to increased life expectancy in individuals with lower education and decreased life expectancy in individuals with higher education.

• Individuals with lower educational attainment require additional attention in order to achieve their potential, actively contribute to society and live to a healthy old age.

05 1015 2025 3035 4045 5055 60

30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 72 74 76 78 80 82 84

Life expectancy

Age

Low education 2006–2008 Low education 2012–2014 High education 2006–2008 High education 2012–2014

05 1015 2025 3035 4045 5055 60

30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 72 74 76 78 80 82 84

Life expectancy

Age

Low education 2006–2008 Low education 2012–2014 High education 2006–2008 High education 2012–2014

0 10 20 30 40 50 60 70 80 90 100

Life expectancy at 30 years of age

Naslov osi

0 10 20 30 40 50 60 70 80 90 100

2005 2014

%

Year

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Socioeconomic Inequalities During Pregnancy

Planned pregnancies result in better outcomes. Women with the lowest educational levels are more likely to suffer from unwanted pregnancies, as their abortion rates are higher than those of more highly educated women..

Figure 6: Rate of legal induced abortions based on education and sex in Slovenia

Less educated women face a higher risk for negative outcomes during pregnancy.

There was no change in the frequency of premature labour and low infant birth weight amongst mothers of different educational levels during the financial crisis.

Figure 7: Percentage of pregnant women smokers in Slovenia, according to educational attainment, 2006–2008 and 2012–2014

Young, uneducated women are most likely to smoke during their pregnancies. The percentage of pregnant smokers increased during the financial crisis, as did the percentage of pregnant women with increased bodyweight.

Less educated women are less likely to receive prenatal care and more likely to present late for prenatal visits. Similarly, less educated women attend prenatal and parenting courses less frequently. The financial crisis had no impact on the educational stratification of expecting women attending prenatal/parenting courses.

0 5 10 15 20 25 30 35 40 45 50

Low education Professional education Middle education High education

%

2006–2008 2012–2014

0 5 10 15 20 25 30 35 40 45 50

20–24 years 25–29 years 30–34 years 35–39 years 40 years or more Legal induced abortionrate per1000 women

Age groups

Low education Professional education Middle education High education

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Health and Behaviour of Slovene Youth

Figure 8: Selected indicators in youth with below- and above-average self-assessment of perceived family wealth 2014, Slovenia

• Youth that self-assess their family's financial status as lower exhibit worse health indicators and behavioural traits.

• There was no increase in inequality among youth in the period from 2006 to 2014, with the exemption of smoking on a weekly basis.

• Slovenia ranks in the countries with lower to mid-size disparities among youth with high/low family wealth.

0 10 20 30 40 50 60 70 80 90 100

Victim of bullying Physical activity (at least twice a week)

Daily breakfast Daily consumption of fruit Weekly smoking Weekly consumption of alcohol Satisfaction with life Common psychosomatic symptoms Obesity (self-assessment) Stress due to schoolwork Self-assessment of health (good or excellent)

%

Above average family wealth Under average family wealth

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Self-assessment of health

• Self-assessment of one's health differs according to education and income – individuals with lower educational levels and lower incomes are less likely to rate their health as good.

• Inequalities in self- assessment of good health occur less often in men than in women and did not statistically differ in the observed period.

Figure 9: Percentage of adults, aged 16–64, who rate their health as “good” or “very good”, EU Member States and Slovenia, by educational attainment, 2005 and 2014

Figure 10: Percentage of adults, aged 16–64, who rate their health as “good” or “very good”, according to sex and financial income (in quintiles), Slovenia, 2005 and 2014

0 10 20 30 40 50 60 70 80 90 100 Slovenia (low education)

Portugal Latvia Lithuania Estonia Hungary Poland Croatia Slovenia (middle education) Germany Slovenia (total) Czech Republic Slovakia France Denmark Austria UK EU27 Luxembourg Finland Bulgaria Italy Belgium The Netherlands Spain Romania Sweden Malta Cyprus Ireland Greece Slovenia (high education)

2014 2005

0 50 100

Slovenija (nizka izobrazba) Portugalska Latvija Litva Estonija Madžarska Poljska Hrvaška Slovenija (srednja izobrazba) Nemčija Slovenija (skupaj) Češka republika Slovaška Francija Danska Avstrija Združeno kraljestvo EU27 Luksemburg Finska Bolgarija Italija Belgija Nizozemska Španija Romunija Švedska Malta Ciper Irska Grčija

Slovenija (visoka izobrazba) 2014 2005

0 10 20 30 40 50 60 70 80 90 100

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

%

Year

First quintile Fifth quintile First quintile Fifth quintile

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0 10 20 30 40 50 60 70 80 90 100

2007 2014

%

Year

100 2030 4050 6070 8090 100110 120130 140150

2006–2008 2012–2014

Age-standardized mortality rate per 100.000

Year

Smoking

Figure 11: Percentage of male/female smokers, according to educational attainment, 25 and older, in 2007 and 2014

Men with lower educational levels were 2.5 times more likely to die of lung cancer than men with higher educational levels, while there was no such difference observed in women. There was no difference in mortality over the two observed time periods.

Figure 12: Age standardised mortality rate due to lung cancer in adults aged 25–75, based on education, comparison of periods 2006–2008 and 2012–2014

Men with lower educational levels and women with middle educational levels are more likely to smoke. There has been a decrease in the percentage of highly educated female smokers over the last period.

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Alcohol

Figure13: Age standardised mortality rate directly attributed to alcohol, per 100,000 inhabitants, based on sex, averages 2006–2008 and 2012–2014, Slovenia

Mortality directly attributed to alcohol has increased in the last period, regardless of sex and educational attainment. Inequalities based on educational attainment have not increased over the last period.

Drinking patterns are largely dependent on cultural environments and attitudes to alcohol consumption. In Slovenia, the frequency of high-risk drinking behaviour increases with higher educational levels.

0 10 20 30 40 50 60 70 80 90 100

2007 2014

%

Leta

Figure 14: Percentage of men and women, 25 and older, with at least one heavy drinking episode over the last 12 months, in 2007 and 2014, according to age and education, Slovenia

100 2030 4050 6070 8090 100110 120130 140150 160170 180

2006–2008 2012–2014

Year

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0 5 10 15 20 25 30 35 40 45 50

25–44 let 45–64 let 65 years or more

%

Age groups 0

5 10 15 20 25 30 35 40 45 50

25–44 years 45–64 years 65 years or more

%

Age groups

Mental health

Highly educated individuals are less likely to present symptoms consistent with clinical depression. Likewise, the employment status of an individual significantly impacts their feelings of anxiety and the frequency of clinical depression.

Figure 15: Presence of symptoms of clinical depression (DSM-IV) over the past two weeks, presence of anxiety over the past 12 months, based on education, Slovenia, 2014

Individuals with lower levels of education are more likely to be prescribed at least one anti-anxiety and antidepressant medication, for all age groups and in both sexes (except for men over 65 receiving prescription anti-anxiety medication) than highly- educated individuals.

Figure 16: Percentage of individuals with at least one prescription for anti-anxiety medication, by sex, age and education, Slovenia, 2015

Figure 17: Percentage of individuals with at least one prescription for antidepressant medication, by sex, age and education, Slovenia, 2015

Low education Middle education High education 0

5 10 15 20 25 30 35 40 45 50

Symptoms of clinical depression Anxiety

%

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The trend of suicide reduction in men has come to a halt in the last observed period. Inequalities based on educational attainment have not changed over the two compared periods .

Figure 18: Age standardised mortality due to suicide according to education, comparison between periods 2006–2008 and 2012–2014, and according to sex, Slovenia

0 10 20 30 40 50 60 70 80 90 100

2006–2008 2012–2014

Years

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Obesity, risk factors and cardiovascular disease

• Consumption of the recommended daily amount of vegetables does not differ by educational attainment.

Women consume vegetables more frequently than men.

• Men are more likely to participate in the recommended amount of physical activity, but those with a lower level of education are less physically active. Likewise, women with a lower level of education are also less physically active.

Figure 19: Frequency of recommended amount of vegetable consumption - once or more per day, based on sex and education, Slovenia, 2014

0 10 20 30 40 50 60 70 80 90 100

%

• The percentage of obese individuals decreases as educational levels get higher and has increased in the observed periods (2007 and 2014), particularly among individuals of both sexes with a secondary-school education and men with a college education.

• Inequality in obesity levels has not changed in the observed period.

0 5 10 15 20 25 30 35 40 45 50

2007 2014

%

Leta

Figure 20: Percentage of obese individuals (BMI ≥ 30) based on sex and education, Slovenia, comparison between 2007 and 2014

Year

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0 10 20 30 40 50 60 70 80 90 100

15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84 85–89 90 or more

• Obese individuals with lower levels of education are most susceptible to cardiovascular disease.

• Individuals with lower educational attainment are more often hospitalised due to cardiovascular disease.

We have observed education-based inequalities in both sexes as regards prescriptions for antihypertensive medication, but more so in younger men than in women.

Figure 21: Percentage of individuals hospitalised due to cardiovascular disease, compared to individuals in all age categories, based on educational level, Slovenia, 2015

%

Figure 22: Percentage of individuals with prescriptions for antihypertensive medication, based on educational attainment, Slovenia, 2015

0 5 10 15 20 25 30

15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84 85–89 90 or more

Age groups (years) Age groups (years)

%

Age groups (years) Age groups (years)

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Unintentional injuries in adults

Inequalities in unintentional injuries lessened during the financial crisis, particularly due to a reduction in mortality of men with lower educational levels.

In times of financial insecurity, individuals tend to act with greater caution and abuse alcohol to a lesser extent.

During the financial crisis, the percentage of deaths in traffic accidents in Slovenia due to intoxicated drivers has decreased.

Figure 23: Age standarised mortality (per 100,000 inhabitants) of men and women aged 25–74 due to unintentional injuries, according to educational attainment, Slovenia, 2006–2008 and 2012–2014

100 2030 4050 6070 8090 100110 120130 140

2006–2008 2012–2014

Year

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Vaccination Against Tick-borne Meningoencephalitis

Vaccination against tick-borne meningoencephalitis (TBE) is largely dependent on education – individuals with higher levels of education are vaccinated in higher percentages than those with middle or lower levels of educations.

0 5 10 15 20 25 30 35 40 45 50

2007 2014

%

Leta

Figure 24: Percentage of individuals vaccinated against TBE at least once in their lifetime, men and women, according to educational attainment, 2007 and 2014

Individuals with low levels of education expressed the least interest in TBE vaccination and furthermore, would be interested in TBE vaccination only if it were free of charge.

I am not vaccinated, as I do not have enough information.

0 10 20 30 40 50 60 70 80 90 100

% 0

10 20 30 40 50 60 70 80 90 100

%

Low education Middle education High education Legend:

I do not intend to get vaccinated.

I am not vaccinated but I would consider it if it were free of charge.

I am not vaccinated, because it is too expensive.

%

Figure 25: Reasons reported by individuals for not having received TBE vaccination, according to sex and education, Slovenia, 2014

Year

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Health in the Elderly

• We have not observed a change in inequalities of the elderly when it comes to their own assessment of their health - individuals with lower levels of education rated their health as “good” least often.

• Elderly individuals with lower education are less capable overall – they tend to be more dependent on others for their care, are less mobile and less likely to be in control of their personal finances. This is why the risk of age-related frailty is larger for this group.

Figure 26: Percentage of individuals over 64 who rated their health as “good” in 2007 and 2014, based on level of attained education, Slovenia

Figure 27: Percentage of individuals over 64 who cannot perform the listed activities or can do so only with great difficulty (based on questionnaire about everyday habits), Slovenia, 2014

Elderly with lower levels of education visited the dentist and underwent dental care less frequently.

Figure 28: Percentage of individuals over 65 who answered that they had last visited a dentist over 12 months ago or had never before visited a dentist, according to educational attainment, Slovenia, 2014

• In the elderly, lower levels of education are connected to higher mortality due to falls.

• Inequalities in fall-related mortality have decreased during the global financial crisis.

Figure 29: Standardised fall-related mortality (per 100,000 inhabitants) for women over 64, according to educational attainment, Slovenia, 2006–2007 and 2013–2014

Low education Middle education High education 0

10 20 30 40 50 60 70 80 90 100

2007 2014

%

Year

0 10 20 30 40 50 60 70 80 90 100

Walking up and

down the stairs Bathing or showering Shopping Taking care of finances

%

0 10 20 30 40 50 60 70 80 90 100

%

0 100 200 300 400 500 600 700

2006–2008 2012–2014

Year

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Financial Accessibility to Healthcare

All internationally comparable indicators show that the Slovene population (all income categories) has very good access to the healthcare system, thus providing households with an additional level of financial security.

This feature of the Slovene healthcare system has therefore been successfully maintained also during the financial crisis.

Figure 30: Percentage of health out-of-pocket expenditure in total household consumption, Slovenia and EU countries, 2014

Differences in the scope and structure of direct healthcare expenditure based on household income categories in Slovenia have increased significantly over the past fifteen years.

Figure 31: Percentage of health out-of-pocket expenditure in total household consumption according to income quintiles, 2000–2015

0 1 2 3 4 5 6 7 8 9 10

Bulgaria Malta Cyprus Greece Hungary Portugal Spain Latvia Sweden Belgium Lithuania The Netherlands Finland Italy Austria Ireland Denmark Estonia Poland EU28 Slovakia Czech Republic Slovenia Croatia Germany Romania UK France Luxembourg

%

1,0 1,2 1,4 1,61,8 2,0 2,2 2,4 2,62,8 3,0

2000 2002 2006 2009 2012 2015

%

Year

1. quintile 2. quintile 3. quintile

4. quintile 5. quintile Total

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Table: Overview of indicators based on educational gradient (inequalities in health due to educational differences) and change in inequality

Indicator Educational

gradient Inequality in the observed time period Life expectancy at age 30

Expected years of life in good health at age 30

Early life Smoking during pregnancy

Prenatal care and preparation for delivery

Pregnancy outcomes Health of youth Self-assessment of health

Preoccupation with school Obesity

Self-assessment of health

Smoking and lung cancer Percentage of smokers

Mortality due to lung cancer

Vaccination against tick-borne meningoencephalitis /

Alcohol and mortality High-risk drinking

Mortality directly attributable

to alcohol Nutrition, physical

activity, obesity and cardiovascular disease

Consumption of vegetables /

Physical activity /

Obesity

Cardiovascular disease /

Hospitalisation due to cardiovascular

disease /

Prescription medications due to

pulmonary hypertension /

Mental health Signs of clinical depression /

Feelings of anxiety /

Use of antidepressants /

Use of anti-anxiety medication /

Suicide Mortality due to unintentional injury

Health in the elderly Self-assessment of good health /

Functionality /

Visit to dentist/orthodontist /

Mortality due to falls Legend:

Inequalites in health observed. Individuals with low levels of education have worse health.

Inequalities in health observed. Individuals with high levels of education have worse health.

Inequalities in health have not been observed. Education levels and health are not linked.

Inequalities in health have decreased within the observed time period.

Inequalities in health have increased within the observed time period.

Inequalities in health based on educational attainment have not changed within the observed time period.

/ No data.

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The Vulnerability of the Unemployed during the Financial Crisis

• Unemployment in Slovenia increased during the financial crisis, especially long-term unemployment, which mainly affected those with lower educational attainment and younger adults aged 15 to 24.

• The health of the unemployed is typically worse than that of employed individuals. This is true for the following indicators: obesity and malnutrition, recommended physical activity, smoking, overconsumption of alcohol.

Figure 32: BMI in employed and unemployed individuals, Slovenia, 2014

Figure 33: Percentage of employed/unemployed individuals who smoke, according to sex and age group, Slovenia, 2014

Figure 34: Hazardous drinking of alcohol in employed/unemployed individuals, based on sex and age group, Slovenia, 2014

0 5 10 15 20 25 30 35 40 45 50

Women Men 15-29 years 30-49 years 50-64 years

%

Employed Unemployed

0 5 10 15 20 25 30 35 40 45 50

Women Men 15-29 years 30-49 years 50-64 years

%

Employed Unemployed 0

10 20 30 40 50 60 70 80 90 100

Employed Unemployed

%

Obesity Overweight Ideal bodyweight Malnourishment

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Longstanding illness/health problem

Moderate/severe activity limitation due to a health problem

Weak social support

Figure 35: Longstanding illness/health problem, impairment in everyday activity and social support in employed/unemployed individuals, Slovenia, 2014

Figure 36: Self-assessed diagnoses and mental health disorders in employed/unemployed individuals, Slovenia, 2014

The unemployed rate their health as »good« less often than employed individuals and often suffer from chronic diseases. They have fewer social connections and have more forms of moderate to severe disability in everyday activity due to health-related conditions. They experience anxiety and depression more often, along with other mental disorders.

0 5 10 15 20 25 30 35 40 45 50

Depression Anxiety Other menthal disorders

%

Employed Unemployed

0 5 10 15 20 25 30 35 40 45 50

Weak social support Moderate/severe activity limitation due to a health

problem

Longstanding illness or health problem

% Employed Unemployed

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0 10 20 30 40 50 60 70 80 90 100

Employed Unemployed

%

Never

Three or more years ago In the last three years

The unemployed use dental services less often than the employed.

Figure 37: Percentage of employed/unemployed individuals who visited a dentist, family doctor or specialist at least once over the last 12 months, Slovenia, 2014

Figure 38: Percentage of employed/unemployed women who report having had a pap smear test, aged 20–64, Slovenia, 2014

Figure 39: Percentage of employed/unemployed individuals who report having done a fecal occult blood test, aged 50–69, Slovenia, 2014

The unemployed are less likely to participate in population-based cancer screening programmes such as ZORA (cervical cancer) and SVIT (colorectal cancer) (self-reported data).

0 10 20 30 40 50 60 70 80 90 100

Dentist Family doctor Specialist

%

Employed Unemployed

0 10 20 30 40 50 60 70 80 90 100

Employed Unemployed

%

Never

Three or more years ago Two to three years ago One to two years ago Over the last three years

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Good practices for tackling inequality

The School Fruit and Vegetable Scheme

Good practice in reducing health inequalities in children and youth

• Fruit and vegetable consumption in schools is decreasing despite the implementation of the School Fruit and Vegetable Scheme, however there are differences in schoolchildren of different socioeconomic classes. In girls of lower socio-economic status, consumption has increased, whereas the decrease in consumption was the lowest for boys of lower socio-economic status.

• In the context of comprehensive inter-sectoral measures, the School Fruit and Vegetable Scheme provided a significant countermeasure to the trend of falling consumption of fruit and vegetables amongst children.

Together for Health – For Better Health and Reduction of Health Inequalities

Good practice of recognising and including vulnerable individuals in prevention programmes

• The average vulnerable individual included in this pilot programme was female, aged 52.

• The most frequent vulnerabilities included unemployment, socioeconomic risks and mental health issues.

• The most common obstacles to the participation of vulnerable

individuals in prevention programmes were being uninformed, health issues and lack of motivation.

• The first point of contact to treat vulnerable individuals was most often a regional office of the Unemployment Service of Slovenia, followed by non-governmental organisations, home care units and health promotion units (within individual community healthcare centres).

• Broader local teams were established following a community-based approach and proved to be an excellent tool for stakeholder networking at local level.

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The Svit programme

Population-based screening and early detection programme for colorectal cancer– example of targeted activities for reducing inequalities

• The Svit screening programme carried out a precise communications strategy aimed at the general public, but taking special notice of marginalised groups – such as the less educated, hearing and verbally impaired and speakers of minority languages.

Svit directed specific efforts to increase the lower participation rate detected in certain local communities and the male population, through the activities of

healthcare professionals, non-governmental organisations, other local stakeholders and Svit programme ambassadors.

• While well-thought out communication channels and simplified messages brought about an improvement in educational inequalities for participation in the Svit programme, there nonetheless remains a very large gap between participation of individuals with higher vs. lower education.

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EXAMINING HEALTH INEQUALITIES IN SLOVENIA DURING THE FINANCIAL CRISIS - Key takeaway messages

Editors: Tina Lesnik, Mojca Gabrijelčič Blenkuš, Ada Hočevar Grom, Tatjana Kofol Bric, Metka Zaletel

Authors: Maja Bajt, Jerneja Farkaš Lainščak, Mojca Gabrijelčič Blenkuš, Marta Grgič Vitek, Ada Hočevar Grom, Helena Jeriček Klanšček, Irena Klavs, Tatjana Kofol Bric, Helena Koprivnikar, Aleš Korošec, Marcel Kralj, Darja Lavtar, Tina Lesnik, Mercedes Lovrečič, Barbara Lovrečič, Kristian Majcen, Barbara Mihevc Ponikvar, Dominika Novak Mlakar, Tjaša Pibernik, Martin Ranfl, Ajda Rogelj, Mateja Rok Simon, Maja Roškar, Maša Serec, Andrej Srakar, Sonja Tomšič, Matej Vinko, Pia Vračko, Sanja Vrbovšek, Gaja Zager Kocjan, Metka Zaletel, Ana Zgaga, Tina Zupanič, Eva Helena Zver.

Translation: Tina Lipušček Design: Andreja Frič Electronic edition

Electronic source: www.nijz.si

Published by: National Institute of Public Health, Trubarjeva 2, Ljubljana Place and date publishing: Ljubljana, 2019

Summarized from:

Lesnik T, Gabrijelčič Blenkuš M, Hočevar Grom A, Kofol Bric T, Zaletel M. Neenakosti v zdravju v Sloveniji v času ekonomske krize. Ljubljana: Nacionalni inštiut za javno zdravje, 2018

Copyright

All rights reserved. Reproduction in part or whole in any way and by any media without the written consent of the author is prohibited. Violations are sanctioned in accordance with copyright and criminal law.

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The inequalities we see in health are only the tip of the iceberg.

Jasminka Dedić, Government Office for Development and European Cohesion Policy of the Republic of Slovenia Striving for equality in health is a dynamic

process, dependent on many factors.

Magda Zupančič, Ministry of Labour, Family and Social Affairs of the Republic of Slovenia

A systems approach and inclusion of key target groups are the main building blocks leading to better health as a fundamental value.

Lea Javornik Novak, Ministry of Labour, Family and Social Affairs

of the Republic of Slovenia Societal changes can shift our

attitudes to health and make specific elements of health more relevant.

Andreja Barle Lakota, Ministry of Education, Science and Sport

of the Republic of Slovenia

Agricultural policy is an additional tool for reducing health inequalities.

Tanja Polak Benkič, Ministry of Agriculture, Forestry and Food of the Republic of Slovenia Vlasta Nussdorfer,

Human Rights Ombudsman of the Republic of Slovenia

National Institute of Public Health Trubarjeva 2, 1000 Ljubljana Telephone: + 386 1 2441 400 E-mail: info@nijz.si