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Health inequalities and equal opportunities

This special edition of the Utrecht Public Health Monitor on health disparities and equality of opportunity describes the existing differences in health, lifestyle and underlying causes of unhealthiness in Utrecht and the development of these differences up to 2019. The data is from before the coronavirus pandemic. The impact of the coronavirus outbreak and subsequent measures are not the same for everyone As such, we have supplemented our figures with an estimate of the situation in Utrecht during the coronavirus pandemic, based on national information on the consequences and risk groups.

This publication describes differences between groups of Utrechters caused by social inequality. It does not address differences resulting from genetic, biological or other individual determinants of health. This special issue describes differences in health, lifestyle and underlying causes by gender, age, education, financial situation, migration background and neighbourhood. These are indicators of the different conditions in which people grow up, learn, work, live, and age. We describe differences in health and lifestyle between men and women and age groups, although these are largely genetic, biological, or individual in nature, as the differences in health opportunities between men and women and different age groups are largely the result of an unequal social, economic, and political context.

The focus on health opportunities shifts attention from the outcome, namely health or lifestyle, to the underlying causes of unhealthiness. In this special issue we distinguish between healthcare, income situation, education and skills, work situation and working conditions, physical environment, safety and social environment. This is in line with the World Health Organization (WHO)  and the G4 proposal against inequality of opportunity . These causes are also identified in the Utrecht Combined Public Health Model. Health opportunities are not equal for everyone. As such, in addition to differences in health and lifestyle, we also describe differences in the underlying causes or opportunities in Utrecht and how they have evolved in recent years.

Health disparities and equality of opportunity in Utrecht

There are certain groups in Utrecht who are more likely to have health issues or an unhealthy lifestyle. These are primarily residents with primary education, pre-vocational secondary educationor lower general secondary education and residents who have difficulty making ends meet. They are also more likely to have poorer health. These groups of residents are more likely to suffer from the underlying causes of unhealthiness, such as financial problems or unfavourable housing conditions. In many cases, this also applies to residents of Overvecht and Zuidwest, people with a non-Western migration background, and the elderly. These people need something more or different to achieve equal opportunity for good health.

In recent years, up to 2019, deprivation primarily increased among Utrechters with lower educational attainment and residents who have difficulty making ends meet. In particular, Utrecht is seeing an increase of differences in income situation, access to health care, housing conditions, social contacts and loneliness. These are important leverage points for Utrecht's approach to health disparities and equality of opportunity.

These differences likely only increased during the coronavirus pandemic. This is particularly true of disparities in health, access to health care, unemployment, housing and living environment, social safety and social contacts. The high-risk groups mentioned above are hit harder during the pandemic. New risk groups have also emerged, such as adolescents and young adults, and those with fewer digital resources or skills. These developments highlight the urgency of a focused approach to health disparities and equality of opportunity.

Reading guide

We describe differences in health and lifestyle among Utrecht adults by gender, age, education, financial situation, migration background, and neighbourhood. We describe
1. the most recent differences in Utrecht, mostly in 2018 or 2019
2. the development of or trends in these differences.
3. Observed changes during the coronavirus pandemic and the estimated impact on health and lifestyle disparities.
We also describe the methodology, indicators and data sources.

Distribution of Utrecht population by age, gender, education level, financial situation, migration background and neighbourhood

 

Health and Lifestyle

Changes during the coronavirus pandemic

COVID-19 and the associated countermeasures have both positive and negative effects on the health of Utrechters. In particular, groups in vulnerable situations are hit hard in terms of physical and mental health. These are mainly people who already have health disadvantages, such as those with lower educational attainment, those who have difficulty making ends meet and those with limited health or language skills. Existing health disparities are expected to widen as a result. We are also seeing new groups emerging in Utrecht that will have problems with their health and well-being as a result of the coronavirus and countermeasures, such as adolescents and young adults, freelancers and people with flexible employment contracts.

New forms of inequality are also emerging, such as differences in the impact of the coronavirus and measures associated with resilience, personality traits, and preferences such as for a quiet or busy social life, for example. While some people are currently experiencing anxiety and loneliness, others are experiencing the pandemic as a quiet period with reduced social pressure. This is a different dividing line in our society than the existing and frequently mentioned dividing lines such as educational attainment and making ends meet. It is a dividing line where the impact of the pandemic on people's health is partly determined by the extent to which they can cope with a constantly shifting new normal in a resilient and healthy way.

Disparities in Utrecht

Disparities in health and lifestyle in 2018 are greatest between groups with different levels of education or groups that do or do not have difficulty making ends meet. Utrechters with good health and a healthy lifestyle are more often under 40, have a bachelor’s or master's degree, do not have difficulty making ends meet and do not have a migration background. The same applies to residents of the Noordoost and Oost districts. Poorer health and lifestyle is more common among Utrechters with a lower level of education (primary school, lower secondary education, or lower secondary vocational education), who have difficulty making ends meet, with a non-Western migration background and inhabitants of the Overvecht district. Differences between men and women are primarily seen in lifestyle, and men are more likely to have an unhealthy lifestyle than women. Residents aged 80 and older with an average health rating of at least good, generally have a better lifestyle than residents aged 55 to 79.

Health

Quality of life
The perceived health of Utrechters with a bachelor's or master's degree is better than that of Utrechters with only primary or secondary education. 56% of Utrechters who have difficulty making ends meet feel healthy. This is 84% among Utrechters who have no difficulty making ends meet. Perceived health also differs among adults from different migration backgrounds. 62% of adults with a non-western migration background have good perceived health. This is 80% among adults without a migration background and 82% among adults with a western migration background.

Perceived health by education, 2018
Perceived meaning and purpose in life differs between Utrechters who can and cannot make ends meet. 68% of Utrechters who have difficulty making ends meet feel that their lives have meaning and purpose, compared to 78% of Utrechters who have no difficulty making ends meet. Adults under the age of 40 are more likely to report that they are able to adapt to changes in their lives than adults aged 80 and older. They are also more likely to feel confident about the future. This is 86% among 19 to 39 year olds, compared to 54% among those over 80. Utrechters who have difficulty making ends meet and Utrechters with lower educational attainment are also less able to adapt to changes in their lives and less likely to feel confident about the future.

Physical and mental health
Chronic conditions, such as cardiovascular disease and diabetes, are much more common among Utrechters with lower educational attainment. Adults with only primary education are also six times more likely to feel severely hampered in their daily activities by chronic conditions than adults with a bachelor’s or master's degree.

Cardiovascular disease by education, 2018

 
Utrechters who have difficulty making ends meet have poorer mental health. 50% of them have at least one mental illness, compared to 22% of Utrechters who have no difficulty making ends meet. Adults who have difficulty making ends meet are also 5.5 times more likely to have a high risk of anxiety disorder or depression than adults who do not have difficulty making ends meet.

Lifestyle

Overweight and obesity are most common among Utrechters aged 55 to 64 and 65 to 79, and least common among 19 to 39 year olds. Adults with only basic education are 2.5 times more likely to be overweight and more than 5.5 times more likely to be obese than among adults with a bachelor’s or master's degree. Smoking is more common among Utrechters who have difficulty making ends meet—32% smoke. This is 17% among Utrechters who do not have difficulty making ends meet. Self-reported [excessive and heavy alcohol use] is low among Utrechters with a non-Western migration background compared to those without a migration background. There is a big difference in heavy alcohol use between neighbourhoods. In Leidsche Rijn, 4% of the inhabitants are heavy drinkers; in the Binnenstad district, this is 17%; and in Oost, almost 14%.

Heavy alcohol use by neighbourhood, 2018

Development in disparities until 2019

Health

Health disparities are widening between groups with different levels of education and people who do or do not have difficulty making ends meet. In general, health disparities are narrowing between different age groups, groups with different migration backgrounds, and between men and women. Utrecht’s elderly population has become increasingly healthy in recent years. The health of this group is improving faster than that of younger groups, narrowing the gap.

The health disadvantage of the group that has difficulty making ends meet is growing. Their perceived health is declining, and there is a stronger decline in feelings of happiness than among residents who do not have difficulty making ends meet. The group that has difficulty making ends meet also has a greater increase in mental illness, limitations in their activities of daily living, chronic conditions in general, and cardiovascular disease in particular, than the group that does not have difficulty making ends meet.

Good level of perceived health by financial situation

Health disparities between groups with different levels of education are exacerbated by the fact that Utrechters with only primary education have a higher risk of anxiety disorders or depression, limitations in their activities of daily living, and cardiovascular disease than those with higher educational attainment.  

Health disparities between groups with different migration backgrounds are generally narrowing, as Utrechters with a non-Western migration background have reported fewer mental or physical chronic conditions (e.g., diabetes) in recent years. Their confidence in the future also increased in 2018 compared to 2016. Differences in limitations form an exception; they are increasing, as the proportion of Utrechters with a migration background who feel limited by disorders increased between 2016 and 2018.

At least two chronic conditions by migration background

Lifestyle

Lifestyle differences in Utrecht are generally narrowing as groups with unhealthier lifestyles show a stronger increase or a lesser decrease in healthy behaviour than other groups. In particular, the differences between younger and older adults are narrowing, as younger Utrechters have started adopting healthier behaviour faster. They have reduced excessive and heavy alcohol use; they have decreased smoking faster and are eating more breakfast more often. Adults under 40 years of age are also exercising less, which has further reduced the difference in exercise between younger and older Utrechters, who were already moving less. However, this is an undesirable decrease, because more people are now exercising less. The gender gap is narrowing as men catch up with women through a greater decline in obesity and excessive alcohol use.  

Lifestyle differences are becoming more pronounced between groups with different levels of education and differences in their ability to make ends meet. Utrechters with only primary education are increasingly seriously overweight (obese) and eat breakfast less often. On the other hand, the differences in alcohol consumption by level of education are narrowing. The decrease in excessive or heavy alcohol use is stronger among Utrechters with secondary education than among those with only primary education. Residents who have difficulty making ends meet were more likely to use alcohol excessively in recent times than those who do not have difficulty making ends meet.

Obesity by education

Method, indicators and data sources


Adults

This special issue focuses on differences in health, lifestyle, and underlying causes in adulthood, primarily because the available data on these topics only concerns adults. As such, this issue does not address disparities for children and youth and does not address intergenerational inequality. Data on children or adolescents are used for a good representation of some causes, such as the use of early childhood education and young people with a starting qualification, as these are good indicators of the quality and performance of the education system and, in turn, the underlying cause “education and skills”

Description of differences

We describe differences in health, lifestyle and underlying causes by gender, age, education, financial situation, migration background and neighbourhood. The text focuses on statistically significant or relevant differences and trends.

Underlying causes for unhealthiness

We distinguish several underlying causes in this special issue of the VMU, in line with the World Health Organization (WHO)  and the G4 proposal against inequality of opportunity , namely healthcare, income situation, education and skills, work situation and working conditions, physical environment, safety and social environment.

Indicators

In identifying these causes, we use the same indicators as the WHO and the G4 as much as possible. The WHO chose these indicators based on their policy relevance and classified them according to the leverage point for addressing disparities in the specific indicator through systemic interventions. For example, the indicator “providing informal care” says something about the organisation of our healthcare system, making it an indicator of the cause “healthcare”. The indicator “not enough money to heat the house” says something about the housing market in Utrecht, making it an indicator for the cause “physical environment”.

Data sources

The main data sources on health, lifestyle and underlying causes in Utrecht are the Health Survey (19 years and older) and the Citizen Survey (16 years and older). The most recent data from the Health Survey was collected in 2018; the data from the Citizen Survey was collected in 2019. We also used registration data from the Utrecht Monitor. The WHO reports on a total of 103 indicators in their Health Equity Status Report. We report on indicators for which Utrecht data are available. We do not report on all WHO indicators. For example, no data is available on the life expectancy or working conditions of different groups in Utrecht.

The estimate of developments in Utrecht during the coronavirus pandemic described in this special issue is based on the following sources. For the description of changes in health disparities and underlying causes during the coronavirus pandemic, we used information from national reports (by RIVM, SCP, GGDrU, Trimbos, among others) supplemented with local Utrecht information from council letters and reports (by Students Research Together and Platform 31, among others). The results were discussed and further focused on the Utrecht context in 12 interviews with municipal officials.

The full report also includes information on differences in health care, income situation, education and skills, work situation, physical environment, safety and social environment. Read more about the results (in Dutch).