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The potential impact of a social redistribution of specific risk factors on socioeconomic inequalities in mortality: illustration of a method based on population attributable fractions
  1. Rasmus Hoffmann1,
  2. Terje Andreas Eikemo1,
  3. Ivana Kulhánová1,
  4. Espen Dahl2,
  5. Patrick Deboosere3,
  6. Dagmar Dzúrová4,
  7. Herman van Oyen5,
  8. Jitka Rychtaříková6,
  9. Bjørn Heine Strand2,
  10. Johan P Mackenbach1
  1. 1Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
  2. 2Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
  3. 3Department of Social research, Vrije Universiteit Brussel, Brussels, Belgium
  4. 4Department of Social Geography and Regional Development, Faculty of Science, Charles University, Prague, Czech Republic
  5. 5Scientific Institute of Public Health, Brussels, Belgium
  6. 6Department of Demography and Geodemography, Faculty of Science, Charles University, Prague, Czech Republic
  1. Correspondence to Dr Rasmus Hoffmann, Department of Public Health, Erasmus Medical Center, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands; r.hoffmann{at}


Background Socioeconomic differences in health are a major challenge for public health. However, realistic estimates to what extent they are modifiable are scarce. This problem can be met through the systematic application of the population attributable fraction (PAF) to socioeconomic health inequalities.

Methods The authors used cause-specific mortality data by educational level from Belgium, Norway and Czech Republic and data on the prevalence of smoking, alcohol, lack of physical activity and high body mass index from national health surveys. Information on the impact of these risk factors on mortality comes from the epidemiological literature. The authors calculated PAFs to quantify the impact on socioeconomic health inequalities of a social redistribution of risk factors. The authors developed an Excel tool covering a wide range of possible scenarios and the authors compare the results of the PAF approach with a conventional regression.

Results In a scenario where the whole population gets the risk factor prevalence currently seen among the highly educated inequalities in mortality can be reduced substantially. According to the illustrative results, the reduction of inequality for all risk factors combined varies between 26% among Czech men and 94% among Norwegian men. Smoking has the highest impact for both genders, and physical activity has more impact among women.

Conclusions After discussing the underlying assumptions of the PAF, the authors concluded that the approach is promising for estimating the extent to which health inequalities can be potentially reduced by interventions on specific risk factors. This reduction is likely to differ substantially between countries, risk factors and genders.

  • Health behaviour
  • health impact assessment
  • international health
  • mortality
  • social inequality
  • demography
  • epidemiology
  • social inequalities
  • social epidemiology
  • public health
  • eastern Europe
  • geography
  • inequalities
  • ageing
  • methodology
  • elderly
  • health expectancy

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  • Funding This work was supported by the Public Health Programme of the European Union, grant number 20081309.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.