Access to this full-text is provided by Springer Nature.
Content available from International Journal for Equity in Health
This content is subject to copyright. Terms and conditions apply.
R E V I E W Open Access
Measuring health inequalities: a systematic
review of widely used indicators and topics
Sergi Albert-Ballestar
1,2
and Anna García-Altés
1,2,3*
Abstract
Background: According to many conceptual frameworks, the first step in the monitoring cycle of health
inequalities is the selection of relevant topics and indicators. However, some difficulties may arise during this
selection process due to a high variety of contextual factors that may influence this step. In order to help
accomplish this task successfully, a comprehensive review of the most common topics and indicators for measuring
and monitoring health inequalities in countries/regions with similar socioeconomic and political status as Catalonia
was performed.
Methods: We describe the processes and criteria used for selecting health indicators from reports, studies, and
databases focusing on health inequalities. We also describe how they were grouped into well-known health topics.
The topics were filtered and ranked by the number of indicators they accounted for.
Results: We found 691 indicators used in the study of health inequalities. The indicators were grouped into 120
topics, 34 of which were selected for having five indicators or more. Most commonly found topics in the list
include “Life expectancy”,“Infant mortality”,“Obesity and overweight (BMI)”,“Mortality rate”,“Regular smokers/
tobacco consumption”,“Self-perceived health”,“Unemployment”,“Mental well-being”,“Cardiovascular disease/
hypertension”,“Socioeconomic status (SES)/material deprivation”.
Conclusions: A wide variety of indicators and topics for the study of health inequalities exist across different
countries and organisations, although there are some clear commonalities. Reviewing the use of health indicators is
a key step to know the current state of the study of health inequalities and may show how to lead the way in
understanding how to overcome them.
Keywords: Health inequalities, Health indicators, Review, Health policy
Introduction
Strong efforts to tackle health inequalities can be seen at
international and national level since the 1980s. In early
2008, the World Health Organization’s (WHO) Global
Commission on Social Determinants of Health called for
action on the social determinants of health, the condi-
tions in which persons are born, grow, work, live, and
age, to “close the gap in a generation”[1]. In late 2008,
the Spanish Public Health General Direction (Dirección
General de Salud Pública) and the Foreign Health of
Health Ministry and Social Policy (Sanidad Exterior del
Ministerio de Sanidad y Política Social) requested the
constitution of the Commission for the Reduction of
Social and Health Inequalities (Comisión para Reducir
las Desigualdades Sociales en Salud en España (CRDSS-
E) [2]. The mission of CRDSS-E was to elaborate on a
proposal of intervention measures to reduce health in-
equalities. The CRDSS-E published two documents: one
analysing health inequalities in the Spanish context [3],
and another describing some policy proposals to tackle
them [4]. In 2011, a total of 125 countries, Spain being
© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
* Correspondence: agarciaaltes@gencat.cat
1
Catalan Health System Observatory, Agència de Qualitat i Avaluació
Sanitàries de Catalunya (AQuAS), 81-95 (2a planta), 08005 Barcelona, Spain
2
CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
Full list of author information is available at the end of the article
Albert-Ballestar and García-Altés International Journal for Equity in Health
(2021) 20:73
https://doi.org/10.1186/s12939-021-01397-3
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
one of them, developed and signed the Rio Political
Declaration on Social Determinants of Health [5]. The
declaration recommended interventions from govern-
ments and international organisations [6].
At a regional level in Catalonia, tackling health inequal-
ities is one of the main goals of both the Catalan Health
Plan 2016–2020 (led by the Health Department of the
Catalan Government) [7] and the Interdepartmental and
Intersectorial Public Health Plan 2017–2020 (PINSAP) [8,
9]. During the past years, various reports and peer-
reviewed papers about the health effects of the economic
crisis on the population of Catalonia were published by
the Catalan Health System Observatory [10–17].
Overall, much effort has been devoted to monitoring
and tackling health inequalities at regional, national, and
international levels. Even so, OECD countries continue
to present large disparities in health, including, for ex-
ample, significant differences in life expectancy between
people with the highest and lowest levels of education
[18]. The selection of topics represents the first step in
monitoring health inequalities according to many con-
ceptual frameworks and is highly relevant, as these
topics will potentially limit the detection of health in-
equalities within the population, hence playing a key role
in providing evidence for posterior decision-making [19,
20]. Yet some difficulties may arise during the selection
of relevant topics, as well as their health indicators. A
wide diversity of indicators for monitoring health in-
equalities have been used across different countries and
organisations; this is due to the high variety of context-
ual factors that may have an influence on it, such as the
study goals or the information resources available.
In order to help accomplish this task successfully, the
objective of this study is to perform a systematic review
of the most common topics and indicators used for
measuring and monitoring health inequalities in the re-
ports, projects, and databases of international, national,
and regional governmental organizations.
The main purpose of this study is to provide a broad
overview of health inequalities topics considered relevant
by different public health organizations. Nevertheless,
the focus of this review is on countries/regions with
similar socioeconomic and political status to Catalonia.
It may also be useful for other organizations who decide
to study or monitor health inequalities to accomplish its
very first step: topic selection. In addition, gaining some
insights about which health issues are being prioritized,
as well as which indicators were used, are considered
secondary goals.
Material and methods
First, a bibliographic search was performed using
PubMed, Google Scholar, and Google search engine with
the terms “health inequalities”,“health observatories”
and “health inequalities indicators”. Occasionally, names
of concrete regions, countries, or organisations were
added to these terms (i.e., “Andalucía health observa-
tory”or “Canada health inequalities”). The search was
performed from March to June of 2019. Once finished, a
set of inclusion criteria was applied; studies included in
the review had to:
1. Include health inequalities indicators: All the
reports that contained no health indicators were
automatically discarded (i.e., policy frameworks
[21]).
2. Have been carried out by a governmental
organisation or a related entity, whether at an
international, national, or regional level: the
reports not published by governmental (or
government-related) organisations were discarded.
3. Have a socioeconomic and political status
similar (or highly related) to Catalonia: some
reports were discarded due to significant differences
in the socioeconomic profile of the countries they
were studying in comparison to Catalonia or Spain.
Once the reports were selected, the authors performed
a quality control check of the indicators shown in the re-
ports and databases. The indicators had to match the
basic anatomy of an indicator as a minimum require-
ment to be considered an indicator. This basic anatomy
consists of containing data, i.e. the numerical data in-
put; and containing good metadata, like a title and an
explanation of how an indicator is defined and calcu-
lated [22]. In addition, the different reports found
were classified according to the geo-political region
they were studying: 1. international, 2. national, and
3. regional (Table 1).
After this selection process, the indicators were
grouped into topics by semantic matching of their
definition as well as by the area of knowledge there
are intended to measure. Most of the topics were
supported by references of relevant organisations like
the WHO or the United Nations (UN) (see Table 2).
Each topic was uniquely named in accordance with
the area of knowledge that instruments were intended
to measure. Indicators from different sources were
often merged due to high similarities between them
(most commonly, the only differences were stratifiers
such as age, gender or region). Every topic had to be
formed by at least five indicators in order to be con-
sidered relevant enough; the topics with less than five
indicators were discarded.
The search was performed by the two researchers, and
the results shared in order to agree on any discrepancies.
All the data was organised in spreadsheets to identify
common indicators, and then sorted by the amount of
Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 2 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Table 1 Reports and datasets identified in the search
Type Organisation/
Institution
Report or database title Number
of
indicators
URL for website or PDF Reference
International WHO Regional Office
for Europe
Data Management Tool 6 http://dmt.euro.who.int/classifications/tree/
B#B03
[28]
International European Commission Health inequalities in the EU 12 https://ec.europa.eu/health/sites/health/files/
social_determinants/docs/
healthinequalitiesineu_2013_en.pdf
[25]
International Social Protection
Committee Indicators
Sub-group (European
Commission)
Portfolio of EU Social Indicators for the
Monitoring of Progress Towards the EU
Objectives for Social Protection and
Social Inclusion
12 https://ec.europa.eu/social/
BlobServlet?docId=14239&langId=en
[26]
International Various organisations
(European
Commission funded
project)
I2SARE 37 https://www.sergas.es/Saude-publica/-I2
SARE-Galicia
[27]
International European Commission European Core Health Indicators
(ECHI)*
64 https://ec.europa.eu/health/indicators/echi/
list_en#id3
[24]
International European Commission Eurostat (SDG) 13 https://ec.europa.eu/eurostat/web/sdi/good-
health-and-well-being
[23]
International The World Bank World Bank Open Data (Indicators
section)
52 https://data.worldbank.org/indicator/ [30]
International WHO 100 Core Health Indicators (plus health-
related SDGs) 2018
100 https://www.who.int/healthinfo/indicators/1
00CoreHealthIndicators_2018_infographic.
pdf?ua=1
[29]
National Institute of Health
Equity
Marmot Indicators Release 2017 10 http://www.instituteofhealthequity.org/
about-our-work/marmot-indicators-release-2
017
[35]
National Canadian Institute for
Health Information
Health Inequalities Map 105 https://infobase.phac-aspc.gc.ca/health-
inequalities/docs/health-inequalities-map-en.
pdf
[34]
National Public Health Agency
of Canada (PHAC)
Key Health Inequalities in Canada: A
National Portrait –Executive Summary
22 https://www.canada.ca/en/public-health/
services/publications/science-research-data/
key-health-inequalities-canada-national-
portrait-executive-summary.html
[33]
National Government of
Scotland
Long-term monitoring of health
inequalities: December 2018 report
14 https://www2.gov.scot/Publications/201
8/12/8085
[37]
National National Health
Service (England)
England Analysis: NHS Outcome
Framework Health Inequalities
Indicators 2016/17
30 https://www.england.nhs.uk/wp-content/
uploads/2017/07/nhs-outcome-framework-
health-inequalities-indicators-2016-17.pdf
[36]
National Institut d’Estadística
d’Andorra
Observatori Social d’Andorra 13 https://observatorisocial.ad/ [31]
National Australian Institute of
Health and Welfare
Health inequalities in Australia:
morbidity, health behaviours, risk
factors, and health service use
20 https://www.aihw.gov.au/getmedia/0cbc6
c45-b97a-44f7-ad1f-2517a1f0378c/
hiamhbrfhsu.pdf
[32]
National WHO Regional Office
for Europe
Health Inequalities in Slovenia 32 http://www.euro.who.int/__data/assets/pdf_
file/0008/131759/Health_inequalities_in_
Slovenia.pdf
[38]
National Instituto Nacional de
Estadística (Portugal)
Indicadores Sociais - 2011 16 https://censos.ine.pt/xportal/xmain?xpid=
INE&xpgid=ine_
publicacoes&PUBLICACOESpub_boui=1492
79938&PUBLICACOEStema=5553
8&PUBLICACOESmodo=2
[40]
National Ministry of Health and
Social Policy of Spain
Moving Dorward Equity in Health:
Monitoring Social Determinants of
Health and the Reduction of Health
Inequalities
30 https://www.mscbs.gob.es/profesionales/
saludPublica/prevPromocion/promocion/
desigualdadSalud/PresidenciaUE_2010/
conferenciaExpertos/docs/
haciaLaEquidadEnSalud_en.pdf
[39]
Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 3 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
indicators they included. The names of the indicators in
the spreadsheets were those given in the original reports
or their metadata information.
Results
In total, 21 reports, projects, and databases were iden-
tified and classified into three categories: 1. inter-
national [8], 2. national [10], and 3. regional [3]. In
the first category, international, all the projects se-
lected were carried out or funded by the European
Commission [23–27], the WHO [28,29]orthe
World Bank [30]. In the following category, national,
studies were conducted by health agencies or
governments of countries such as Andorra [31],
Australia [32], Canada [33,34], England [35,36],
Scotland [37], Slovenia [38], Spain [39]orPortugal
[40]. In the last category, regional, some reports pub-
lished by Spanish regions were included (Andalucía
[41], Barcelona [42], Valencia [43]). A total of 691
health indicators were identified (Table 1).
Following an iterative process of evaluation, we identi-
fied a core set of 120 candidate topics, of which 34 were
finally selected (Fig. 1). Table 2describes a complete list
of 34 topics with the corresponding definition of each
topic. The ten most commonly used were: “Life expect-
ancy”,“Infant mortality”,“Obesity and overweight
Table 1 Reports and datasets identified in the search (Continued)
Type Organisation/
Institution
Report or database title Number
of
indicators
URL for website or PDF Reference
Regional Observatorio
Valenciano de la Salud
Desigualdades en Salud en la
Comunidad Valenciana
26 https://www.sp.san.gva.es/DgspPortal/
docs/20180301_Desigualdades_Salud_OVS2
018.pdf
[43]
Regional Ajuntament de
Barcelona
Desigualtats en salut, respostes a nivell
local: Polítiques per reduir les desigualtats
en salut a la ciutat de Barcelona
22 http://www.consorci.org/media/upload/
arxius/coneixement/salut-publica/2017/
D_%20Malmusi_Desigualtats_28-09-2017.pdf
[42]
Regional Escuela Andaluza de
Salud Pública
Guía de indicadores para medir las
desigualdades de género en salud y sus
determinantes
55 https://www.easp.es/project/guia-de-
indicadores-para-medir-las-desigualdades-
de-genero-en-salud-y-sus-determinantes/
[41]
Fig. 1 Flowchart of the processes undertaken to review the most common topics in the study of health inequalities
Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 4 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Table 2 List of topics ranked by the number of health indicators grouped within
Topic Description of measured topics Reference
Life expectancy Time that a concrete population is expected to live. [23–30,33–39,41–43]
Infant mortality Death of young children under the age of 1 in a population. [24–30,33,34,36,38–42]
Obesity and overweight (BMI) Measurement of people having more body fat than is optimally healthy,
to an extent that it may have a negative effect on health.
[22,24,25,27,29–33,36,38,
42,43]
Mortality rate Measurement of the number of deaths in a particular population, scaled
to the size of that population, per unit of time.
[25–27,29,30,34,37,38,40–
43]
Regular smokers/ tobacco
consumption
Measurement of the number of people consuming tobacco (smoking)
in a population.
[23–25,27,29,31–34,38,42,
43]
Self-perceived health Measurement of the expression of subjective assessment by the
respondent of his/her health.
[23–26,31,32,34,36–38,42,
43]
Unemployment Measurement of people above a specified age that are not in paid
employment or self-employment and are currently available for work
during the reference period.
[24,25,27,28,30,34,36,38,
39,41,42],
Mental well-being Level of psychological well-being or an absence of mental illness. [24,29,33,34,36–39,41–43]
Cardiovascular disease/ hypertension Measurement of the number of people affected by cardiovascular
disease (CVD) or hypertension in a population.
[24,27,29,32,34,36–38,41,
43]
Socioeconomic status (SES)/ material
deprivation
Measurement of the social standing or class of individuals in a population,
as well as the state of economic strain and durables.
[24,25,28,33–35,38,39,42],
Diabetes/ insulin resistance Measurement of people affected by diabetes (a chronic, metabolic disease
characterised by elevated levels of blood glucose) or insulin resistance in
a population.
[24,25,29,30,32–34,38,41],
Physical activity Measurement of physical activity (any bodily movement produced by
skeletal muscles that requires energy expenditure) in a population.
[24,29,31,32,34,38,39,42],
Cancer Measurement of people affected by cancer (group of diseases that can start
in almost any organ or tissue of the body when abnormal cells grow
uncontrollably, go beyond their usual boundaries to invade adjoining parts
of the body and/or spread to other organs) in a population.
[24,25,27,33,34,36,37,43]
HIV Measurement of people affected by HIV (an infection that attacks the body’s
immune system, specifically the white blood cells, called CD4 cells) in a
population.
[23,24,27,29,30,34,40,41],
Long-term limitations/ chronic
illnesses
Measurement of people affected by diseases or conditions that are persistent
or long-lasting.
[23–26,31,34,36,37]
Tuberculosis Measurement of people with health issues caused by the infection of the
bacteria Mycobacterium tuberculosis in a population.
[23,29,30,33,34,40,42,43]
Hazardous alcohol consumption Measurement of hazardous alcohol consumption in a population. [24,29,32–34,37,38]
Low birthweight Measurement of birth weights of infants of 2499 g or less in a population. [27,29,34,37,38,41,42],
Perinatal, neonatal and stillbirths
mortality
Measurement of foetus or neonate deaths in a population. [24,27,29,30,36,38,43]
General practitioner (GP) utilisation Measurement of the utilisation of general practitioners (medical doctors) in
a population.
[24,26,31,32,34,36,39]
Suicide/self-harm Measurement of the number of intentionally self-caused deaths and/or
other intentional self-harm injuries in a population.
[25,29,33,34,36,38,43]
Healthcare resources Measurement of resources such as materials, personnel or facilities that can
be used to provide healthcare.
[24,27,30,38–40,43]
Alcohol consumption Measurement of people consuming alcohol (a toxic and psychoactive
substance with dependence-producing properties) regularly in a population.
[24,25,31,32,37,38]
Road traffic accidents (injuries and
deaths)
Measurement of deaths and injuries due to road traffic accidents (crashes)
in a population.
[23,24,27,29,30,38],
Food consumption (vegetables, fruit,
salt)
Measurement of people ingesting solid foods in a population. [24,29,32,34,38,39]
Primary studies/ illiteracy Measurement of people with primary studies (first stage of
formal education) or illiterate (not able to read) in a population.
[24,28,32,35,39,42]
Child well-being Indicators to measure the general health, proper growth, and well-being
of children.
[31,33,35,39–41],
Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 5 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
(BMI)”,“Mortality rate”,“Regular smokers/tobacco con-
sumption”,“Self-perceived health”,“Unemployment”,
“Mental well-being”,“Cardiovascular disease/hyperten-
sion”,“Socioeconomic status (SES)/material deprivation”.
However, some topics that ranked below these were
closely related with some of the most common topics;
for example, “Perinatal, neonatal and stillbirths mortal-
ity”might be considered as a subtype of “Infant mortal-
ity”; and “Perceived mental health”is similar to both
“Mental well-being”and “Self-perceived health”. Further-
more, some indicators may represent antithetically the
same area of knowledge; that is the case for the indica-
tors in the topic “Long-term limitations/chronic ill-
nesses”and the indicator “Healthy Life Years (HLY)”
[within the topic “Life expectancy”], where the former
(long-term limitations or chronic illnesses) is used to de-
termine the latter (the end of a healthy life condition).
Nevertheless, the metadata of the health indicators
within each topic was highly homogeneous: they all had
similar definitions and methodology.
In general, the indicators within each topic were very
similar. In fact, often the differences among them were re-
lated to the different stratifiers (such as sex, age or region)
used for their calculation. For example, in the first topic
“Life expectancy”, indicators have different variations:
“Life expectancy at birth”[23–25,27–29,32,33,37,40–
42], “Life expectancy at birth by sex”[22,24–27,33,34],
“Life expectancy at a certain age”[25,33,35,40], “Life ex-
pectancy by educational attainment level”[25], and “Life
expectancy at birth by socioeconomic status”[25]. Com-
plex measures of inequality, such as “Slope index of in-
equality (SII) for male and female life expectancy”[34]
may be considered another (more advanced) variation.
Furthermore, in the case of a health outcomes or diag-
nostics (such as mortality or cancer) the concrete disease or
cause may also play an important role in the heterogeneity
found among the health indicators. Indicators are focused
on different aspects, such as prevalence and incidence, mor-
tality, preventive measures, or treatments. For example, for
the topic “HIV”:“HIV incidence”[23,26,28,33,40],
“Prevalence of HIV, male/female, by ages”[29,39]and
“AIDS-related mortality rate”[28,39] are the most com-
mon, yet “Antiretroviral therapy (ART) coverage”[28]and
“HIV test results for TB patients (positive results)”[28] can
also be relevant.
The results of the study show that the most common
topics are related to:
–Mortality/life expectancy: “Life expectancy”[44,45],
“Infant mortality”[46]or“Mortality rate”[47] are
widely used to study health inequalities.
–Incidence/mortality rates of specific diseases:
“Cardiovascular disease/hypertension”,“Cancer
(incidence or mortality)”[48], “Diabetes/insulin
resistance”[49], “HIV”[50], “Tuberculosis (TB)”[51]
or “Respiratory diseases”.
–Social determinants of health [52]:
◦“Living and working conditions”where this
could be studied at an individual level, was highly
ranked: “Unemployment”[53] and “Primary
studies/illiteracy”. Otherwise, these indicators were
at the bottom of the list.
◦This was similar for “Individual lifestyle factors
and social and community networks”topics, which
can also be studied at an individual level: “Obesity
and overweight (BMI)”[54,55], “Regular smokers/
tobacco consumption”[56], “Alcohol consumption”
[57], “Hazardous alcohol consumption”,“Physical
activity”[58], and “Food consumption (vegetables,
fruit, salt)”.
◦Socioeconomic level: “Socioeconomic status
(SES)/material deprivation”[59,60].
Table 2 List of topics ranked by the number of health indicators grouped within (Continued)
Topic Description of measured topics Reference
Respiratory disease Measurement of people affected by a disease affecting the organs and
tissues that make gas exchange in a population.
[24,29,32,36,38,41],
Work-related health risks Measurements of risks and/or diseases as a result of an exposure to risk
factors from work activity in a population.
[23,24,29,36,39,43]
Dental care/ oral health Measurement of people with oral diseases or provided with dental health
services in a population.
[26,32–34,36,38],
Policy and legislation Indicators measuring policy-making initiatives. [24,28,29,36,39,40]
Perceived mental health Measurement of the expression of subjective assessment by the respondent
of his/her mental health and/or psychological well-being.
[24,30,33,34,36]
Unintentional injuries Measurement of people affected by any injury that is not caused on
purpose or with intention to harm in a population.
[24,33,36,38,41],
Pregnancy care/ breastfeeding Indicators measuring the care provided during pregnancy or other
pregnancy-related issues, such as breastfeeding, in a population.
[24,32,34,39,41],
Hip fractures and surgical procedures Measurement of the amount of surgical procedures and/or relevant fractures
that will likely require surgical procedures (i.e. hip fractures) in a population.
[24,30,36,41,43]
Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 6 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
◦Healthcare system: “Healthcare resources”and
“Policy and Legislation”.
Discussion
Main results of the study
The results of the study showed that the most com-
mon topics were related to mortality/life expectancy,
incidence/mortality rates of specific diseases (i.e., TB
or HIV), and social determinants of health, such as
living and working conditions, and individual lifestyle
factors and social and community networks, according
to Dahlgren and Whitehead’s model of the social de-
terminants of health [52]. The indicators that can be
studied at an individual level tended to be highly
ranked, in comparison to those that are studied at
different levels (such as hospital or region), which
tended to be at the bottom. Many methodological dif-
ferences between indicators were due to stratifiers in
their calculation.
Study selection criteria
To include health inequalities indicators was a funda-
mental requirement for any report in order to be in-
cluded in the review. Hence, although some reports
provided in-depth insights about tackling health inequal-
ities (i.e., [21,61]) they were not selected due to lack of
health indicators monitoring.
In addition, to be carried out by a governmental or
a government-related organisation was also an import-
ant requirement, as many academic and/or private in-
stitutions carry out studies and reviews of health
inequalities, but their policy-making influence is lim-
ited. Their reports tend to be focused on concrete
knowledge fields, such as gender influence [62], the
effects of economic crises [63], or access to healthcare
[64]; which are also relevant for the study of health
inequalities but whose authorship does not fit the se-
lection criteria, as the main interest of this paper is
identifying the health inequalities indicators used by
health agencies or similar government-related entities.
The reports not produced by this kind of organisation
were rejected.
Lastly, to have a socioeconomic and politic status simi-
lar or highly related to Catalonia criteria was intended
to exclude reports whose health indicators were adapted
to least developed/developing countries where, for ex-
ample, access to treatments of diarrhea for infants may
still be an issue [65]. Hence, some reports were dis-
carded due to significant differences in the socioeco-
nomic profile of the countries they are studying in
comparison to Catalonia or Spain.
Thesecriteriawereappliedtoallthereportsand
studies found after an extensive search. The addition
of country/region names in the search responded to
the need of knowing how particular regions of inter-
est were dealing with health inequalities. Interest in
regions was mainly based on previous knowledge of
concrete public health organizations studying those
regions, as well as interest in looking for other orga-
nizations in charge of tackling health inequalities in
regions similar to Catalonia. Nevertheless, as in any
review, it is not possible to ensure that absolutely all
the reports suitable for this study were found during
the search, nor that they were selected after applying
the selection criteria.
Grouping health indicators into topics
As stated above, the most frequent health indicators
were grouped into topics according to the health domain
they were measuring (with each indicator related to only
one topic). For example, although “Percentage of 15-
year-olds who were overweight in 2009–10, EU Member
States by sex”[25] and “Obesity rate by body mass index
(BMI) (sdg_02_10)”[23,66] are different indicators per
se, they are both intended to measure the same health
issue and, hence, were grouped under the same topic
“Obesity and overweight (BMI)”under the indicator
name “Obesity and/or overweight (total, by sex, age, or
educational level)”.
Most of the selected health indicators were taken
from the official statistics of different countries or
international organisations, whose development and
methodology has been closely consolidated over many
years and respond to international standards. In
addition, most of these indicators are related to rele-
vant knowledge areas for the study of health inequal-
ities, such as lifestyle habits, deprivation, and
mortality.
To prioritise the most relevant topics, all the groups
with less than five health indicators were deleted.
This meant that, unfortunately, interesting topics such
as the “Years of potential life lost”[34,36,42], “Un-
met health needs”[23,26,39]and“Passive smokers”
[33,34] were not taken into consideration. Neverthe-
less, this selection does not imply per se a periodic
monitoring of the selected health indicators, as spe-
cific topics not present in this list may be studied ac-
cording to ultimate needs.
Relevance of the most common topics
All the topics aim to measure and study the relation
between determinants of health and health outcomes.
Interestingly, three of the top five topics in the list
(see Table 2) are related to mortality: life expectancy,
infant mortality, and mortality rate. Life expectancy at
birth is an indicator of mortality conditions and, by
proxy, of health conditions [44]. Hence, life
Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 7 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
expectancy as well as other mortality-related topics
are widely used in the study of health inequalities.
Living and working conditions, such as BMI or smok-
ing, are also key factors in the study of health inequal-
ities as both share a strong socioeconomic gradient [54,
56]. Therefore, as may be expected, they appeared
among the top 10 positions in the list of topics (see
Table 2). According to our review, the most common
way to measure socioeconomic status is to analyse the
unemployment rates and material deprivation level of
the population.
In Spain, some regions use less common health in-
dicators for studying health inequalities that may be
interesting for particular knowledge areas. For ex-
ample, the Valencian Observatory of Health uses the
“Caregiver profile”, which they report to be mostly
women, without primary studies, 57-years-old on
average, and reporting bad self-perceived health. In
addition, they also use “Reasons why contraceptive
methodsarenotusedbyageandnationalityof
women”as well as a “Sexual-health information re-
sources (school, parents, friends, etc.)”,whichmay
help to understand possible sexual health inequalities
[43]. In the Andalusian School of Public Health, the
indicator “Psychosis and mental illnesses due to drugs
or alcohol abuse”may be helpful to estimate various
negative health outcomes of alcohol and substance
abuse that the healthcare system will need to address
[41]. Even so, more than a half of topics in Table 2
appear in their reports.
Asmaybeexpected,thehealthindicatorsusedin
other reports produced by the Catalan Health System
Observatory, such as the “Community Health Indica-
tors”, match the implicit measurement concept be-
hind many of the topics: obesity and overweight,
mortality by age (including infant), self-perceived
health, and population with primary studies are some
of them [67].
Health indicators
As can be seen in Table 3, health indicators were com-
bined within each topic if stratifiers such as population
sex, age, or region were the only difference in their cal-
culation methodologies. Some indicators were also
merged if they were formerly different in the way they
expressed the same data (i.e., raw number, rate per 1000
or 100,000).
The health indicators within each topic often cover
a different aspect relevant to health inequalities. For
example, in the topic “Tuberculosis”[23,29,33,34,
40,42,43] indicators about incidence, prevalence, or
mortality can be observed. In addition, health indica-
tors about treatment coverage or vaccination are also
included in this topic. Overall, in most topics,
indicators try to measure every relevant (and measur-
able)aspectofthetopic.
Common stratifiers are sex, age, and studied region,
something that is coherent with the determinants of
health perspective and the focus on inequalities. How-
ever, the stratifiers found are highly heterogeneous
and may also include socioeconomic status, educa-
tional level, or nationality/country of origin, among
many others.
Research fitted to monitor health inequalities
This comprehensive review was carried out to help
accomplish the first step in the process for tackling
and monitoring health inequalities: selecting high-
impact issues and health indicators [19,20]. The
next steps in the analysis will be to carefully take
into account stratifiers such as area of residence,
gender, age, and nationality. Lastly, after the identifi-
cation of key health inequalities, decision-making
stakeholders will need to play a role during the last
steps: determining priorities of action and imple-
menting changes. The time variable will play a key
role in the monitoring, as it will indicate the pos-
sible health consequences of policy-making decisions
[19,20].
Conclusions
Reviewing the most common health indicators and
topics used in the study of health inequalities may
help research teams in different ways. First, having
an overview of what is being done by their neigh-
bouring countries or regions may highlight issues
that should not be missed when selecting relevant
health topics to study. Second, even if some topics
might not ultimately be chosen as a priority of ac-
tion, having a complete list of key issues will provide
an overview of what is relevant in the study of health
inequalities, as well as some interesting insights.
Lastly, knowing what other research institutions are
working on will promote potential collaborations be-
tween organizations, creating synergies and bonds
that may lead to better understanding and monitor-
ing of health inequalities.
At a regional level, these results are highly valuable
for the first stages of health inequalities monitoring
cycles in Catalonia. This study provided the basis for
choosing health topics to study as well as helped gain
insights about which indicators should be used. In
addition, regions with similar socioeconomic status
and goals in tackling health inequalities may benefit
from this research. Similarly, at a national and inter-
national level these results may help organizations
shift the focus towards undermined health inequalities
Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 8 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Table 3 List of indicators by topic
Topics Indicators Reference
Life expectancy Life expectancy at birth or at certain age (total, by sex, educational level
and/or socioeconomic status)
[23–30,33–36,38,41–43]
Health-adjusted life expectancy [33,34]
Inequality in life expectancy, slope index of inequality (SII) for male and
female life expectancy
[35,39]
Healthy life years (total, by sex, region and/or socioeconomic status) [25,26,36,37,39,43]
Slope index of inequality for male and female disability-free life expectancy [35]
Infant mortality Infant mortality (total, by sex, by socioeconomic status, deprivation or
disposable family income)
[24–30,33,34,36,38,40–42]
Infant mortality of newborns weighting at least 500 g [34]
Inequality in infant mortality [39]
Highest and lowest infant mortality rates per 1000 live births and measures
of inequality between EU Member States, 2000–2010
[25]
Obesity and overweight (BMI) Obesity and/or overweight (total, by sex, age, or educational level) [22,24,25,27,29–33,36,38,
42,43]
Body mass index [24]
Mortality rate All-cause mortality (total, by sex, age, or region) [25,27,29,34,37,38,41–43]
Death rates by cause of death [26,29,40,42]
% completeness of death registration with cause-of-death information [30]
Regular smokers /tobacco consumption Smoking/tobacco consumption (total, by frequency of consumption, age,
sex, employment and occupational status and/or by difficulties
experienced in paying bills)
[23–25,27,29,31–34,38,42]
Tobacco and alcohol consumption [43]
Pregnant women smoking [24]
Self-perceived health Self-perceived health (total, by age and/or sex) [23–26,31,32,34,37,38,42,
43]
Total health gain as assessed by patients for elective procedures: physical
health related procedures/psychological therapies
[36]
Unemployment Unemployment (total, by duration/long-term) [24,25,27,28,30,38,42]
Employment of people with long-term conditions/mental illness/
disabilities
[36,41]
Eligibility for employment insurance (aged 15–69) [34]
Age dependency ratio (% working-age population) [30]
Population living in jobless households [39]
Employment gap [39]
Mental well-being Risk of psychological suffering [42]
Health-related quality of life for people with mental illness
(eventual or recovery)
[36]
Psychological well-being or discomfort (by age, by using GHQ-12) [24,37,43]
Mental disorders or illness (ICD9MC: 290–319 / including addictions) [39,41]
Morbidity: neurotic, personality, and other non-psychotic mental disorders
(except drugs or alcohol) (ICD9MC: 300–302, 306–319)
[41]
Depression (mental health) [38]
Mental illness hospitalisation rate (total, by age) [33,34]
Coverage of services for severe mental health disorders [29]
Cardiovascular disease/ hypertension Mortality due to cardiovascular causes, including heart diseases
(total, by sex and/or age)
[27,34,36,37,43]
Arterial hypertension [32,38,41]
Blood pressure [24,29]
Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 9 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Table 3 List of indicators by topic (Continued)
Topics Indicators Reference
Proportion of stroke patients reporting an improvement in activity [36]
Cardiovascular and heart diseases (including heart attacks, angina pectoris,
and heart failure)
[38]
First ever hospital admission for heart attack (aged under 75 years) [37]
30-day in-hospital case-fatality AMI and stroke [24]
Socioeconomic status (SES)/ material
deprivation
Working poor [33,34,39]
Disposable family income/family SES [39,42]
Income tax base [38]
People in households in receipt of means-tested benefits [35]
Slope index of inequality for people in households in receipt of
means-tested benefits
[35]
% at risk of poverty –with less than 60% of the median income/% at
persistent risk of poverty (by intensity of poverty)
[39]
% who own a house and car [39]
% areas with > 20% population poor [39]
Age-standardised percentage of people aged 25 and over by severity of
material deprivation
[25]
SII Income/SII Deprivation (by perceived health)/inequality relative index/
Gini coefficient (income distribution)/salary gap/income inequality
(S80/S20) within and across local areas
[25,28,39]
Population below poverty line and income inequality [24]
Diabetes / Insulin resistance Age-standardised prevalence rate of anti-diabetic drug recipients [38]
Diabetes (excluding gestational) (by region, age) [25,30,32–34,41]
Raised blood glucose/diabetes among adults [29]
Diabetes control [24]
Physical activity Physical activity, active or moderately active (total or during free time, by
sex and/or age)
[24,31,34,38]
Sedentarism/insufficient physical activity [29,32,42]
% children by the number of hours of physical activity during a week [38]
Little social or recreational activity [39]
Cancer Cancer mortality (total, by sex, age) [27,36,37]
Cancer incidence (total, by age) [25,34,37]
Lung cancer incidence or mortality [33,34,43]
Survival rates cancer (1–5 years from all cancers/diagnosed at stages 1 and
2)
[24,36]
Colorectal cancer screening, past 5 years (aged 50–74) [34]
HIV HIV incidence / prevalence (total, by sex, age) [24,27,29,30,34,40,41]
AIDS-related mortality rate [29,40]
People living with HIV who know their status [29]
Antiretroviral therapy coverage [29]
Prevention of mother-to-child transmission [29]
HIV test results for TB patients (positive results) [29]
Death rate due to TB, HIV, and hepatitis by sex [23]
Long-term limitations/ chronic illnesses Health-related quality of life for people with long-term conditions [36]
Long-term/chronic conditions, limitations, or illness (total, by age, sex) [24,25,31,34,37]
Self-reported chronic morbidity or limitations in daily activities [24,26]
Physical and sensory functional limitations [24]
Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 10 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Table 3 List of indicators by topic (Continued)
Topics Indicators Reference
Death rate due to chronic diseases by sex [23]
Tuberculosis Incidence/prevalence of TB (by country of origin, nationality, age, and sex) [29,30,33,34,40,42,43]
Evolution of anti-TB vaccination (BCG) [40]
TB notification rate [29]
Coverage for TB treatment/drug susceptibility testing (for active, latent
infection or drug-resistant)
[29]
Death rate due to TB, HIV, and hepatitis by sex [23]
Hazardous alcohol consumption Hazardous alcohol consumption/heavy drinking (total, by age) [24,33,34,38]
Alcohol-related deaths (aged 45–74 years) [37]
High-risk alcohol consumption [32]
Harmful use of alcohol, defined according to the national context as
alcohol per capita consumption (aged 15 years and older) within a
calendar year in litres of pure alcohol
[29]
Low birthweight Low birthweight [27,29,34,37,38,42]
Preterm delivery [29,38]
Hospital discharges due to delayed intrauterine growth, foetal malnutrition,
shortened pregnancy and low birth weight, caesarean sections, and low
birth weight infants (by province)
[41]
Small for gestational age [34]
Perinatal, neonatal, and stillbirths/foetal
mortality
Perinatal mortality [24,27,43]
Neonatal mortality rate [29,30,36]
Under-5 mortality rate [29,30]
Stillbirth mortality [29,36]
Foetal mortality by nationality [43]
Stillbirths, perinatal mortality, and infant mortality [38]
General practitioner (GP) utilisation Health professionals (including doctor/GP/specialist) consultations
(by time period)
[31,32,34]
Care utilisation (including GP) [24,26]
Experience of GP services/Out of Hours service [36]
% without a GP [39]
Suicide/self-harm Suicide mortality [25,29,33,34,38]
Suicide and mortality from injury of undetermined intent among people
with recent contact from NHS
[36]
Suicides and self-injuries [43]
Healthcare resources Hospital beds [24,27,30]
Health facilities [40]
% areas understaffed in health & education [39]
Physicians employed (total or rate, by region) [24,27,38,40]
Specialist surgical workforce (per 100,000 population) [30]
Nurses employed including/excluding midwives (total and rate) [24,27,40]
Alcohol consumption Alcohol consumption (total, by sex) [24,31,38]
Alcohol first hospital admissions (aged under 75 years) [37]
Alcohol risk [32]
Patterns of alcohol consumption [25]
Road traffic accidents (injuries and
deaths)
Mortality caused by road traffic injury (per 100,000 people) [29,30]
Healthy life years lost by traffic accidents and falls [38]
Road injuries and deaths (register-based and self-reported) [23,24,27]
Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 11 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Table 3 List of indicators by topic (Continued)
Topics Indicators Reference
Food consumption (vegetables, fruit,
salt)
Fruit/vegetable consumption (total, by times a day, by age) [24,34,38]
Salt intake [29,32]
Low access to healthy food [39]
Primary studies/ illiteracy Population by education (including early school leavers) [24,28,39,42]
Young people who are not in education, employment or training [35]
Days away from study or work [32]
Results in math and literacy or years of education [39]
% illiterate or does not know the language well [39]
Child well-being Hospital discharges in girls and boys by age [41]
Children well-being/achieving a good level of development at age 5 [35,39]
Early childhood development [33]
Incidence of one of the 17 most common disorders in children, by sex
and age
[31]
Respiratory disease Mortality rate from respiratory disease (including COPD, total, by age) [36,38]
COPD and associated diseases (ICD9MC: 490-496) [24,41]
Bronchitis and acute bronchiolitis including emphysema (ICD9MC: 466) [32,41]
Care-seeking for symptoms of pneumonia [29]
Work-related health risks Health-related quality of life for carers [36]
Occupational diseases [43]
Work accidents [39]
Health worker density and distribution [29]
Work-related health risks [24]
People killed in accidents at work [23]
Dental care/ oral health Dental consultations [26,32,34]
Tooth extractions in secondary care for children under 10 [36]
Dental care (regular brushing of teeth, regular visits to the dentist, proper
diet, and the use of protective agents)
[38]
Dental disease (caries and periodontal disease)] [36,38]
Dental pain or discomfort, past month (aged 18+) [34]
Inability to chew [33,34]
Decay-missing-filled teeth index (aged 6–17) [34]
Policy and legislation A measure of the effectiveness of post-diagnostic care in sustaining
independence and improving quality of life
[36]
New cases of International Health Regulations (IHR)-notifiable diseases and
other notifiable diseases
[29]
Total net official development assistance to medical research and basic
health sectors prepared
[29]
International health regulations capacity and health emergency
preparedness
[29]
Integrated programmes in settings, including workplace, schools, hospital [24]
Expenditure on public health administrations [40]
Legislation, plans and funds to fight discrimination and structural health
inequalities
[28,39]
Prevention of HIV in key populations [29]
Policies and practices on healthy lifestyles including nutrition [24]
Perceived mental health Psychological distress (total or by place, by age) [24,30,34]
Excess under 75 mortality rates in adults with common mental illness [36]
Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 12 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
topics or explore new areas of knowledge (yet unstud-
ied or with a different perspective).
Abbreviations
AIDS: Acquired immune deficiency syndrome; AMI: Acute myocardial
infarction; BCG: Bacillus Calmette-Guérin; BMI: Body mass index;
COPD: Chronic obstructive pulmonary disease; CRDSS-E: Comisión para
Reducir las Desigualdades Sociales en Salud en España; CVD: Cardiovascular
disease; ECHI: European Core Health Indicators; GHQ-12: 12-Item General
Health Questionnaire; GP: General practitioner; HI: Health indicators;
HIV: Human Immunodeficiency Virus; HLY: Healthy Life Years;
ICD9MC: International Classification of Diseases, Clinical Modification;
IHR: International Health Regulations; NHS: National Health Service;
PDF: Portable document format; PHAC: Public Health Agency of Canada;
PINSAP: Interdepartmental and Intersectorial Public Health Plan;
PTCA: Percutaneous transluminal coronary angioplasty; SDG: Sustainable
Development Goals; SES: Socioeconomic status; SII: Slope index of inequality;
TB: Tuberculosis; URL: Uniform resource locator; UN: United Nations;
WHO: World Health Organization
Acknowledgements
We thank Neus Carrilero-Carrió (Agència de Qualitat i Avaluació Sanitàries de
Catalunya (AQuAS), Barcelona, Spain) for support in reviewing drafts and as-
sistance with writing.
Authors’contributions
SA performed the main bibliographic review as well as the selection and
organisation of health indicators and topics. AGA supervised the whole
process, contributed to the conceptualisation of the paper and provided
extensive comments and improvements to the drafts. The author(s) read and
approved the final manuscript.
Funding
All the activities performed were funded by the Agència de Qualitat i
Avaluació Sanitàries de Catalunya (AQuAS) and CIBER de Epidemiología y
Salud Pública (CIBERESP).
Availability of data and materials
No analysis of quantitative data was performed. Hence, data availability
declaration is not applicable.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Catalan Health System Observatory, Agència de Qualitat i Avaluació
Sanitàries de Catalunya (AQuAS), 81-95 (2a planta), 08005 Barcelona, Spain.
2
CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.
3
Institut d’Investigació Biomèdica (IIB Sant Pau), Barcelona, Spain.
Received: 6 October 2020 Accepted: 28 January 2021
References
1. World health organization (WHO). Meeting report of the world conference
on social determinants of health. Rio de Janeiro, 19-21. Geneva: WHO; 2011.
p. 2012. http://www.who.int/sdhconference/resources/wcsdh_report/en/.
Accessed 24 July 2019
2. Comisión para Reducir las Desigualdades Sociales en Salud en España.
Propuesta de políticas e intervenciones para reducir las desigualdades
sociales en salud en España. Gac Sanit. 2012:182–9.
3. Comisión para Reducir las Desigualdades Sociales en Salud en España.
Análisis de situación para la elaboración de una propuesta de políticas e
intervenciones para reducir las desigualdades sociales en salud en España.
Madrid: Ministerio de Sanidad y Política Social; 2009. http://www.mscbs.gob.
es/profesionales/saludPublica/prevPromocion/promocion/desigualdadSalud/
docs/Analisis_reducir_desigualdes.pdf. Accessed 24 July 2019.
4. Comisión para Reducir las Desigualdades Sociales en Salud en España.
Avanzando hacia la equidad: propuesta de políticas e intervenciones
para reducir las desigualdades sociales en salud en España. Madrid:
Ministerio de Sanidad y Política Social; 2010. http://www.mscbs.gob.es/
profesionales/saludPublica/prevPromocion/promocion/desigualdadSa
lud/docs/Propuesta_Politicas_Reducir_Desigualdades.pdf.Accessed24
July 2019.
5. World Health Organization (WHO). Rio political declaration on social
determinants of health Rio de Janeiro, Brazil. Geneva: WHO; 2011. p. 2012.
https://www.who.int/sdhconference/declaration/en/. Accessed 24 July 2019
6. Working Group for Monitoring Action on the Social Determinants of Health.
Towards a global monitoring system for implementing the Rio Political
Declaration on Social Determinants of Health: developing a core set of
indicators for government action on the social determinants of health to
improve health equity. Int J Equity Health. 2018;17(1):136.
7. Government of Catalonia. Health plan for Catalonia 2016–2020. Barcelona:
Ministry of Health of Catalonia; 2016. http://salutweb.gencat.cat/web/.
content/_departament/pla-de-salut/Pla-de-salut-2016-2020/documents/hea
lth-plan-catalonia_2016_2020.pdf. Accessed 24 July 2019
8. Comissió Interdepartamental de Salut. Pla interdepartamental i intersectorial
de salut pública. Barcelona: Ministry of Health of Catalonia; 2017. http://sa
lutpublica.gencat.cat/web/.content/minisite/aspcat/sobre_lagencia/pinsap/
01Els_Plans/PINSAP_2017-2020/PINSAP_2017-2020-Complet.pdf. Accessed
24 July 2019
9. Cabezas-Peña C. Catalonia, Spain. Regions for Health Network (RHN).
Geneva: WHO; 2018. http://www.euro.who.int/__data/assets/pdf_file/0004/3
73387/rhn-catalonia-eng.pdf. Accessed 24 July 2019
Table 3 List of indicators by topic (Continued)
Topics Indicators Reference
Perceived mental health (fair or poor) [33,34]
Pregnancy care/ breastfeeding Breastfeeding (total, having ever breastfed, initiation, exclusive, by age) [24,32,34]
Recommended duration of breastfeeding [32]
Hospital discharge for giving birth (ICD9MC: 650) [41]
% pregnant women receiving prenatal care [39]
Hip fractures and surgical procedures Proportion of patients with hip fractures recovering to their previous
levels of mobility/walking ability at 30 days
[36]
Fractures including hip, vertebral and forearm fractures
(ICD9MC: 800–829) (by province, sex, age)
[41,43]
Number of surgical procedures including PTCA, hip, cataract
(per 100,000 population)
[24,30]
Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 13 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
10. Observatori del Sistema Salut de Catalunya. Efectes de la crisi econòmica en
la salut de la població de Catalunya. Barcelona: Agency for Health Quality
and Assessment of Catalonia; 2014. http://observatorisalut.gencat.cat/web/.
content/minisite/observatorisalut/contingutsadministratius/observatori_
efectes_crisi_salut_document.pdf. Accessed 24 July 2019
11. Observatori del Sistema Salut de Catalunya. Efectes de la crisi econòmica en
la salut de la població de Catalunya. Anàlisi territorial. Agency for Health
Quality and Assessment of Catalonia: Barcelona; 2015. http://observatorisa
lut.gencat.cat/web/.content/minisite/observatorisalut/ossc_crisi_salut/
Fitxers_crisi/Salut_crisi_informe_2015.pdf. Accessed 24 July 2019
12. Observatori del Sistema Salut de Catalunya. Desigualtats socioeconòmiques
en la salut i la utilització de serveis sanitaris públics en la població de
Catalunya. Agency for Health Quality and Assessment of Catalonia:
Barcelona; 2017. http://observatorisalut.gencat.cat/web/.content/minisite/
observatorisalut/ossc_crisi_salut/Fitxers_crisi/Salut_crisi_informe_2016.pdf.
Accessed: 13 September 2019
13. Observatori del Sistema Salut de Catalunya. Central de Resultats: Efectes de la
crisi econòmica en la població infantil de Catalunya. Barcelona: Agency for
Health Quality and Assessment of Catalonia; 2014. http://observatorisalut.genca
t.cat/web/.content/minisite/observatorisalut/contingutsadministratius/observa
tori_efectes_crisi_salut_monografic.pdf.Accessed20March2020
14. Observatori del Sistema Salut de Catalunya. Central de Resultats: Evolució
de la utilització de serveis i el consum de fàrmacs 2008–2015. Barcelona:
Agency for Health Quality and Assessment of Catalonia; 2008. http://observa
torisalut.gencat.cat/web/.content/minisite/observatorisalut/ossc_central_
resultats/informes/fitxers_estatics/MONOGRAFIC_25_CRISI_EVOLUCIO_2
008-2015.pdf. Accessed 20 Mar 2020
15. García-Altés A, Ruiz-Muñoz D, Colls C, Mias M, Martín BN. Socioeconomic
inequalities in health and the use of healthcare services in Catalonia:
analysis of the individual data of 7.5 million residents. J Epidemiol
Community Health. 2018;72(10):871–9.
16. Ruiz-Muñoz D, Colls C, Mias M, Martín N, García-Altés A. Desigualtats
socioeconòmiques en la salut i la utilització dels serveis sanitaris públics en
la població de Catalunya. Ann Med. 2017;100:172–6https://www.academia.
cat/files/499-448-FITXER/provesievidencies1.pdf. Accessed 20 Mar 2020.
17. Genoveva B, Ruiz-Muñoz D, García-Altés A. Efectes de la crisi econòmica en
la salut de la població de Catalunya: anàlisi territorial. Ann Med. 2016;99:
126–31 https://www.academia.cat/files/499-386-FITXER/provesievidencies.
pdf. Accessed 24 July 2019.
18. Health for Everyone?. OECD Health Policy Studies. Paris: OECD; 2019. https://
www.oecd-ilibrary.org/social-issues-migration-health/health-for-everyone_3
c8385d0-en. Accessed 9 Jan 2021.
19. World Health Organization (WHO). Handbook on health inequality
monitoring with a special focus on low- and middle-income countries.
Geneva: WHO; 2013.
20. UK Department of Health. Health equity audit: a self-assessment tool.
London: Department of Health, 2004: 25. https://webarchive.nationala
rchives.gov.uk/20120105214155/http://www.dh.gov.uk/en/Publicationsa
ndstatistics/Publications/PublicationsPolicyAndGuidance/DH_4070715.
Accessed 13 Sept 2019.
21. WHO Regional Office for Europe. Health 2020: A European policy framework
and strategy for the 21st century. Geneva: WHO; 2013:190. http:// www.
euro.who.int/__data/assets/pdf_file/0011/199532/Health2020-Long.pdf.
Accessed 24 July 2019.
22. Pencheon D. The good indicators guide: understanding how to use and
choose indicators. Coventry: NHS Institute for Innovation and Improvement;
2017. https://www.england.nhs.uk/improvement-hub/publication/the-good-
indicators-guide-understanding-how-to-use-and-choose-indicators. Accessed
25 Mar 2020
23. Eurostat. SDG 3. Good health and well-being. Luxembourg: European
Commission. https://ec.europa.eu/eurostat/web/sdi/good-health-and-well-
being. Accessed 8 Apr 2020.
24. ECHI-European Core Health Indicators. Luxembourg: European Commission.
https://ec.europa.eu/health/indicators/echi/list_en#id3. Accessed 8 Apr 2020.
25. Marmot M. Health inequalities in the EU - final report of a consortium.
Luxembourg: Publications Office of the European Union; 2013. [https://ec.
europa.eu/health//sites/health/files/social_determinants/docs/healthinequa
litiesineu_2013_en.pdf]. Accessed 8 Apr 2020
26. Social Protection Committee. Indicators Sub-group. Portfolio of EU social
indicators for the monitoring of progress towards the EU objectives for
social protection and social Inclusion. Luxembourg: Publications Office of
the European Union; 2015. http://ec.europa.eu/social/BlobServlet?docId=
14239&langId=en. Accessed 8 Apr 2020
27. I2sare project. Galicia, Spain profile. Regional Health Profiles in the European
Union, 2010. www.sergas.es/Saude-publica/-I2SARE-Galicia. Accessed 8 Apr 2020.
28. World Health Organization (WHO). Data Management Tool. Copenhagen:
WHO Regional Office for Europe. http://dmt.euro.who.int/classifications/tree/
B#B02. Accessed 8 Apr 2020.
29. World Health Organization (WHO). 100 core health indicators (plus health-
related SDGs). Geneva: WHO; 2018. www.who.int/healthinfo/indicators/1
00CoreHealthIndicators_2018_infogr.April 2020. Accessed 8 April 2020
30. The World Bank. Health. Data. Washington DC: The World Bank. https://data.
worldbank.org/topic/health. Accessed 8 Apr 2020.
31. Observatori Social d'Andorra. Sant Julià de Lòria (Andorra): Centre d’Estudis
Andorrans. Govern d'Andorra https://observatorisocial.ad/index.php.
Accessed 8 Apr 2020.
32. Turrell G, Stanley L, de Looper M. Oldenburg B. Health inequalities in
Australia: morbidity, health behaviours, risk factors and health services use
(AIHW). Canberra; 2006. www.aihw.gov.au/getmedia/0cbc6c45-b97a-44f7-a
d1f-2517a1f0378c/hiamhbrfhsu.pdf. Accessed 8 Apr 2020
33. Public Health Agency of Canada. Key Health Inequalities in Canada: A
National Portrait. Ottawa: Government of Canada; 2018. http://www.canada.
ca/en/public-health/services/publications/science-research-data/key-health-
inequalities-canada-national-portrait-executive-summary.html. Accessed 8
Apr 2020
34. Canadian Institute of Health Information. Health Inequalities Data Tool.
Ottawa: Government of Canada https://health-infobase.canada.ca/health-
inequalities/data-tool/index. Accessed 8 Apr 2020.
35. Institute of Health Equity. Marmot indicators release 2017. London: Institute
of Health Equity; 2017. http://www.instituteofhealthequity.org/about-our-
work/marmot-indicators-release-2017. Accessed 8 Apr 2020
36. NHS England Analytical Services & the Equality and Health Inequalities Unit.
England Analysis: NHS Outcome Framework Health Inequalities Indicators.
London: NHS England; 2016. http://www.england.nhs.uk/wp-content/uploa
ds/2017/07/nhs-outcome-framework-health-inequalities-indicators-2016-17.
pdf. Accessed 8 Apr 2020
37. Scottish Government. Long-term monitoring of health inequalities. Scottish
Government: Edinburgh; 2018. http://www.gov.scot/publications/long-term-
monitoring-health-inequalities-december-2018-report. Accessed 8 Apr 2020
38. Buzeti T, Djomba JK, BlenkušMG, Ivanuša M, Klanšček HJ, Kelšin N, et al.
Health inequalities in Slovenia. Ljubljana: National Institute of Public Health;
2011. http://www.euro.who.int/__data/assets/pdf_file/0008/131759/Health_
inequalities_in_Slovenia.pdf. Accessed 8 Apr 2020
39. Ministry of Health and Social Policy of Spain. Moving forward equity in
health: monitoring social determinants of health and the reduction of
health inequalities. Madrid: Ministry of Health and Social Policy of Spain;
2010. http://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/
promocion/desigualdadSalud/PresidenciaUE_2010/conferenciaExpertos/
docs/haciaLaEquidadEnSalud_en.pdf. Accessed 8 Apr 2020
40. Instituto Nacional de Estatística-Statistics Portugal. Indicadores Sociais 2011.
Lisbon: Instituto Nacional de Estatística-Statistics Portugal; 2012. https://
censos.ine.pt. Accessed 8 Apr 2020
41. García-Calvente MM, del Río LM, Marcos-Marcos J. Guía de indicadores para
medir las desigualdades de género en salud y sus determinantes. Escuela
Andaluza de Salud Pública. Junta de Andalucía: Granada; 2015. http://www.
easp.es/project/guia-de-indicadores-para-medir-las-desigualdades-de-
genero-en-salud-y-sus-determinantes. Accessed 8 Apr 2020
42. Malmusi D. Desigualtats en salut, respostes a nivell local: Polítiques per
reduir les desigualtats en salut a la ciutat de Barcelona. Barcelona:
Ajuntament de Barcelona; 2017. http://www.consorci.org/media/upload/a
rxius/coneixement/salut-publica/2017/D_%20Malmusi_Desigualtats_28-09-2
017.pdf. Accessed 8 Apr 2020
43. Observatorio Valenciano de la Salud. Desigualdades en Salud en la
Comunidad Valenciana. Valencia: Generalitat. Conselleria de Sanitat
Universal i Salut Pública; 2018. http://www.sp.san.gva.es/DgspPortal/docs/2
0180301_Desigualdades_Salud_OVS2018.pdf. Accessed 8 Apr 2020
44. United Natios (UN). Life expectancy at birth. New York: UN. http://www.un.
org/esa/sustdev/natlinfo/indicators/methodology_sheets/health/life_expecta
ncy.pdf. Accessed 19 Mar 2020.
45. Shryock HS, Siegel JS, Stockwell EG. The methods and materials of
demography. San Diego: Academic Press; 1976.
Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 14 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
46. Global Health Observatory (GHO) data. Infant mortality. Geneva: World
Health Organization (WHO); 2018. http://www.who.int/gho/child_health/
mortality/neonatal_infant/en/. Accessed 8 Apr 2020
47. Porta M, editor. A dictionary of epidemiology, sixth edition. Oxford: Oxford
University Press; 2016. http://www.oxfordreference.com/view/10.1093/acref/
9780199976720.001.0001/acref-9780199976720. Accessed 8 Apr 2020
48. World Health Organization (WHO). Cancer. Geneva: WHO. http://www.who.
int/health-topics/cancer#tab=tab_1. Accessed 7 Apr 2020.
49. World Health Organization (WHO). Diabetes. Geneva: WHO. http://www.
who.int/health-topics/diabetes#tab=tab_1. Accessed 7 Apr 2020.
50. World Health Organization (WHO). HIV/AIDS. Geneva: WHO. http://www.
who.int/health-topics/hiv-aids#tab=tab_1. Accessed 7 Apr 2020.
51. World Health Organization (WHO). Tuberculosis. Geneva: WHO. http://www.
who.int/health-topics/tuberculosis#tab=tab_1. Accessed 7 Apr 2020.
52. Bambra C, Gibson M, Sowden A, Wright K, Whitehead M, Petticrew M.
Tackling the wider social determinants of health and health inequalities:
evidence from systematic reviews. J Epidemiol Community Health. 2010;
64(4):284–91.
53. Organisation for Economic Co-operation and Development (OECD). OECD
Glossary of Statistical Terms-Unemployed–ILO Definition. Paris: OECD; 2003.
https://stats.oecd.org/glossary/detail.asp? ID=2791. Accessed 7 Apr 2020
54. Pigeyre M, Rousseaux J, Trouiller P, Dumont J, Goumidi L, Bonte D, et al.
How obesity relates to socio-economic status: identification of eating
behavior mediators. Int J Obes. 2016;40(11):1794–801.
55. World Health Organization (WHO). Obesity and overweight. Geneva: WHO.
http://www.who.int/en/news-room/fact-sheets/detail/obesity-and-
overweight. Accessed 7 Apr 2020
56. WHO, Tobacco and inequities Guidance for addressing inequities in
tobacco-related harm Written by: Belinda Loring. 2014.
57. World Health Organization (WHO). Harmful use of alcohol. Geneva: WHO.
http://www.who.int/health-topics/alcohol#tab=tab_1. Accessed 7 Apr 2020.
58. World Health Organization (WHO). Physical activity. Geneva: WHO. http://
www.who.int/news-room/fact-sheets/detail/physical-activity. Accessed 7 Apr
2020.
59. American Psychological Association (APA). Socioeconomic Status.
Washinton DC. http://www.apa.org/topics/socioeconomic-status/. Accessed
6 Apr 2020.
60. Eurostat. Glossary: Material deprivation - Statistics Explained. Luxembourg:
European Commission. https://ec.europa.eu/eurostat/statistics-explained/
index.php/Glossary:Material_deprivation. Accessed 6 Apr 2020.
61. Solar O, Irwin A. A conceptual framework for action on the social
determinants of health. Social Determinants of Health Discussion Paper 2.
Geneva: World Health Organization (WHO); 2010. p. 79.
62. Salcedo N, Saez M, Bragulat B, Saurina C. Does the effect of gender modify
the relationship between deprivation and mortality? BMC Public Health.
2012;12:574.
63. Regidor E, Barrio G, Bravo MJ, de la Fuente L. Has health in Spain been
declining since the economic crisis? J Epidemiol Community Health. 2014;
68(3):280–2.
64. Consulting Services Limited ICF. Towards a fairer and more effective
measurement of access to healthcare across the EU final. London: ICF; 2018.
https://ec.europa.eu/health/sites/health/files/cross_border_care/docs/2018_
measurement_accesstohealthcare_frep_en.pdf. Accessed 6 Apr 2020
65. Ebinger JO, Hamso B, Gerner F, Lim A, Plecas A. Europe and Central Asia
region. New York: World Bank; 2008. https://elibrary.worldbank.org/doi/abs/1
0.1596/25984. Accessed 6 Apr 2020
66. Eurostat. Eurostat - Tables, Graphs and Maps Interface (TGM) table.
Luxembourg: European Commission; 2018. https://ec.europa.eu/eurostat/
tgm/table.do?tab=table&init=1&language=en&pcode=sdg_02_10&plugin=1.
Accessed 28 Feb 2020
67. Catalan Healthcare System Observatory. Indicadors de salut comunitària.
Barcelona: Agència de Qualitat i Avaluació Sanitàries de Catalunya.
Departament de Salut; 2017. http://observatorisalut.gencat.cat/ca/observa
tori-desigualtats-salut/indicadors_comunitaria/. Accessed 25 Mar 2020
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Albert-Ballestar and García-Altés International Journal for Equity in Health (2021) 20:73 Page 15 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
onlineservice@springernature.com
