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BMJ Open. 2019 Jun 1;9(5):e024823. doi: 10.1136/bmjopen-2018-024823.

Health-related educational inequalities in paid employment across 26 European countries in 2005-2014: repeated cross-sectional study.

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Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands.
Netherlands Organization for Applied Scientific Research TNO, Leiden, The Netherlands.



The study investigates the trends in health-related inequalities in paid employment among men and women in different educational groups in 26 countries in 5 European regions.


Individual-level analysis of repeated cross-sectional annual data (2005-2014) from the EU Statistics on Income and Living Conditions.


26 European countries in 5 European regions.


1 844 915 individuals aged 30-59 years were selected with information on work status, chronic illness, educational background, age and gender.


Absolute differences were expressed by absolute differences in proportion in paid employment between participants with and without a chronic illness, using linear regression. Relative differences were expressed by prevalence ratios in paid employment, using a Cox proportional hazard model. Linear regression was used to examine the trends of inequalities.


Participants with a chronic illness had consistently lower labour force participation than those without illnesses. Educational inequalities were substantial with absolute differences larger within lower educated (men 21%-35%, women 10%-31%) than within higher educated (men 5%-13%, women 6%-16%). Relative differences showed that low-educated men with a chronic illness were 1.4-1.9 times (women 1.3-1.8 times) more likely to be out of paid employment than low-educated persons without a chronic illness, whereas this was 1.1-1.2 among high-educated men and women. In the Nordic, Anglo-Saxon and Eastern regions, these health-related educational inequalities in paid employment were more pronounced than in the Continental and Southern region. For most regions, absolute health-related educational inequalities in paid employment were generally constant, whereas relative inequalities increased, especially among low-educated persons.


Men and women with a chronic illness have considerable less access to the labour market than their healthy colleagues, especially among lower educated persons. This exclusion from paid employment will increase health inequalities.


chronic illness; employment; social inequalities; trend analysis

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