Socioeconomic Gradients In Health Research Articles

Does Socioeconomic Inequality in Health Persist among Older People Living in Resource-Poor Urban Slums?

Using self-reported health that assesses functionality or disability status, this paper investigates whether there are any differences in health status among older people living in a deprived area of Nairobi, Kenya. Data from a cross-sectional survey of 2,037 men and women aged 50 years and older are used to examine the association between socioeconomic position and self-reported health status across 6 health domains. Education, occupation, a wealth index, and main source of livelihood are used to assess the presence of a socioeconomic gradient in health. All the indicators showed the expected negative association with health across some, but not all, of the disability domains. Nonetheless, differences based on occupation, the most commonly used indicators to examine health inequalities, were not statistically significant. Primary level of education was a significant factor for women but not for men; conversely, wealth status was associated with lower disability for both men and women. Older people dependent on their own sources of livelihood were also less likely to report a disability. The results suggest the need for further research to identify an appropriate socioeconomic classification that is sensitive in identifying poverty and deprivation among older people living in slums.

The contribution of psychological distress to socio-economic differences in cause-specific mortality: a population-based follow-up of 28 years

BackgroundPsychological factors associated with low social status have been proposed as one possible explanation for the socio-economic gradient in health. The aim of this study is to explore whether different indicators of psychological distress contribute to socio-economic differences in cause-specific mortality.MethodsThe data source is a nationally representative, repeated cross-sectional survey, "Health Behaviour and Health among the Finnish Adult Population" (AVTK). The survey results were linked with socio-economic register data from Statistics Finland (from the years 1979-2002) and mortality follow-up data up to 2006 from the Finnish National Cause of Death Register. The data included 32451 men and 35420 women (response rate 73.5%). Self-reported measures of depression, insomnia and stress were used as indicators of psychological distress. Socio-economic factors included education, employment status and household income. Mortality data consisted of unnatural causes of death (suicide, accidents and violence, and alcohol-related mortality) and coronary heart disease (CHD) mortality. Adjusted hazard ratios were calculated using the Cox regression model.ResultsIn unnatural mortality, psychological distress accounted for some of the employment status (11-31%) and income level (4-16%) differences among both men and women, and for the differences related to the educational level (5-12%) among men; the educational level was associated statistically significantly with unnatural mortality only among men. Psychological distress had minor or no contribution to socio-economic differences in CHD mortality.ConclusionsPsychological distress partly accounted for socio-economic disparities in unnatural mortality. Further studies are needed to explore the role and mechanisms of psychological distress associated with socio-economic differences in cause-specific mortality.

Health problems account for a small part of the association between socioeconomic status and disability pension award. Results from the Hordaland Health Study

BackgroundLow socioeconomic status is a known risk factor for disability pension, and is also associated with health problems. To what degree health problems can explain the increased risk of disability pension award associated with low socioeconomic status is not known.MethodsInformation on 15,067 participants in the Hordaland Health Study was linked to a comprehensive national registry on disability pension awards. Level of education was used as a proxy for socioeconomic status. Logistic regression analyses were employed to examine the association between socioeconomic status and rates of disability pension award, before and after adjusting for a wide range of somatic and mental health factors. The proportion of the difference in disability pension between socioeconomic groups explained by health was then calculated.ResultsUnadjusted odds ratios for disability pension was 4.60 (95% CI: 3.34-6.33) for the group with elementary school only (9 years of education) and 2.03 (95% CI 1.49-2.77) for the group with high school (12 years of education) when compared to the group with higher education (more than 12 years). When adjusting for somatic and mental health, odds ratios were reduced to 3.87 (2.73-5.47) and 1.81 (1.31-2.52). This corresponds to health explaining only a marginal proportion of the increased level of disability pension in the groups with lower socioeconomic status.ConclusionThere is a socioeconomic gradient in disability pension similar to the well known socioeconomic gradient in health. However, health accounts for little of the socioeconomic gradient in disability pension. Future studies of socioeconomic gradients in disability pension should focus on explanatory factors beyond health.

Socioeconomic Heterogeneity in the Effect of Health Shocks on Earnings: Evidence from Population-Wide Data on Swedish Workers

In this paper, we test for the existence of socioeconomic heterogeneity in the effect of health shocks on labor market outcomes using register data on the total population of Swedish workers. We estimate fixed effect models and use unexpected hospitalizations as a measure of health shocks. Our results suggest large heterogeneity in the effects, where low educated individuals suffer relatively more from a given health shock. This result holds across a wide range of different health shocks and our results suggest that the heterogeneity increases by age. We test several potential explanations to these results. Extensive sensitivity analyses, including a difference-in-differences matching model, show that our estimates are robust to a number of potential threats. We conclude that socioeconomic heterogeneity in the effect of health shocks offers one explanation to why the socioeconomic gradient in health widens during middle ages.

Social Inequality and Health: A Commentary

Medical anthropologists have had a long interest in the subject of social inequality and health. Critical medical anthropologists (Farmer 1999; Singer 1986) and biocultural anthropologists (Goodman and Leatherman 1998; Thomas 1998) have all argued for the systematic study of structured economic and social inequality in communities and their impact on health. In this issue of MAQ, Ricardo Godoy and his colleagues add a new dimension to the anthropological study of this subject. My aim here is to provide a bit more background, to better contextualize their study. Although anthropologists have a deep interest in the subject of inequality and health, we have contributed proportionately little to the debate. The inverse association between socioeconomic status (SES) and health, and the related positive association between social integration and health, are probably the most widely replicated of any associations observed between social variables and health outcomes. And, the SES–health relationship is certainly the most often replicated association of these two relationships. Social epidemiology is the field that has contributed the most to this literature (Berkman and Kawachi 2000). This of course will be familiar to the many medical anthropologists who are acquainted with the literature in epidemiology. Regardless of who is doing the research, however, the question remains: why? What is it about social inequality that leads to ill health? This may seem like a silly question when you consider the grinding poverty (or absolute material deprivation) under which some people live as described in the ethnographic literature by, for example, Nancy Scheper-Hughes (1992). Her careful ethnographic description of the desolate poverty experienced by many living in a Brazilian favela (or “shantytown”) makes it clear that some people are sicker because they are poor, oppressed, and exploited. On the other hand, it is not such a crazy question when you look at the socioeconomic gradient in health found in Michael Marmot’s Whitehall study (Marmot 1994). Whitehall, of course, refers generally to the British civil service. From the housekeeping staff to the titled ministers, the inverse gradient in health can be seen. Granted, the differences in health may not be as great as those between the poorest Brazilians and Brazilian members of the international elite, but the gradient, nevertheless, is there. And, these British civil servants are fortunate to live in a society with a national health care service and with the economic wherewithal

Les gradients socioéconomiques des habitudes de santé et du surpoids chez des enfants de milieux économiques distincts

Background: The socio-economic gradient in health does not seem to apply to overweight among Canadians adults. In the present study, we sought to determine the socio-economic gradient in overweight among Canadian children in distinct economic settings. We further examined socio-economic gradients in underlying behaviours, healthy eating and active living, as well as parental support for these behaviours. Methods: We surveyed 6,430 grade five students and their parents in Alberta and Nova Scotia. Students completed dietary and activity questionnaires and had their height and weight measured. Parents completed questions on socio-economic background and their support for their child’s health behaviours. We applied multi-level regression methods to characterize the socio-economic gradients. Results: In both Alberta and Nova Scotia, we observed socio-economic gradients whereby children with parents who were more highly educated and had higher earnings were more physically active and less likely overweight. In contrast, we did not observe a socio-economic gradient with respect to healthy eating. Relative to socio-economically disadvantaged parents, those with better education and higher income were more likely to report encouraging their children’s healthy eating and physical activity. Socio-economically disadvantaged parents, though, reported more engagement in physical activities with their children. Conclusion: Whereas the socio-economic gradient in overweight among Canadian adults is fading, we did not observe such a phenomenon among children. The mechanism preserving the socio-economic gradient among children may be related to more encouragement given to healthy eating and physical activity in the more socio-economically advanced families. Key words: Childhood overweight; nutrition; physical activity; socio-economic gradient; public health; social environment

Income-related health inequalities in the Nordic countries: Examining the role of education, occupational class, and age

Numerous studies have concluded that people's socioeconomic position is related to mortality and morbidity, but that the strength of this association varies considerably both within and between European regions. This has spurred several researchers to more closely examine educational and occupational gradients in health in the Nordic countries to clarify the causes of cross-national differences. However, comparable studies using income as an indicator of socioeconomic position are still lacking. This study uses recent and highly comparable data to fill this gap. The aim of this study is threefold. First, we ask to what extent there is an income gradient in health in the Nordic countries, and to what extent the association differs between these countries. Second and third, we examine whether differences in the attenuation of the income gradient by education and occupational class, and age-specific differences between countries, may act as explanations for differences in the income gradient between the Nordic countries. The data source are three waves of the European Social Survey (ESS, 2002/2004/2006), which included 17,801 people aged 25 and over from Denmark, Finland, Norway, and Sweden. Two subjective health measures (physical/mental self reported health and limiting longstanding illness) were analysed by means of logistic regression. The results show that, in all countries, people reported significantly better health and were less likely to suffer from longstanding illness as they had a higher income. This association is strongest in Norway and Finland and weakest in Denmark. The income gradient in health, but not country differences in this gradient, is partly explained by education and occupational class. Additionally, the strength of the income gradient in health varies between age groups. The relatively high health inequalities between income groups in Norway and Finland are already visible in the youngest age groups. The results imply that the socioeconomic gradient in health will arguably not be strongly reduced in the near future as a result of cohort replacement, as has been suggested in previous studies. Health policy interventions may be particularly important five to ten years prior to retirement and in early adulthood.

Socioeconomic gradients in health in international and historical context

This article places socioeconomic gradients in health into a broader international and historical context. The data we present supports the conclusion that current socioeconomic gradients in health within the United States are neither inevitable nor immutable. This literature reveals periods in the United States with substantially smaller gradients, and identifies many examples of other countries whose different social policy choices appear to have led to superior health levels and equity even with fewer aggregate resources. The article also sheds light on the potential importance of various hypothesized mechanisms in driving major shifts in U.S. population health patterns. While it is essential to carefully examine individual mechanisms contributing to health patterns, it is also illuminating to take a more holistic view of the set of factors changing in conjunction with major shifts in population health. In this article, we do so by focusing on the period of the 1980s, during which U.S. life expectancy gains slowed markedly relative to other developed countries, and U.S. health disparities substantially increased. A comparison with Canada suggests that exploring broad social policy differences, such as the weaker social safety net in the United States, may be a promising area for future investigation.

Socio-economic gradients in health behaviours and overweight among children in distinct economic settings.

The socio-economic gradient in health does not seem to apply to overweight among Canadians adults. In the present study, we sought to determine the socio-economic gradient in overweight among Canadian children in distinct economic settings. We further examined socio-economic gradients in underlying behaviours, healthy eating and active living, as well as parental support for these behaviours. We surveyed 6430 grade five students and their parents in Alberta and Nova Scotia. Students completed dietary and activity questionnaires and had their height and weight measured. Parents completed questions on socio-economic background and their support for their child's health behaviours. We applied multi-level regression methods to characterize the socio-economic gradients. In both Alberta and Nova Scotia, we observed socio-economic gradients whereby children with parents who were more highly educated and had higher earnings were more physically active and less likely overweight. In contrast, we did not observe a socio-economic gradient with respect to healthy eating. Relative to socio-economically disadvantaged parents, those with better education and higher income were more likely to report encouraging their children's healthy eating and physical activity. Socio-economically disadvantaged parents, though, reported more engagement in physical activities with their children. Whereas the socio-economic gradient in overweight among Canadian adults is fading, we did not observe such a phenomenon among children. The mechanism preserving the socio-economic gradient among children may be related to more encouragement given to healthy eating and physical activity in the more socio-economically advanced families.

Accurately Measuring Health Over the Life Course

This paper develops a new method of estimating rich, dynamic models of health based on multiple health measures available in the HRS. We apply these methods to investigate what generates the large socioeconomic gradient in health. Preliminary results suggest a large role for initial differences in health at age 50 that persist into old age.

Canadian progress in early child development – putting science into action

Canadian progress in early child development – putting science into action

Socioeconomic differences in health over the life cycle in an Egalitarian country

A strong cross-sectional relationship between health and socioeconomic status is firmly established. This paper adopts a life cycle perspective to investigate whether the socioeconomically disadvantaged, on top of a lower health level, experience a sharper deterioration of health over time. Data are drawn from the Dutch Central Bureau of Statistics (CBS) Health Interview Surveys covering the period 1983-2000. The analysis focuses on the self-rated health and disability of persons aged 16-80. We show that in the Netherlands, as in the US, the socioeconomic gradient in health widens until late-middle age and narrows thereafter. The analysis and the available evidence suggests that the widening gradient is attributable both to health-related withdrawal from the labor force, resulting in lower incomes, and the cumulative protective effect of education on health outcomes. The less educated appear to suffer a double health penalty in that they begin adult life with a slightly lower health level, which subsequently declines at a faster rate.

Wie gleich kann Gesundheit sein? Ethische und gerechtigkeitstheoretische Aspekte gesundheitlicher Ungleichheiten

It is well-documented that the socio-economic status has an important influence on health. In all developed countries, health is closely correlated with income, education, and type of employment, as well as with several other social determinants. While data on this socio-economic health gradient have been available for decades, the moral questions surrounding social health inequalities have only recently been addressed within the field of public health ethics. The present article offers a brief overview of relevant data on social health inequalities and on some explanatory models from epidemiology, social medicine and related disciplines. The main part explores three influential normative accounts addressing the issue of health inequalities. Finally, an agenda for future work in the field of public health ethics and health inequalities is sketched, with particular attention to the German context.

Commentary: How does 'insurance' improve equity in health?

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Ethnicity Matters: The Socioeconomic Gradient in Health among Asian Americans

This study examines the relationship between socioeconomic indicators and health status among Asian Americans using data from the 2001 California Health Interview Survey (CHIS), a population-based random-digit-dial survey with race-ethnic supplemental samples. Multivariate logistic regression analyses show that the inverse relationship between socioeconomic position and health status is similar for Asian Americans when measured as an aggregate group compared to Whites. However, when specific Asian American ethnic groups are examined, the relationship varies greatly. For example, among Chinese Americans and Vietnamese Americans, education is a significant predictor of poor health status, but household income is more significant among Korean Americans. The importance of disaggregation for subgroup populations in research and policy is discussed.

Early childhood health, reproduction of economic inequalities and the persistence of health and mortality differentials

The persistence of adult health and mortality socioeconomic inequalities and the equally stubborn reproduction of social class inequalities are salient features in modern societies that puzzle researchers in seemingly unconnected research fields. Neither can be satisfactorily explained with standard theoretical frameworks. In the domain of health and mortality, it is unclear if and to what an extent adult health and mortality disparities across socioeconomic status (SES) are the product of attributes of the positions themselves, the partial result of health conditions established earlier in life that influence both adult health and economic success, or the outcome of the reverse impact of health status on SES. In the domain of social stratification, the transmission of inequalities across generations has been remarkably resistant to satisfactory explanations. Although the literature on social stratification is by and large silent about the role played by early health status in shaping adult socioeconomic opportunities, new research on human capital formation suggests this is a serious error of omission. In this paper we propose to investigate the connections between these two domains. We use data from male respondents of the 1958 British Cohort to estimate (a) the influence of early health conditions on adult SES and (b) the contribution of early health status to observed adult health differentials. The model incorporates early conditions as determinants of traits that enhance (inhibit) social mobility and also conventional and unconventional factors that affect adult health and socioeconomic status. Our findings reveal that early childhood health plays a small, but non-trivial role as a determinant of adult SES and the adult socioeconomic gradient in health. These findings enrich current explanations of SES inequalities and of adult health and mortality disparities.

Air Quality and Early-Life Mortality

Smoke from massive wildfires blanketed Indonesia in late 1997. This paper examines the impact that this air pollution (particulate matter) had on fetal, infant, and child mortality. Exploiting the sharp timing and spatial patterns of the pollution and inferring deaths from “missing children” in the 2000 Indonesian Census, I find that the pollution led to 15,600 missing children in Indonesia (1.2 percent of the affected birth cohorts). Prenatal exposure to pollution drives the result. The effect size is much larger in poorer areas, suggesting that differential effects of pollution contribute to the socioeconomic gradient in health.

Air Quality and Early-Life Mortality: Evidence from Indonesia's Wildfires

Smoke from massive wildfires blanketed Indonesia in late 1997. This paper examines the impact that this air pollution (particulate matter) had on fetal, infant, and child mortality. Exploiting the sharp timing and spatial patterns of the pollution and inferring deaths from "missing children" in the 2000 Indonesian Census, I find that the pollution led to 15,600 missing children in Indonesia (1.2 percent of the affected birth cohorts). Prenatal exposure to pollution drives the result. The effect size is much larger in poorer areas, suggesting that differential effects of pollution contribute to the socioeconomic gradient in health.

Socioeconomic Differences in Health Over the Life Cycle in an Egalitarian Country

A strong relationship between health and socioeconomic status is firmly established. Yet, partly due to the multidimensional and dynamic nature of the variables, the causal mechanisms connecting them are poorly understood. This paper argues that adoption of a life-cycle perspective is essential to uncover these causal pathways. A life-cycle perspective also allows investigation of whether the socioeconomically disadvantaged, on top of a lower health level, experience a sharper deterioration of their health over the life cycle. We show that in the Netherlands, as in the US, the socioeconomic gradient in health widens until late-middle age and narrows thereafter. The analysis and the available evidence suggests that the widening gradient is attributable both to health-related withdrawal from the labor force, resulting in lower incomes, and the cumulative protective effect of education on health outcomes. The less educated suffer a double health penalty in that they begin adult life with a slightly lower health level, which subsequently declines at a faster rate. The observed narrowing of the gradient in old age is partly an artefact stemming from the fact that only the most healthy of the disadvantaged survive into old age. It also reflects that after middle age, withdrawal from the labor force increasingly occurs for non health-related reasons.

Free market capitalism, social accountability and equity in early human (child) development.

A University of Chicago Nobel Laureate in economics, RW Fogel, and a Dutch economist, JW Drukker, found that as the wealth of Western countries improved following the Industrial Revolution, life expectancy increased and the mean height of their populations improved (1,2). Since height is a product of genes and nutrition, they concluded that improved health was related to improved socioenvironments and better nutrition of children, not improvements in health care. Today, the health of populations in developed countries is a socioeconomic gradient. These health gradients (3) are linear, which means that whatever the socioeconomic factors influencing health today are, they affect everyone in society, including the wealthiest. The effect, however, is greatest on the poorest members of society. The Canadian Institute for Advanced Research’s (CIAR) population health program led by Robert Evans (University of British Columbia [Vancouver, British Columbia]) examined the factors contributing to the health gradients in Canada and other countries. They concluded that in the United Kingdom, Canada and the United States (US), the major factor contributing to inequities in health was more than poverty and a lack of health care (3). Hertzman et al (4) – members of the CIAR’s population health program – proposed that the socioeconomic conditions in early life affected adult health (physical and mental) throughout life. They and others suggested that the development of the brain and related biological pathways in early life were important factors. This led to the hypothesis that if the socioeconomic gradient in health was influenced by brain and biological pathway development in the early years, it was possible that there were similar socioeconomic gradients in education and behaviour (5). The CIAR established a program in human development to explore the concept. The scientists in this program found that the socioeconomic gradients in literacy, numeracy and behaviour were similar to the health gradients (6). They suggested that the effect of experience in early life on the development of the architecture and function of the brain was important in contributing to inequities in health and education. In 2002, the CIAR established a new program, ‘Experience-based Brain and Biological Development’ to study how genes and experience shape brain development that influences health, learning and behaviour trajectories throughout life.