Understanding Health Inequalities Research Articles

Economic Segmentation and Health Inequalities in Urban Post-Reform China.

During economic reform, Chinese economic labor markets became segmented by state sector associated with a planned redistributive economy and private sector associated with the market economy. By considering an economic sector as a concrete institutional setting in post-reform China, this paper compares the extent to which socioeconomic status, measured by education and income, is associated with self-rated health between state sector and private sector. The sample is limited to urban Chinese employees between the ages of 18 and 55 who were active in the labor force. By analyzing pooled data from the 1991–2006 Chinese Health and Nutrition Survey, I find that there is a stronger association between income and self-rated health in the private sector than in the state sector. This study suggests that sectoral differences between market and redistributive economies are an important key to understanding health inequalities in post-reform urban China.

The Political Economy of Health: A Research Agenda for Addressing Health Inequalities in Canada

Public policy creates health inequalities among Canadians by inequitably distributing the social determinants of health (SDOH). Political decisions by authorities bring about these public policies, yet to date there has been little resistance to these decisions by the Canadian public. This article proposes a research agenda for investigating why this might be the case by considering a) Canada’s identification as a liberal welfare state; b) the relative power and influence of the corporate and business sector, labour, and civil society in shaping SDOH-related public policy-making; c) how population health researchers and public health practitioners understand health inequalities and their role in reducing them; and d) the public’s understanding of SDOH and public policy-making.

Measures of socioeconomic status and self-reported glaucoma in the U.K. Biobank cohort.

PurposeTo determine ocular, demographic, and socioeconomic associations with self-reported glaucoma in the UK Biobank.MethodsBiobank is a study of UK residents aged 40–69 years registered with the National Health Service. Data were collected on visual acuity, intraocular pressure (IOP), corneal biomechanics, and questionnaire from 112 690 participants. Relationships between ocular, demographic, and socioeconomic variables with reported diagnosis of glaucoma were examined.ResultsIn all, 1916 (1.7%) people in UK Biobank reported glaucoma diagnosis. Participants reporting glaucoma were more likely to be older (mean 61.4 vs 56.7 years, P<0.001) and male (2.1% vs 1.4%, P=0.001). The rate of reported glaucoma was significantly higher in Black (3.28%, P<0.001) and Asian (2.14%, P=0.009) participants compared with White participants (1.62%, reference). Cases of reported glaucoma had a higher mean IOP (18 mm Hg both eyes, P<0.001), lower corneal hysteresis (9.96 right eye, 9.89 left eye, P<0.001), and lower visual acuity (0.09 logMAR right eye, 0.08 logMAR left eye, P<0.001) compared with those without (16 mm Hg both eyes, hysteresis 10.67 right eye, 10.63 left eye, 0.03 logMAR right eye, 0.02 logMAR left eye). The mean Townsend deprivation index was −0.72 for those reporting glaucoma and −0.95 for those without (P<0.001), indicating greater relative deprivation in those reporting glaucoma. Multivariable logistic regression showed that people in the lowest income group (<£18 000/year) were significantly more likely to report a diagnosis of glaucoma compared with any other income level (P<0.01). We observed increasing glaucoma risk across the full range of income categories, with highest risk among those of lowest income, and no evidence of a threshold effect.ConclusionsIn a large UK cohort, individuals reporting glaucoma had more adverse socioeconomic characteristics. Study of the mechanisms explaining these effects may aid our understanding of health inequality and will help inform public health interventions.

Invited Commentary: A-P-C... It's Easy as 1-2-3!

Investigations of age, period, and cohort effects are difficult because the 3 factors are linearly dependent. In a novel application, Kramer et al. (Am J Epidemiol. 2015;182(4):302-312) have used graphical analysis and statistical models to estimate the impact that age, period, and cohort effects have had on trends in black-white inequalities in heart disease mortality. Using a constrained regression approach (with the first 2 periods' effects constrained to zero), Kramer et al. find evidence that age and cohort effects figure more prominently than do period effects in contributing to relative black-white mortality differences, and they argue that early-life exposures should be given greater consideration for mitigation of racial differences in heart disease. In this invited commentary, I argue that the utility of age-period-cohort models for understanding health inequalities depends on the plausibility of the assumptions used to break the link between the 3 factors. Based on the existing age-period-cohort literature, alternative assumptions seem likely to produce substantially different results. I also argue that interpretations of the impacts of age, period, and cohort effects on racial inequalities in heart disease mortality may depend on whether inequalities are assessed on the absolute scale or the relative scale.

Development of an Urban Health Impact Assessment methodology: indicating the health equity impacts of urban policies.

An overarching recommendation of the global Commission on Social Determinants of Health was to measure and understand health inequalities and assess the impact of action. In a rapidly urbanising world, now is the time for Urban HIA. This article describes the development of robust and easy-to-use HIA tools to identify and address health inequalities from new urban policies. Rapid reviews and consultation with experts identified existing HIA screening tools and methodologies which were then analyzed against predefined selection criteria. A draft Urban HIA Screening Tool (UrHIST) and Urban HIA methodology (UrHIA) were synthesised. The draft tools were tested and refined using a modified Delphi approach that included input from urban and public health experts, practitioners and policy makers. The outputs were two easy-to-use stand-alone urban HIA tools. The reviews and consultations identified an underpinning conceptual framework. The screening tool is used to determine whether a full HIA is required, or for a brief assessment. Urban health indicators are a readily available and efficient means of identifying variations in the health of populations potentially affected by policies. Indicators are, however, currently underutilised in HIA practice. This may limit the identification of health inequalities by HIA and production of recommendations. The new tools utilise health indicator data more fully. UrHIA also incorporates a hierarchy of evidence for use during impact analysis. The new urban HIA tools have the potential to enhance the rigour of HIAs and improve the identification and amelioration of health inequalities generated by urban policies.

Childhood conscientiousness predicts the social gradient of smoking in adulthood: a life course analysis

Background and aimsThe social gradient in smoking is well known, with higher rates among those in less advantaged socioeconomic position. Some recent research has reported that personality characteristics partly explain...

A higher level of education amplifies the inverse association between income and disability in the Spanish elderly.

This paper aims to estimate if the education level modifies the association of income with disability prevalence in the elderly. Education can have a confounding effect on income or interact with it as a health determinant. It is important to analyze the relationship between socio-economic status and disability in older people, because it helps to better understand health inequalities and organize appropriate social policies. The study is based on the Survey on Disability, Personal Autonomy and Dependency Situations (Spanish National Statistics Institute). Binary logistic regression models are adjusted (bivariate, adjusted for gender and age, with all variables and with the interaction between income and education levels). A bad adjustment of the model is detected and a scobit link is added, which helps to differentiate disabled and non-disabled individuals better. People with difficulty in carrying out activities of daily living are much older, frequently women and with low education and income levels. The significant interaction between education level and income means that the odds of being disabled is 43% less in people of high income compared with people of low income if they are well educated, while it is only 21%, among those with low education. A higher education level amplifies significantly the inverse association between income and disability in the Spanish elderly, what suggests that those with higher education will profit more than those with lower education from universal economic benefits policies aimed at the disabled, increasing health inequalities between groups.

The politics of relative deprivation: A transdisciplinary social justice perspective

Relative deprivation was defined by Townsend (1987, p. 125) as “a state of observable and demonstrable disadvantage, relative to the local community or the wider society or nation to which an individual, family or group belongs”. This definition is widely used within social and health sciences to identify, measure, and explain forms of inequality in human societies based on material and social conditions. From a multi-disciplinary social science perspective, we conducted a systematic literature review of published material in English through online database searches and books since 1966. We review the concept and measurement of relative ‘deprivation’ focussing on area-based deprivation in relation to inequities in health and social outcomes. This paper presents a perspective based in Aotearoa/New Zealand where colonisation has shaped the contours of racialised health inequities and current applications and understandings of ‘deprivation’.We provide a critique of Townsend's concept of deprivation and area-based deprivation through a critical, structural analysis and suggest alternatives to give social justice a better chance. Deprivation measures used without critical reflection can lead to deficit framing of populations and maintain current inequities in health and social outcomes. We contend therefore that the lack of consideration of (bio)power, privilege, epistemology and (bio)politics is a central concern in studies of deprivation. Our review highlights the need for the academy to balance the asymmetry between qualitative and quantitative studies of deprivation through trans-disciplinary approaches to understanding deprivation, and subsequently, social and health inequities. We recommend that deprivation research needs be critically applied through a decolonising lens to avoid deficit framing and suggest that there is space for a tool that focuses on measuring the unequal distribution of power and privilege in populations.

Primary care priorities in addressing health equity: summary of the WONCA 2013 health equity workshop.

BackgroundResearch consistently shows that gaps in health and health care persist, and are even widening. While the strength of a country’s primary health care system and its primary care attributes significantly improves populations’ health and reduces inequity (differences in health and health care that are unfair and unjust), many areas, such as inequity reduction through the provision of health promotion and preventive services, are not explicitly addressed by general practice. Substantiating the role of primary care in reducing inequity as well as establishing educational training programs geared towards health inequity reduction and improvement of the health and health care of underserved populations are needed.MethodsThis paper summarizes the work performed at the World WONCA (World Organization of National Colleges and Academies of Family Medicine) 2013 Meetings’ Health Equity Workshop which aimed to explore how a better understanding of health inequities could enable primary care providers (PCPs)/general practitioners (GPs) to adopt strategies that could improve health outcomes through the delivery of primary health care. It explored the development of a health equity curriculum and opened a discussion on the future and potential impact of health equity training among GPs.ResultsA survey completed by workshop participants on the current and expected levels of primary care participation in various inequity reduction activities showed that promoting access (availability and coverage) to primary care services was the most important priority. Assessment of the gaps between current and preferred priorities showed that to bridge expectations and actual performance, the following should be the focus of governments and health care systems: forming cross-national collaborations; incorporating health equity and cultural competency training in medical education; and, engaging in initiation of advocacy programs that involve major stakeholders in equity promotion policy making as well as promoting research on health equity.ConclusionsThis workshop formed the basis for the establishment of WONCA’s Health Equity Special Interest Group, set up in early 2014, aiming to bring the essential experience, skills and perspective of interested GPs around the world to address differences in health that are unfair, unjust, unnecessary but avoidable.

The importance of economic, social and cultural capital in understanding health inequalities: using a Bourdieu-based approach in research on physical and mental health perceptions.

In this article we adopt a Bourdieu-based approach to study social inequalities in perceptions of mental and physical health. Most research takes into account the impact of economic or social capital on health inequalities. Bourdieu, however, distinguishes between three forms of capital that can determine peoples' social position: economic, social and cultural capital. Health research examining the effects of cultural capital is scarce. By simultaneously considering and modelling indicators of each of Bourdieu's forms of capital, we further the understanding of the dynamics of health inequalities. Using data from a large-scale representative survey (N = 1825) in Flanders, Belgium, we find that each of the forms of capital has a net effect on perceptions of physical and mental health, which persists after controlling for the other forms of capital and for the effects of other correlates of perceived health. The only exception is that the cultural capital indicators are not related to mental health. These results confirm the value of a Bourdieu-based approach and indicate the need to consider economic, social and cultural capital to obtain a better understanding of social inequality in health.

Contextualizing Disparities: The Case for Comparative Research on Social Inequalities in Health.

Research on healthcare disparities is making important descriptive and analytical strides, and the issue of disparities has gained the attention of policymakers in the US, other nation-states, and international organizations. Still, disparities scholarship remains US-centric and too rarely takes a cross-national comparative approach to answering its questions. The US-centricity of disparities research has fostered a fixation on race and ethnicity that, although essential to understanding health disparities in the United States, has truncated the range of questions researchers investigate. In this article, we make a case for comparative research that highlights its ability to identify the institutional factors may affect disparities. We discuss the central methodological challenges to comparative research. After describing current solutions to such problems, we use data from the World Values Survey to show the impact of key social fault lines on self-assessed health in Europe and the U.S. The negative impact of SES on health is more generalizable across context, than the impact of race/ethnicity or gender. Our analysis includes a limited number of countries and relies on one measure of health. The paper represents a first step in a research agenda to understand health inequalities within and across societies.

The diffusion of health technologies: Cultural and biological divergence

This paper proposes the hypothesis that genetic distance to the health frontier influences population health outcomes. Evidence from a world sample suggests that genetic distance, interpreted as long-term cultural and biological divergence, is an important factor in understanding health inequalities across countries. Specifically, the paper documents a remarkably robust negative link between genetic distance to the United States and population health—as measured by life expectancy at birth and the adult survival rate—even after accounting for an extensive set of possible confounders, such as GDP per capita and various climatic factors. Consistent with the interpretation that genetic distance is related to population health indirectly through human barriers to the diffusion of modern health technologies, the evidence indicates that the gene gradient emerges at the onset of the international epidemiological transition.

The Diffusion of Health Technologies: Cultural and Biological Divergence

This paper proposes the hypothesis that genetic distance to the health frontier influences population health outcomes. Evidence from a world sample suggests that genetic distance, interpreted as long-term cultural and biological divergence, is an important factor in understanding health inequalities across countries. In particular, the paper documents a remarkably robust negative link between genetic distance to the United States and population health --- as measured by life expectancy at birth and the adult survival rate --- even after accounting for an extensive set of possible confounders, such as GDP per capita and various climatic factors. Consistent with the interpretation that genetic distance is related to population health indirectly through human barriers to the diffusion of modern health technologies, the evidence indicates that the gene gradient emerges at the onset of the international epidemiological transition.

Unravelling the impact of ethnicity on health in Europe: the HELIUS study

BackgroundPopulations in Europe are becoming increasingly ethnically diverse, and health risks differ between ethnic groups. The aim of the HELIUS (HEalthy LIfe in an Urban Setting) study is to unravel the mechanisms underlying the impact of ethnicity on communicable and non-communicable diseases.Methods/designHELIUS is a large-scale prospective cohort study being carried out in Amsterdam, the Netherlands. The sample is made up of Amsterdam residents of Surinamese (with Afro-Caribbean Surinamese and South Asian-Surinamese as the main ethnic groups), Turkish, Moroccan, Ghanaian, and ethnic Dutch origin. HELIUS focuses on three disease categories: cardiovascular disease (including diabetes), mental health (depressive disorders and substance use disorders), and infectious diseases. The explanatory mechanisms being studied include genetic profile, culture, migration history, ethnic identity, socio-economic factors and discrimination. These might affect disease risks through specific risk factors including health-related behaviour and living and working conditions. Every five years, participants complete a standardized questionnaire and undergo a medical examination. Biological samples are obtained for diagnostic tests and storage. Participants’ data are linked to morbidity and mortality registries. The aim is to recruit a minimum of 5,000 respondents per ethnic group, to a total of 30,000 participants.DiscussionThis paper describes the rationale, conceptual framework, and design and methods of the HELIUS study. HELIUS will contribute to an understanding of inequalities in health between ethnic groups and the mechanisms that link ethnicity to health in Europe.

Attitudes towards health inequalities amongst GP trainers in Glasgow, and their ideas for changes in training

WHAT IS ALREADY KNOWN IN THIS AREA: Recent government policy has emphasised the important role that GPs have to play in addressing health inequalities. The RCGP curriculum asserts the importance of gaining a better understanding of health inequalities during GP training. GP training in Scotland continues to take place in disproportionately affluent areas. WHAT THIS WORK ADDS: This is the first study to look at attitudes of GP trainers towards health inequalities and to explore their ideas for changes in training that may address health inequalities. There were noticeable differences in the views of GP trainers--both in terms of the causes of health inequalities and the role of primary care in tackling inequalities--depending on whether they were based in more affluent or more deprived practices. Practice rotations were suggested by all groups as a means to give GP trainees exposure to the particular challenges of both affluent and deprived practice populations. SUGGESTIONS FOR FUTURE RESEARCH: Pilot studies of practice rotations between deprived and affluent areas would be of value. Evaluation of nMRCGP assessments (particularly the Clinical Skills Assessment, CSA) with regard to representativeness of general practice in deprived areas should be considered. Further qualitative research into the attitudes of GP trainees towards health inequalities, and GP trainers from different--less deprived--practice areas, would also be of interest. [corrected].

Ethnicity, Migration and the ‘Social Determinants of Health’ Agenda*

One of the most promising recent developments in health policy has been the emergence of a global 'health equity' movement concerned with the social determinants of health. In European research and policy-making, however, there is an strong tendency to reduce 'social determinants' to 'socioeconomic determinants' and to ignore the role of ethnicity, migration and other factors in the creation of inequities. This threatens to hold up the development of work on ethnicity and migration and thus to perpetuate inequities linked to these factors. The present article sets out to illustrate this tendency and to investigate the reasons which may underlie it. The justifications often put forward for neglecting ethnicity and migration are shown to be erroneous. An integrated approach, simultaneously taking account of socioeconomic status, migration and ethnicity as well as other determinants of inequity, is essential if work on the social determinants of health is to make progress. Equity is indivisible; researchers investigating different aspects of social stratification should not treat each other as rivals, but as indispensible allies. An integrated, intersectional, multivariate and multilevel approach will improve our understanding of health inequities and make available more resources for tackling them.

How Society Shapes the Health Gradient: Work-Related Health Inequalities in a Comparative Perspective

Analyses in comparative political economy have the potential to contribute to understanding health inequalities within and between societies. This article uses a varieties of capitalism approach that groups high-income countries into coordinated market economies (CME) and liberal market economies (LME) with different labor market institutions and degrees of employment and unemployment protection that may give rise to or mediate work-related health inequalities. We illustrate this approach by presenting two longitudinal comparative studies of unemployment and health in Germany and the United States, an archetypical CME and LME. We find large differences in the relationship between unemployment and health across labor-market and institutional contexts, and these also vary by educational status. Unemployed Americans, especially of low education or not in receipt of unemployment benefits, have the poorest health outcomes. We argue for the development of a broader comparative research agenda on work-related health inequalities that incorporates life course perspectives.

Impact of educational level on health-related quality of life (HRQL): results from Germany based on the EuroQol 5D (EQ-5D)

To date, there is hardly any study focussing on the question how the concept of HRQL could deepen our understanding of health inequalities. The study aims at describing this potential by analysing data for adults from Germany. The analyses are based on three national, representative surveys conducted from 2006 to 2008. HRQL was assessed by the EuroQol-5D (EQ-5D), the descriptive part (problems in five dimensions) and the valuation of health by visual analogue scale (VAS) rendering a value between '0' (worst) and '100' (best imaginable). The major independent variable is educational level (high vs. low). Four other variables were included (i.e. age, sex, per capita income and chronic disease). Multivariate analyses were performed by logistic and linear regression. Data were available for 5676 persons aged ≥ 20 years (response rate 73%). The prevalence of 'moderate or severe problems' is especially high in the dimension 'pain/discomfort' (low resp. high educational level: 46.3% resp. 25.0%). The mean VAS-value is 79.8 (low resp. high educational level: 75.3 resp. 83.6). Bivariate and multivariate analyses show that similar differences in VAS-values can be seen even after restricting the analyses to participants with a chronic disease. Empirical analyses concerning HRQL could further our understanding of health inequalities. They indicate that low status groups are faced with a double burden, first by increased levels of health impairments, and second by lower levels of HRQL once health is impaired. Thus, the extent of health inequalities could be underestimated if measures of HRQL are not taken into account.

Towards a Public Health Curriculum in Undergraduate Medicine

The need to adequately train medical professionals in public health has been recognised internationally. Despite this, public health curricula, particularly in undergraduate medicine, are poorly defined. This study explored the public health disciplines that newly qualified doctors in the United Kingdom (UK) should know. We developed a 31-item questionnaire covering public health subject areas and expected competencies that medical graduates should know. The questionnaire was then administered to a stratified sample of medically trained individuals across a number of postgraduate schools of public health in the UK. Following administration, a ranking list was developed by subject area and by competency. There was an 85% response rate (69/81). Subject areas ranked highest included epidemiology, health promotion and health protection. Sociology and the history of public health ranked lowest. Competencies perceived as important by the respondents included understanding health inequalities, empowering people about health issues and assessing the effectiveness of healthcare programmes. Our study identifies the expected public health subject areas and competencies that newly graduating medical students should know. They provide a context through which to begin addressing concerns over the disparity between these expectations and what is actually taught in medical school, highlighting the continuing need to reframe undergraduate public health education in the UK.

Spatial aberration vs. geographical substance: Representing place in public health surveillance

Public health surveillance involves the routine and ongoing collection, analysis and dissemination of health information for a variety of stakeholders—including both public health officials and the public. Much of the current focus of public health surveillance is on detecting aberrations in space—largely inspired by concerns about bioterrorism and newly emerging infectious diseases. We argue that the current focus on spatial aberrations has limited the development of public health surveillance by excluding a more explicit geographical understanding and representation of place. A more place-focused public health surveillance could represent geography in ways that are useful to a broader audience, provide information on the social and physical contexts related to health, facilitate a better understanding of health inequalities, and can benefit from local knowledge. Geographers can make important contributions to public health practice by contributing to more meaningful definitions of place in the design and operation of public health surveillance systems.