Health inequalities and the welfare state: perspectives from social epidemiology
George A. Kaplan
Center for Social Epidemiology and Population Health, University of Michigan, Ann Arbor, Michigan, USA
Norsk Epidemiologi 2007; 17 (1): 9-20 9
Available online PDF [12p.] at:
http://www.ub.ntnu.no/journals/norepid/2007-1/2007(1)%2003-Kaplan.pdf
It might be assumed that welfare states that have done so much to reduce inequality of opportunity have also reduced inequality of health outcomes. While great advances have been seen in reducing the rates of many diseases in welfare states, disparities in health have not been eliminated. Is it the case that lowering
risks overall will leave disparities that cannot be remediated, and that such efforts are at the point of diminishing returns?
The evidence suggests that this is not true. Instead the lens of social epidemiology can be used to identify groups that are at unequal risk and to suggest strategies for reducing health inequalities through upstream, midstream, and downstream interventions. The evidence suggests that these interventions be targeted at low socioeconomic position, place-based limitations in opportunities and resources, stages of the life course and the accumulation of disadvantage across the life course, and the underlying health-related factors that are associated with the marginalization and exclusion of certain groups. In their commitment to the values of equity and social justice, welfare states have unique opportunities to demonstrate the extent to which health inequalities can be eliminated…."
Health inequalities and the welfare state / Helseulikheter og velferdsstat (Volume 17, No. 1, 3 - 87).
Norwegian Journal of Epidemiology
Guest editors: Else-Karin Grøholt, Espen Dahl og Jon Ivar Elstad.
Click 
to view the abstract / Klikk på for å se sammendraget
· Else-Karin Grøholt, Espen Dahl and Jon Ivar Elstad: Health inequalities and the welfare state, 3-8, pdf
§ Summary: This issue of the Norwegian Journal of Epidemiology is based on the research conference Health Inequalities and the Welfare State at the Soria Moria Conference Center in Oslo, Norway, October 10-11 2006. The main purpose of the conference was to support, stimulate, disseminate and contribute to research in Norway on social inequalities in health. Nine papers are included in this issue, in addition to this introduction. One paper is based on one of the keynote lectures, while the other eight papers demonstrate some of the themes and approaches in current Norwegian research on socioeconomic health inequalities. Most of the articles have been authored by researchers who are working on a doctoral thesis or have recently attained their doctoral degree. The papers cluster into four groups. One cluster has a common denominator in intervention and policies to reduce health inequalities. A second focuses on marginalised groups, whereas a third cluster draws attention to the possible impact of the social context on individual health. The last paper addresses health inequalities among adolescents. The main focus of the Soria Moria conference was how and why social health inequalities continue to exist in the Norwegian society with a long tradition of a social democratic welfare model. We are pleased to note that health inequalities are becoming a prioritised health policy issue in Norway, and hope this issue of the Norwegian Journal of Epidemiology will contribute to a sharper focus on monitoring of, research on, and interventions to reduce social inequalities in health.
· George A. Kaplan: Health inequalities and the welfare state: perspectives from social epidemiology, 9-20, pdf
§ Summary: It might be assumed that welfare states that have done so much to reduce inequality of opportunity have also reduced inequality of health outcomes. While great advances have been seen in reducing the rates of many diseases in welfare states, disparities in health have not been eliminated. Is it the case that lowering risks overall will leave disparities that cannot be remediated, and that such efforts are at the point of diminishing returns? The evidence suggests that this is not true. Instead the lens of social epidemiology can be used to identify groups that are at unequal risk and to suggest strategies for reducing health inequalities through upstream, midstream, and downstream interventions. The evidence suggests that these interventions be targeted at low socioeconomic position, place-based limitations in opportunities and resources, stages of the life course and the accumulation of disadvantage across the life course, and the underlying health-related factors that are associated with the marginalization and exclusion of certain groups. In their commitment to the values of equity and social justice, welfare states have unique opportunities to demonstrate the extent to which health inequalities can be eliminated.
· Sille Ohrem Naper og Espen Dahl: Sosialhjelpsmottakeres dødelighet: I hvilken grad kan overdødeligheten tilskrives deres sosiale status? 21-28 , pdf
§ Sammendrag: I denne artikkelen undersøker vi dødelighet blant sosialhjelpsmottakere i Norge, som sammenlignes med dødeligheten i resten av befolkningen, og om en antatt overdødelighet kan forklares ved sosiale forhold som kjennetegner dem som har status som sosialhjelpsmottakerne, og som har betydning for dødelighetsnivå. Data er hentet fra FD-trygd og omfatter hele den norske befolkningen i aldersgruppen 18-57 år i 1992. Vi analyserer dødeligheten fra 1994 til 2003. Sosialhjelpsmottakere er definert som personer som mottok sosialhjelp i 1993 (N=146 176), og det skilles mellom korttids- og langtidsmottakere (≥ 6 måneder). Menn og kvinner behandles separat. En serie multiple Cox regresjonsmodeller er estimert for å belyse problemstillingene. Den enkleste modellen, som kun inneholder sosialhjelp og alder, viser at dødeligheten til sosialhjelpsmottakere er langt høyere enn andres. Hasardratioene (HR) for mannlige kortidsmottakere av sosialhjelp sammenlignet med befolkningen er 3,5 (95% KI = 3,34-3,62), for langtidsmottakere 4,8 (4,64-5,01). For kvinner er HR henholdsvis 2,8 (2,60-2,93) og 3,9 (3,66-4,15). Overdødeligheten blant sosialhjelpsmottakere reduseres ettersom forklaringsvariablene introduseres. I den fulle modellen, som inneholder alder, sivilstand, utdanning, inntekt og uførepensjon, er HR for kvinner redusert med 60 prosent for korttidsmottakere, og 50 prosent for langtidsmottakere, noe mindre for menn. HR er fortsatt høye i de justerte modellene, særlig for langtidsmottakere av sosialhjelp. De er nå for menn, korttid: 2,1 (1,98-2,15) og langtid: 3,1 (2,98-3,23), kvinner, korttid: 1,7 (1,61-1,82) og langtid: 2,5 (2,29-2,62). I lys av tidligere forskning på feltet argumenter vi for at et livsløpsperspektiv er fruktbart for å forstå sosialhjelpsmottakeres overdødelighet. Samtidig peker vi på flere trekk ved posisjonen som sosialhjelpsmottaker som kan være helseskadelig.
· Sturla Gjesdal, John Gunnar Mæland, Jan Hagberg and Kristina Alexanderson:
Socioeconomic inequalities and mortality among disability pensioners in Norway – a population-based cohort study, 29-35, pdf
§ Summary: Background: The study assessed the mortality related to disability pension (DP) status in Norway during 1990-96 and investigated whether socioeconomic factors explained the increased mortality. Methods: A 10% random sample of the Norwegian population aged 30-59 years, 73,420 women and 75,500 men, were followed-up with respect to death or emigration in 1990-96. DP-status, age, gender, educational level and mean income before inclusion were used as explanatory variables in Cox' regression analysis with death as endpoint. The analyses were stratified for gender and separately for persons who had obtained DP before 1985 (early) and in 1985-1989 (late). Results: The majority of persons with DP had only basic education and belonged to the lowest income level. Among the women 6.2% in the DP-group died during follow-up compared to 1.2% of those in the non-DP group. The corresponding percentages for men were 14.5% and 2.3%. The age-adjusted hazard ratios (HRs) were 3.5 and 2.5 for women with early and late DP, and 4.3 and 3.3 among men. After adjustment for socioeconomic variables, the HRs were 2.9 and 2.2 for women, and 2.2 and 1.9 for men. Conclusions: Nearly half of the excess mortality related to DP-status was explained by low socioeconomic status among the men. Among women, HR related to DP was not significantly reduced after the adjustments for socioeconomic variables. These findings indicate a strong impact of the medical factors underlying the DP decision, especially among women, but also an important role of the socioeconomic factors related to DP status.
· Jon Ivar Elstad, Dag Hofoss og Espen Dahl: Hva betyr de enkelte dødsårsaksgrupper for utdanningsforskjellene i dødelighet?, 37 -42, pdf
§ Sammendrag: Artikkelen analyserer utdanningsforskjellene i dødelighet og undersøker hvilke dødsårsaksgrupper som særlig bidrar til de sosioøkonomiske helseforskjellene. Data kommer fra Statistisk sentralbyrås database FD-Trygd. Analyseutvalget består av praktisk talt alle bosatte i Norge i 1993 alder 25-66 år (N = 2,2 millioner). Data har informasjon om utdanning og dødsfall/dødsårsaker 1994-2003 og ble analysert med logistisk regresjon (utfallsvariabel død/ikke-død 1994-2003 alle årsaker samlet og 18 dødsårsaksgrupper, aldersjustert). Beregninger av hvor mange dødsfall som kunne være unngått om dødsrisiko for alle hadde vært lik den faktiske risiko for høyere universitetsutdanning er foretatt. Analysene viste at oddsratioer (OR) for dødsfall, alle årsaker, økte systematisk med synkende utdanningsnivå. Utdanningsforskjellene var spesielt store for stoffmisbruksrelaterte dødsfall og over gjennomsnittet for alkoholrelaterte dødsfall, lungekreft, kroniske lungelidelser. Variasjonene med utdanning var også særlig store for ischemisk hjertesykdom blant kvinnene. De fleste kreftformene unntatt lungekreft viste forholdsvis små utdanningsforskjeller. Blant kvinnene var det ingen utdanningsulikhet for tykk/endetarmskreft, brystkreft, selvmord og trafikkulykker. Om dødsrisikoen i alle utdanningsgrupper hadde vært lik risikoen blant dem med høyere universitetsutdanning ville 43 000 av de 104 000 dødsfallene som faktisk fant sted 1994-2003 vært unngått. Dødsfall i hjerte- og karlidelser, lungekreft og kronisk lungesykdom sto for nær 60% av de "ekstra" dødsfallene for begge kjønn. Store helsegevinster vil oppnås om utdanningsforskjellene i dødelighet reduseres. En minsking av ulikhetene i dødelighet i hjerte- og karlidelser, lungekreft og kronisk lungesykdom ville ha særlig betydning for å redusere de samlete utdanningsforskjellene i dødelighet.
· Camilla Hem, Øyvind Næss and Bjørn Heine Strand:
Social inequalities in causes of death amenable to health care in Norway, 43 -48 pdf
§ Summary: Objective: Investigate if there are educational inequalities in causes of death considered amenable to health care in Norway and compare this with non-amenable causes. Methods: The study used the concept of "amenable mortality", which here includes 34 specific causes of death. A linked data file, with information from the Norwegian Causes of Death Registry and the Educational Registry was analyzed. The study population included the whole Norwegian population in two age groups of interest (25-49 and 50-74 years). Information on deaths was from the period 1990-2001. Education was recorded in 1990 and it was grouped in four categories as: basic, lower secondary, higher secondary and higher. In the study men and women were analysed seperately. The analysis was conducted for all amenable causes pooled with and without ischemic heart disease. A Cox proportional hazard regression model was fitted to estimate hazard rate ratios. Results: The study showed educational differences in mortality from causes of death considered amenable to health care, in both age groups and sexes. This was seen both when including and excluding ischemic heart disease. The effect sizes were comparable for amenable and non-amenable causes in both age groups and sexes. Conclusions: This study revealed systematic higher risk of death in lower educational groups in causes of death considered amenable to health care. This indicates potential weaknesses in equitable provision of health care for the Norwegian population. Additional research is needed to identify domains within the health care system of particular concern.
· Anne Karen Jenum, Catherine Lorentzen, Sidsel Graff-Iversen, Sigmund Andersen, Ann Kristin Ødegaard, Ingar Holme, Kåre Birkeland og Yngvar Ommundsen: Kan lokalbaserte strategier bidra til å redusere sosiale helseforskjeller? MoRo-prosjektet – bakgrunn, hovedresultater og erfaringer, 49 - 57, pdf
§ Sammendrag: I en multietnisk bydel i Oslo med høy dødelighet og lav sosioøkonomisk status ble en teoribasert befolkningsrettet intervensjon for å fremme fysisk aktivitet utviklet og evaluert. Alle i alderen 31-67 år i intervensjonsbydelen og et aldersmatchet utvalg i kontrollbydelen ble invitert til en helseundersøkelse i 2000, og 2950 (48%) møtte. Store etniske forskjeller i diabetesforekomst ble funnet. I aldersgruppen 30-59 år var forekomsten hos sør-asiatiske kvinner 27,5% (95% KI 18,1-36,9) og hos menn 14,3% (8,0-20,7), mot 2,9% (1,9-3,9) hos norske kvinner og 5,9% (4,2-7,5) hos menn. De etniske forskjellene var signifikante etter justering for alder, midje/hofteratio, fysisk aktivitet og utdanning. Etter ytterligere justering for kroppshøyde var OR for kvinner (også justert for paritet) 6,0 (2,3-15,4) og for menn 1,9 (0,9-4,0). En sterk invers assosiasjon mellom diabetes og utdanning og inntekt ble funnet hos de vestlige. Hos innvandrere ga økt inntekt økt risiko for diabetes. Etter intervensjonen møtte 67% til oppfølgingsundersøkelsen i 2003. Endringer i fysisk aktivitet, dagligrøyking og biologiske variabler ble beregnet hos dem som møtte begge ganger. Netto økning i fysisk aktivitet (forskjell i endring fra 2000-2003 mellom bydelene) var 9,5% (p=0,008). Andel inaktive ble redusert med 22%. Andelen som gikk opp i vekt, ble redusert med 50% i forhold til kontrollbydelen (p<0,001). Gunstige effekter ble funnet for kolesterol/HDL-kolesterol ratio, triglyserider og glukose, systolisk blodtrykk og andel dagligrøykere. Resultatene for vekt, lipider og glukose var sammenlignbare for deltakere med høy og lav utdanning, og vestlig og ikke-vestlig bakgrunn. Teoribaserte intervensjoner for å endre atferd og biologiske risikofaktorer for hjerte- og karsykdom og diabetes i lokalsamfunn med høy dødelighet og lav sosioøkonomisk status, bør inngå i en nasjonal strategi for å redusere sosiale helseforskjeller.
· Erik R. Sund, Stig H. Jørgensen, Andy Jones, Steinar Krokstad and Marit Heggdal:
The influence of social capital on self-rated health and depression – The Nord-Trøndelag health study (HUNT), 59-69, pdf
§ Summary: The article examines the relationship between neighbourhood social capital and two health outcomes: selfrated health and depression. A total of 42,571 individuals aged 30–67 years participated in a cross-sectional total population health study in Nord-Trøndelag in 1995–1997 (HUNT II) and were investigated using multilevel modelling. Aims were, first, to investigate potential area effects after accounting for the characteristics of individuals in the neighbourhoods (N = 155), and, second, to explore the relationships between contextual social capital (the level of trust at the neighbourhood level and the level of local organizational activity) and the two health measures. Models with stepwise inclusion of individual level factors attenuated the ward level variance for both self-rated health (PCV: 41%) and depression (PCV: 43%). The inclusion of the two contextual social capital items attenuated the ward level variance for both self-rated health and depression, however to varying degrees. At the individual level, contextual social capital was associated with both self-rated health and depression. Individuals living in wards with a low level of trust experienced an increased risk of 1.36 (95% CI: 1.13-1.63) for poor self-rated health compared to individuals in wards with a high level of trust. For depression, this effect was even stronger (OR 1.52, 1.23-1.87). The associations with the level of organizational activity were inconsistent and weaker for both health outcomes. It was concluded that geographical variations in self-rated health and depression are largely due to the socioeconomic characteristics of individuals. Nevertheless, contextual social capital, expressed as the level of trust, was found to be associated with depression and self-rated health at individual level.
· Kjetil A. van der Wel: Social capital and health – a multilevel analysis of 25 administrative districts in Oslo, 71-78 pdf
§ Summary: Background: Studies of place and health have recently gained increased interest among social researchers. This interest has brought society back to the study of health inequalities and drawn attention to the health effects of contextual psychosocial phenomena. Social cohesion, generalised trust, social networks and social participation are seen as being such phenomena in the social environment that affect health. Methods: This study investigates the association between social capital and self reported health in Oslo. I have used data from the Oslo Health Study 2000 (HUBRO), which includes 11,807 respondents residing in 25 administrative districts. For the multilevel analysis, contextual social capital was measured by aggregating the individual variables generalised trust and participation in voluntary organisations. In addition to the individual variables, the association between social capital and health was controlled for median income, economic inequality and educational level in the administrative districts. Results: In the models that only include the individual variables, both contextual trust and organisational participation had significant effects on self reported health. The associations between place, social capital, and health was attenuated and partly rendered insignificant by the other contextual variables. Conclusions: This study concludes that social capital is not associated with health when other contextual variables are taken into account, and suggests that previous findings may be mediated by median income and the educational level in the areas under study. However, strong conclusions cannot be drawn from this study due to low statistical power and the low response rate. None the less, the study supports the hypothesis that place matters for health.
· Torbjørn Torsheim, Ingrid Leversen og Oddrun Samdal: Sosial ulikhet i ungdoms helse: Er helseatferd viktig?, 79-86, pdf
§ Sammendrag: Studier har påvist sosioøkonomiske forskjeller i ungdoms helse. I følge atferdsforklaringer på ulikhet har ungdom fra familier med lav sosioøkonomisk status dårligere helse som et resultat av at de har et høyere nivå av risikoatferd og et lavere nivå av beskyttende atferd. Det empiriske grunnlaget for en slik forklaring er imidlertid svakt. Målet med studien var å undersøke rollen helseatferd kan ha for sosioøkonomiske forskjeller i ungdoms helse. Studien bygger på data fra den norske delen av "Helsevaner blant skoleelever 2005/06". Et utvalg av 6447 skoleelever i aldersgruppen 11 til 16 år besvarte spørreskjemaer. Sosioøkonomisk status ble målt med en indeks for foreldrenes status bestående av foreldrenes yrke, familiens velstand og antall bøker i hjemmet. Helseatferd ble målt ved epidemiologiske indikatorer for kosthold, fysisk aktivitet, stillesittende aktivitet/ser mye på tv, røyking og alkoholbruk. Ordinal logistisk regresjonsanalyse viste at ungdom med lav status hadde høyere odds ratioer for selvrapportert dårligere helse. Kontroll for helseatferd resulterte i en klar reduksjon i odds ratioen for dårligere helse, en indikasjon på delvis mediering. Stianalyse indikerte at røyking, fysisk aktivitet og inntak av frukt og grønnsaker bidro til mediering av sammenhengen mellom sosioøkonomisk status og selvrapportert helse. Samlet tyder resultatene på at helseatferd kan være en medierende mekanisme for sosioøkonomiske forskjeller i ungdoms helse. Langtidskonsekvensen av helseatferd antyder et behov for intervensjoner som retter seg mot flere former for helseatferd.
· Minneord for Knut Westlund, pdf
| * * * * This message from the Pan American Health Organization, PAHO/WHO, is part of an effort to disseminate
information Related to: Equity; Health inequality; Socioeconomic inequality in health; Socioeconomic
health differentials; Gender; Violence; Poverty; Health Economics; Health Legislation; Ethnicity; Ethics;
Information Technology - Virtual libraries; Research & Science issues. [DD/ IKM Area] "Materials provided in this electronic list are provided "as is". Unless expressly stated otherwise, the findings
and interpretations included in the Materials are those of the authors and not necessarily of The Pan American
Health Organization PAHO/WHO or its country members".
------------------------------------------------------------------------------------ PAHO/WHO Website: http://www.paho.org/ EQUITY List - Archives - Join/remove: http://listserv.paho.org/Archives/equidad.html |
No comments:
Post a Comment