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International Variation in the Size of Mortality Differences Associated with Occupational Status
Abstract
Previous international comparisons on the size of mortality differences associated with occupational status have relied on inequality indices with one or more limitations. This study reassesses the international pattern of inequalities in mortality using an inequality index devised recently.
Data on mortality by social class were obtained from longitudinal studies from seven countries. The data referred to men aged 35-64 years. The follow-up period was approximately 1971-1981. The size of mortality differences associated with occupational status was measured using a modification of the Relative Index of Inequality.
The smallest inequalities in mortality are observed for Norway and Denmark. Larger inequalities are observed for Sweden (compared to Norway circa 1.5 times as large), England and Wales (2 times), Finland (4-5 times) and France (6-8 times). Inequalities in a Dutch city, Rotterdam, are as large as in Danish and Swedish cities, and smaller than in Finnish and French cities. Results of sensitivity analyses suggest that probably only a small part of this international pattern can be attributed to differences between countries with respect to occupational classification.
The results of most previous international comparisons agree with the general pattern observed here. This simultaneous comparison of various countries shows that the frequently cited difference between Sweden, and England and Wales is small when viewed in a wider international context.
... Main causes of death are known and reported annually [2]. For the past few decades, multiple studies have identified the importance of characteristics that contribute to mortality other than traditional medical care, e.g., income, education, occupational status, social class [3][4][5][6][7][8][9][10][11]. Many of these previous studies have been ecological in design, i.e., characteristics of individuals have been related to death rates within the group aggregate. ...
... These are similar findings to causes of natural death at the U.S. national level [13]. These individuals may have had long term and cumulative exposure to risk factors or contributory lifestyles habits, whether due to socioeconomic and cultural aspects or personal choice, that combined with lack of medical access, potentially contributed to premature mortality [3][4][5][6][7][8][9][10]. ...
The purpose of the study was to identify circumstances of death, disease states, and sociodemographic characteristics associated with premature natural and drug-related deaths among 25–59 year olds. The study also aimed to address the paucity of research on personal, community-based, and societal factors contributing to premature death. A population-based retrospective chart review of medical examiner deaths within a highly populated and ethnically diverse county [in Texas] was undertaken to identify individuals dying prematurely and circumstances surrounding cause of death [in 2013]. The sample data (n = 1282) allowed for analysis of decedent demographic variables as well as community characteristics. Descriptive statistics, multivariable logistic regression, and geospatial analyses were used to test for associations between the type of death (natural or drug-related) and demographics, circumstances of death, disease types and community characteristics. Census tract data were used to determine community characteristics. Highly clustered premature deaths were concentrated in areas with low income and under-educated population characteristics. Two-thirds of decedents whose death were due to disease had not seen a healthcare provider 30 days before death despite recent illness manifestations. Opioids were found in 187 (50.5%) of the drug-related deaths, with 92.5% of deaths by opioids occurring in combination with other substances. The study findings went beyond the cause of death to identify circumstances surrounding death, which present a more comprehensive picture of the decedent disease states and external circumstances. In turn, these findings may influence the initiation of interventions for medically underserved and impoverished communities.
... A multidimensional indicator of social precariousness captures the socioeconomic category of individuals based on four dimensions that traditionally enable individuals to be positioned socially (Cambois and Jusot 2007;Kunst and Mackenbach 1994): education, employment category, housing conditions and household income. While the correlation between these dimensions is high, they each play a different role in health status and mortality. ...
The Covid‐19 pandemic marked the year 2020. In Belgium, it led to a doubling in deaths, mainly grouped into two periods. This article aims to compare the relative importance of predictors and individual and spatial determinants of mortality during these two waves to an equivalent non‐pandemic period and to identify whether and to what extent the pandemic has altered the sociodemographic patterns of conventional mortality. The analyses relate to all‐cause mortality during the two waves of Covid‐19 and their equivalent in 2019. They are based on matching individual and exhaustive data from the Belgian National Register with tax and population census data. A multi‐level approach combining individual and spatial determinants was adopted. Mortality patterns during and outside the pandemic are very similar. As in 2019, age, sex, and household composition significantly determine the individual risk of dying, with a higher risk of death among the oldest people, men, and residents of collective households. However, their risk of death increases during the Covid period, especially in the 65–79 age group. Spatial information is no more significant in 2020 than in 2019. However, a higher risk of death is observed when the local excess mortality index or the communal proportions of single‐person households or disadvantaged people increase. While the Covid pandemic did not fundamentally alter conventional mortality patterns, it did amplify some of the pre‐existing differences in mortality.
... These variables are either individual or contextual. Individual variables include (1) A multidimensional indicator of social precariousness captures the socioeconomic category of individuals based on four dimensions that traditionally enable individuals to be positioned socially (Cambois & Jusot, 2007;Kunst & Mackenbach, 1994): education, employment category, and housing conditions from the 2011 census, and household income from the 2017 tax returns. While the correlation between these dimensions is high, they each play a different role in health status and mortality. ...
Context
The year 2020 was marked by the Covid-19 pandemic. In Belgium, it led to a doubling in deaths, mainly grouped into two periods. This article aims to compare the relative importance of predictors and individual and spatial determinants of mortality during these two waves to an equivalent non-pandemic period and to identify whether and to what extent the pandemic has altered the sociodemographic patterns of conventional mortality.
Methods
The analyses relate to all-cause mortality during the two waves of Covid-19 and their equivalent in 2019. They are based on matching individual and exhaustive data from the Belgian National Register with tax and population census data. A multi-level approach was adopted combining individual and spatial determinants.
Results
Mortality patterns during the pandemic are very similar to those observed outside the pandemic. As in 2019, age, sex, and household composition significantly determine the individual risk of dying, with a higher risk of death among the oldest people, men, and residents of collective households. However, their risk of death increases during the Covid period, especially in the 65–79 age group. Spatial information is no more significant in 2020 than in 2019. However, a higher risk of death is observed when the local excess mortality index or the proportions of isolated or disadvantaged people increase.
Conclusions
While the Covid pandemic did not fundamentally alter conventional mortality patterns, it did amplify some of the pre-existing differences in mortality.
... The copyright holder for this this version posted September 5, 2023. ; https://doi.org/10.1101/2023.09.04.23295014 doi: medRxiv preprint A multidimensional indicator of social precariousness captures the socioeconomic category of individuals based on four dimensions that traditionally enable individuals to be positioned socially (Cambois & Jusot, 2007;Kunst & Mackenbach, 1994): education, employment category, and housing conditions from the 2011 census, and household income from the 2017 250 tax returns. While the correlation between these dimensions is high, they each play a different role in health status and mortality. ...
Context
The year 2020 was marked by the Covid-19 pandemic. In Belgium, it led to a doubling in deaths, mainly grouped into two periods. This article aims to compare the relative importance of predictors and individual and spatial determinants of mortality during these two waves to an equivalent non-pandemic period and to identify whether and to what extent the pandemic has altered the sociodemographic patterns of conventional mortality.
Methods
The analyses relate to all-cause mortality during the two waves of Covid-19 and their equivalent in 2019. They are based on matching individual and exhaustive data from the Belgian National Register with tax and population census data. A multi-level approach was adopted combining individual and spatial determinants.
Results
Mortality patterns during the pandemic are very similar to those observed outside the pandemic. As in 2019, age, sex, and household composition significantly determine the individual risk of dying, with a higher risk of death among the oldest people, men, and residents of collective households. However, their risk of death increases during the Covid period, especially in the 65–79 age group. Spatial information is no more significant in 2020 than in 2019. However, a higher risk of death is observed when the local excess mortality index or the proportions of isolated or disadvantaged people increase.
Conclusions
While the Covid pandemic did not fundamentally alter conventional mortality patterns, it did amplify some of the pre-existing differences in mortality.
... Comment mesurer les inégalités sociales ? Différentes dimensions sont utilisées pour déterminer le positionnement social des individus : le niveau d'instruction, le statut socio-professionnel, les conditions de logement et le revenu (Cambois et Jusot, 2007 ;Kunst et Mackenbach, 1994 ;Hummer et al., 1998). Si la corrélation entre ces dimensions est élevée, il n'en demeure pas moins qu'elles peuvent avoir un rôle différent sur l'état de santé et la mortalité. ...
RésuméLes inégalités sociales de mortalité au-delà de 65 ans sont une problématique importante dans le contexte actuel de vieillissement de la population, d’augmentation de l’espérance de vie et de politiques visant à augmenter l’âge légal de départ à la retraite. Cet article pose trois questions : les inégalités sociales face à la mort, très présentes aux âges actifs, se maintiennent-elles durant la vieillesse ? Comment ont-elles évolué au cours de ces dernières décennies ? Quel est le rôle de l’état de santé sur le différentiel social de mortalité aux âges élevés ? Nous utiliserons une base de données appariant les informations du Registre national (1991-2016) avec celles des recensements de la population de 1991, 2001 et 2011. Des tables de mortalité par groupe social et état de santé subjectif ont été calculées et nous aurons aussi recours à des modèles de régression logistique. Les résultats montrent qu’au-delà de 65 ans, les inégalités sociales face à la mort sont importantes et ont même augmenté aux cours des 25 dernières années. En contrôlant l’état de santé, des différences de mortalité subsistent entre les groupes sociaux mais varient en importance en fonction du gradient social. Les plus âgés doivent donc faire l’objet d’une attention particulière, non seulement parce qu’il s’agit d’une population intrinsèquement plus fragile mais aussi parce que leurs effectifs croissent. Il s’agit là d’un défi actuel et futur majeur de santé publique.AbstractSocial inequalities in mortality beyond the age of 65 are an important issue in the current context of population ageing, increased life expectancy and policies aimed at extending the legal retirement age. This article asks three questions: do social inequalities in the face of death, which are very present at working ages, continue in old age? How have they evolved over the last few decades? What is the role of health status on the social differential in mortality at advanced ages? We will use a database matching information from the National Register (1991-2016) with information from the 1991, 2001 and 2011 population censuses. Mortality tables by social group and subjective health status have been calculated. We also use logistic regression models. The results show that social inequalities in the face of death beyond the age of 65 are significant and have even increased over the last 25 years. Controlling for health status, mortality differences remain between social groups but vary in magnitude along the social gradient. The elderly therefore need specialattention, not only because they are an inherently more fragile population, but also because their numbers are increasing. This is a major current and future public health challenge.
... Nous avons calculé les indices de surmortalité et les tables de mortalité par groupe social. Ce dernier est identifié à partir d'un indicateur multidimensionnel prenant en considération quatre dimensions permettant traditionnellement de positionner socialement les individus : le niveau d'instruction, la catégorie socioprofessionnelle, les conditions de logement et le revenu du ménage (Cambois et Jusot, 2007 ;Kunst et Mackenbach, 1994). Si la corrélation entre ces dimensions est élevée, il n'en demeure pas moins qu'elles peuvent avoir un rôle différent sur l'état de santé et la mortalité. ...
... Partly, comparative studies on socioeconomic inequalities in health were still rarely published in journals on health research in the 1970s and 1980s. After that comparative studies emerged gradually in Britain, the Nordic countries and elsewhere [19][20][21][22][23][24][25]. The reasons behind the emergence of Nordic studies include, for example, interest in the welfare states and the related availability of level of living surveys coordinated between countries. ...
Aims
We examined the development of research articles published in the Scandinavian Journal of Public Health and its predecessors Acta Socio-Medica Scandinavica and the Scandinavian Journal of Social Medicine from 1969 until 2020 to be able to identify the place of international comparisons of socioeconomic inequalities in health in the journal.
Methods
Altogether 3237 research articles were screened to yield 126 comparative research articles. Examining full texts of the comparative articles led to 13 articles reporting comparisons of health inequalities.
Results
The first one came out in 1972, but the rest only after the mid-1990s. The most common socioeconomic indicator was education, but also occupational class and income was used. The most common health indicator was self-rated health. The articles compared Nordic countries with each other, but also with non-Nordic countries. Although the number of comparative studies on health inequalities was relatively small, there were examples of well-designed studies using advanced methodology. We examined only published journal articles over the past five decades, not submitted but rejected papers.
Conclusions
In the Scandinavian Journal of Public Health and its predecessors, comparisons of health inequalities were few and emerged relatively late, that is, during the past two decades.
... Adolescents were ranked within each country, survey year, sex and age group to draw their ridit-score, ranging from 0 (lowest affluence) to 1 (highest affluence). Ridit-scores, previously applied in social inequality studies [45,46], are based on cumulative probabilities. The ridit of the category i is the sum of the proportions ( ) of individuals in each category below the category i (i.e. ...
Purpose
To assess country-level trends in the prevalence of daily consumption of sugary (2002–2018) and diet (2006–2018) soft drinks among European adolescents, overall and by family material affluence.
Methods
We used 2002, 2006, 2010, 2014 and 2018 data from the ‘Health Behaviour in School-aged Children’ survey. Nationally representative samples of adolescents completed a standardised questionnaire at school, including a short food frequency questionnaire (n = 530,976 and 21 countries for sugary soft drinks; n = 61,487 and 4 countries for diet soft drinks). We classified adolescents into three socioeconomic categories for each country and survey year, using the Family Affluence Scale. Multilevel logistic models estimated time trends, by country.
Results
Sugary soft drinks: the prevalence of daily consumption (≥ 1×/day) declined in 21/21 countries (Plinear trends ≤ 0.002). Absolute [range − 31.7 to − 3.4% points] and relative [range − 84.8 to − 22.3%] reductions varied considerably across countries, with the largest declines in Ireland, England and Norway. In 3/21 countries, the prevalence of daily consumption decreased more strongly in the most affluent adolescents than in the least affluent ones (P ≤ 0.002). Daily consumption was more prevalent among the least affluent adolescents in 11/21 countries in 2018 (P ≤ 0.002). Diet soft drinks: overall, daily consumption decreased over time in 4/4 countries (Plinear trends ≤ 0.002), more largely among the most affluent adolescents in 1/4 country (P ≤ 0.002).
Conclusions
Daily consumption of sugary and diet soft drinks in European adolescents decreased between 2002 (2006 for diet drinks) and 2018. Public health interventions should continue discouraging daily soft drink consumption, particularly among adolescents from lower socioeconomic groups.
... Comparing data from the 1960s to those for the late 1970s and 1980s, U.S. studies reveal that 14 Inequality and Exclusion in Access to HealthCare … 281 income and educational differentials have widened over time (Williams and Collins, 1995;Thorat, 2007;United Nations, 2020). Similarly, widening socio-economic differentials in mortality have been observed in England, Wales, France, Finland, Norway, and the Netherlands (Department of Health & Social Security, 1980) and in other parts of the world (Mackenbach et al., 1989;Kunst & Mackenbach, 1994;Solar & Irwin, 2010;Borooah et al., , 2015Lynch, 2017). ...
Available literature shows that lockdowns and reassignment of health infrastructure carried out in response to the COVID-19 pandemic adversely affected several national health programmes in India. The National Tuberculosis Elimination Programme (NTEP) is one such important health programme that faced serious setbacks due to the pandemic since TB interventions require constant follow up of patients by frontline workers. We endeavoured to understand how TB frontline activities are affected by the ongoing COVID-19 pandemic interventions. The chapter draws on qualitative in-depth interviews with TB health visitors (TBHV) and patients, which were conducted before and after the outbreak of the pandemic. Our findings show that the pandemic situation has weakened the critical frontline interventions of NTEP since the frontline activities of DOTS, including active case finding, follow up of sputum examination, distribution of medicine, monitoring of patients with side effects and patient support measures, were either slowed down or temporarily suspended in several instances. Also, the existing vicious cycle of TB and poverty got exacerbated with the pandemic for female patients due to job loss, lack of supporting systems and improper adherence to treatment regimen. Most importantly, the pandemic has exposed the weaknesses of Indian health delivery system that fell short of health personnel and physical infrastructure, especially doctors, nursing staff, hospital beds, medical supplies and equipment. Hence, there is a need for restructuring of the health system in India with equitable distribution of infrastructure and development of a dedicated public health cadre to respond effectively to the crisis such as the present one so that other equally prioritised public health interventions are not hampered.
... Comparing data from the 1960s to those for the late 1970s and 1980s, U.S. studies reveal that 14 Inequality and Exclusion in Access to HealthCare … 281 income and educational differentials have widened over time (Williams and Collins, 1995;Thorat, 2007;United Nations, 2020). Similarly, widening socio-economic differentials in mortality have been observed in England, Wales, France, Finland, Norway, and the Netherlands (Department of Health & Social Security, 1980) and in other parts of the world (Mackenbach et al., 1989;Kunst & Mackenbach, 1994;Solar & Irwin, 2010;Borooah et al., , 2015Lynch, 2017). ...
The present paper views anatomical and epidemiological differences among gender have led to the differential proclivity of diseases among gender. The risk of cervical cancer or ovarian cancer or breast cancer is rather high among women, whereas vulnerability to testicular and prostate cancer is more common among men. But this gender-driven epidemiological occurrence has nothing to do with the differences in life expectancy or morbidity status among genders. This new approach has unravelled the structured inequality embedded in a given society to deconstruct the fatalistic explanation of the morbidity status of women. According to this approach, women’s proclivity to fall prey to recurring ailments or morbidity is biological. A Feminine Mystique is constructed to domesticate her and the patriarchal discriminatory values, which have been feeding into a girl child to make her a docile subject, have their invariable impact on her health outcome. The paper identifies household as the fountainhead of discrimination against women. It also engages with ‘gender inequality in health’ as a whole new approach to uncover women’s vulnerabilities within household.
... A further method uses a regression model to transform a categorical outcome into a cardinal variable (Kunst and Mackenbach 1994). However, the transformation derived from the estimated coefficients in the regression will be sensitive to the regression specification and to the choice of independent variables. ...
Approaches to measuring health inequalities are often problematic because they use methods that are inappropriate for categorical data. In this paper we focus on “pure” or univariate health inequality (rather than income-related or bivariate health inequality) and use a concept of individual status that allows a consistent treatment of such data. We take alternative versions of the status concept and apply methods for treating categorical data to examine self-assessed health inequality for the countries included in the World Health Survey. We also use regression analysis on the apparent determinants of these health inequality estimates. We show that the status concept that is used will affect health-inequality rankings across countries and the way health inequality is related to countries’ median health, income, demographics and governance.
... Результаты последующих исследований, направленных на выявление общих причин градиентного характера связи между здоровьем и социально-экономическим положением (Doorslaer 1992;Kunst, Mackenbach 1994), подтверждали влияние принципов осуществления государственной социальной политики, функционирования социальных институтов, объемов социальных расходов и расходов на здравоохранение на статусные неравенства в здоровье. Выявленные различия позволили сформулировать три основные теории, раскрывающие механизмы оказываемого воздействия: режимный подход («Regime approach»), институциональный подход («Institutional approach») и расходный подход («Expenditure approach») (Bergqvist et al. 2013). ...
The article is dedicated to studying the theoretical concepts of status inequalities in health from the moment of their origin to the present day, their prerequisites and mutual influence, key provisions, analytical and explanatory models. The processes of static and dynamic research paradigms formation, their origins, conceptual foundations, and methodological differences are described. Problem of status inequalities in health is associated with the period of Western society’s industrialization, when changes in the structure of labor market were accompanied by increasing of urbanization and urban population density, social inequalities and infectious diseases mortality among representatives of financially deprived groups. The ongoing socio-epidemiological processes attract the attention of researchers, who had practical aim to ensure the safety of living environment. Development of scientific knowledge focused on the problems of individual and common living, leaded to formation of disciplinary-specific grounds for studying the causes of health inequalities. Over the past 40 years studying of status inequalities in health has been accompanied by better understanding of factors that affect health in various status groups and creating research methodology that supposed studying interactions between levels of social organization and mechanisms of individual social and psychological adaptation to social reality changes.
... Comparing data from the 1960s to those for the late 1970s and 1980s, U.S. studies reveal that income and educational differentials have widened over time (Duleep, 1989;Pappas et al., 1993;Williams and Collins, 1995). Similarly, widening socioeconomic differentials in mortality have been observed in England, Wales, France, Finland, Norway, and the Netherlands (Department of Health and Social Security, 1980;Kunst and Mackenbach, 1994;Mackenbach et al., 1989). ...
Population dynamics and determinants of poverty are associated in a way that affects access to resources which influence health. The popular belief often is that population growth causes problems including poverty. Scientific arguments, however, have fairy well established that it is the nature of development, which is important to ensures availability, access and utilization of resources, services and opportunities for different population groups. Population growth is an insufficient explanation for denial of access to resources because development disparities across globe render different populations exposed to vulnerabilities of varied kinds. Disparities in health between different social groups are the function of unequal way in which the determinants of health are distributed in society. Beyond its effects on health, inequality has far reaching consequences on social trust and cohesion affecting social institutions; and also on mortality and health outcomes. Factors such as income, employment status, housing, education, social position, and social exclusion have direct and indirect bearings on health over lifetimes. In many countries there is evidence of a social gradient in health, with those in more advantaged positions enjoying generally better health and lower mortality. In India, caste is an important axes on which discrimination and denial occurs causing poor health outcome. In term of income and social indicators, India is one of the most unequal countries in the world. The present paper endeavours to understand the determinants of disparity among population groups across countries which influence access to health care with special reference to India.
... Dieses Jahr (2019) sind es exakt 25 Jahre, seit eine Forschergruppe um Johan Mackenbach (Erasmus Universität Rotterdam) die ersten systematischen Ländervergleiche zu Mortalitätsunterschieden nach sozioökonomischer Stellung publiziert hat. Von Beginn weg wurden zwei Sozialindikatoren verwendet, nämlich Bildung [19] und Berufsstatus [20]. Bereits im Folgejahr erschien mit Unterstützung durch die Europäische Kommission der erste Ländervergleich sozialer Unterschiede in der selbst wahrgenommenen Gesundheit [17]. ...
Background
In 1989 the first international comparisons of mortality differences according to educational level and occupational status were published. A few years later systematic comparisons between European countries were initiated at the Erasmus University in Rotterdam. This became a trigger for several European Union (EU)-funded collaboration programs scrutinizing social inequalities in health. The collaboration revealed substantial differences in mortality within and between European populations.
Objective
This article provides a synthesis of the most important research results over the past 30 years and also identifies existing research gaps and potentials.
Material and methods
Descriptive summary of research results comparing European countries regarding male and female all-cause and cause-specific mortality according to educational level and occupational status.
Results
In all European populations analyzed there was a consistent gradient with substantial and in part increasing advantages for higher socioeconomic status groups. There is, however, substantial variation between individual countries. This also applies to trends and cause of death-specific analyses. While relative differences have increased in virtually all populations, absolute differences have often decreased in many populations. Among women and in higher ages the relative differences were smaller. Within Europe, the southern countries had the smallest and the eastern countries the largest gradients. Tobacco and alcohol-related diseases had an especially noteworthy impact on trends and gradients.
Conclusion
The evidence for social health inequalities and their determinants has substantially improved during the past 30 years; however, there remains substantial potential for future research questions, for example concerning the contribution of the different phases of life to healthy aging.
... Enfin, la mortalité par cancer du poumon présente plutôt un clivage est-ouest alors qu'aucun schéma régional ne transparaît au niveau de la mortalité par cancer du sein chez les femmes et de la mortalité par cancer de la prostate chez les hommes [Grimmeau et al., 2015]. Ces résultats sont en grande partie confirmés par l'étude réalisée par Renard et al., [2015] Mackenbach, Kunst, 1994 ;Van Oyen et al., 2010]. En outre, cette variable se modifie très peu avec le temps et ne change pas avec la proximité du décès, ce qui n'est pas le cas, par exemple, du revenu, du secteur d'activité et du type/statut d'activité [Valkonen, 2002]. ...
Despite medical advances and improvements in health and social security systems, responsible for increasing life expectancy, social and spatial inequalities in mortality are intensifying in Western countries. This article analyse the evolution of social differences in mortality in Belgium over the last 25 years and their spatial transposition at the districts level. It is based on the matching of National Register data with those of the 1991, 2001 and 2011 population censuses, whereby social and district-based mortality tables were produced. Social groups are formed from a multidimensional indicator combining the level of education, socio-professional category and housing characteristics.The results highlight the existence in Belgium of significant social inequalities with regard to death, which have increased since the beginning of the 1990s. These mortality differences and their increase concern men as well as women and all ages, but especially people aged 25 to 50 years old. As part of the health transition, the disadvantaged social group is significantly behind other social groups, with a smaller contribution of people over 65 to improving life expectancy at birth.These trends are found at the regional and districts level. Moreover, within the same social group, significant mortality differences remain between Flanders and Wallonia as well as between the types of districts. This shows that, while spatial variations in mortality largely depend on the socioeconomic characteristics of their population, elements related to the physical, social and institutional environment of populations also contribute to it.
... Although the literature shows that the use of a DES is associated with socioeconomic status, most previous studies have used aggregated socioeconomic measures at a regional or community level as a proxy for individual patients [7,8]. Furthermore, researchers have largely overlooked the relationship between the occupation of patients and disparities in the use of DES, despite the fact that the literature shows a clear link between a patient's occupation and their access to, benefits from, and experience with health care [9][10][11][12][13][14]. ...
Objectives
One of the main objectives behind the expansion of insurance coverage is to eliminate disparities in health and healthcare. However, researchers have not yet fully elucidated the reasons for disparities in the use of high-cost treatments among patients of different occupations. Furthermore, it remains unknown whether discretionary decisions made at the hospital level have an impact on the administration of high-cost interventions in a universal healthcare system. This study investigated the adoption of drug-eluting stents (DES) versus bare metal-stents (BMS) among patients in different occupations and income levels, with the aim of gauging the degree to which the inclination of health providers toward treatment options could affect treatment choices at the patient-level within a universal healthcare system.
Design and participants
We adopted a cross-sectional observational study design using hierarchical modeling in conjunction with the population-based National Health Insurance database of Taiwan. Patients who received either a BMS or a DES between 2007 and 2010 were included in the study.
Results
During the period of study, 42,124 patients received a BMS (65.3%) and 22,376 received DES (34.7%). Patients who were physicians or the family members of physicians were far more likely to receive DES (OR: 3.18, CI: 2.38–4.23) than were patients who were neither physicians nor in other high-status jobs (employers, other medical professions, or public service). Similarly, patients in the top 5% income bracket had a higher probability of receiving a DES (OR: 2.23, CI: 2.06–2.47, p < .001), than were patients in the lowest income bracket. After controlling for patient-level factors, the inclination of hospitals (proportion of DES>50% or between 25% and 50%) was shown to be strongly associated with the selection of DESs (OR: 3.64 CI: 3.24–4.09 and OR: 2.16, CI: 2.01–2.33, respectively).
Conclusions
Even under the universal healthcare system in Taiwan, socioeconomic disparities in the use of high-cost services remain widespread. Differences in the care received by patients of lower socioeconomic status may be due to the discretionary decisions of healthcare providers.
... A growing literature that that takes as it point of departure Idler and Benyamini (1997) In some exceptional circumstances, health status is measured using a censored continuous variable approach (for example when visual analogue scales are employed). If, instead of this, a binary approach is followed (for example, measuring morbidity of a certain condition), inequalities can be measured using a standard limited-dependent model such as a logistic regression techniques (Kunst and Mackenbach 1994). As a result, it might be argued, the odds ratio of the underlying social position variable could say something about the extent to which social position inuences health status. ...
Much of the theoretical literature on inequality assumes that the equalisand is a cardinal variable like income or wealth. However, health status is generally measured as a categorical variable expressing a qualitative order. Traditional solutions involve reclassifying the variable by means of qualitative models and relying on inequality measures that are mean independent. We argue that the way status is conceptualised has important theoretical implications for measurement as well as for policy analysis. We also bring to the data a recently proposed approach to measuring self-reported health inequality that meets both rigorous and practical considerations. We draw upon the World Health Survey data to examine alternative pragmatic methods for making health-inequality comparisons. Findings suggest significant differences in health-inequality measurement and that regional and country patterns of inequality orderings do notcoincide with any reasonable categorisation of countries by health system organisation.
... L'influence des facteurs socioéconomiques a été étudiée sur la morbidité et la mortalité en général, dans de nombreuses pathologies et facteurs de risques, et notamment dans les cancers [Albano et al., 2007 ;Bentley et al., 2008 ;Braaten et al., 2009 ;Menvielle et al., 2007 ;Menvielle et al., 2005 ;Shack et al., 2007]. De vastes études européennes ont montré que la mortalité prématurée était à l'aube du XXIème siècle plus importante dans les catégories sociales défavorisées et que la France était le pays dans lequel ce gradient social était le plus marqué et qu'il s'aggravait [Kunst et al., 1998 ;Kunst and Mackenbach, 1994b ;Kunst and Mackenbach, 1994a]. Plusieurs études nord-américaines et européennes se sont intéressées à montrer que, au-delà du risque de survenue, En France, les premières étude portaient surtout sur les caractéristiques géographiques : plusieurs travaux sur les cancers colo-rectaux dans le Calvados ont trouvé une différence d'incidence selon la définition de la zone urbaine ou rurale de résidence des patients [Pottier et al., 1989]. ...
In developed countries, breast cancer is currently the leading cancer in women in terms of incidence and mortality (standardized rate of 101.5 and 17.7 per 100,000 person-years in 2005, respectively). Many risk factors and prognostic factors have been studied and are well known. Research is under way with regard to every step in the development of breast cancer, but the impact of socio-economic and geographic factors, at the individual and environmental level with regard to the disease have never been studied in France.The general aim of this work was to explore the impact of these factors in different ways to build on our knowledge and to develop practical applications in the primary, secondary or tertiary prevention of breast cancer.In our first study, we showed that women with a low socio-educational level were less likely to have benefited from at least one mammography within the 6 years or at least one gynaecological consultation within the 3 years before the diagnosis of breast cancer. These women also had a more advanced tumour at diagnosis than did women with a higher socio-educational level. These variables also came to light as predictors of a poor prognosis in terms of survival. In our second study, we showed that access to a surgeon specialised in breast cancer surgery, which is associated with better survival, was influenced by the socio-economic level of the patient's place of residence, as well as the distance between the patient's home and reference centres for cancer treatment, where the specialised surgeons work. In our third study, we showed that in contrast to many cancers, the incidence of breast cancer was highest in the most socio-economically privileged areas, and this whatever the age of the patient. We have no explanation for this phenomenon, particularly with regard to the youngest age group of women. Finally, the aim of our fourth study, which is currently on-going, is to study at the individual level, using the new European deprivation index adapted to France, to what extent economic wealth and social standing, as well as the proximity of medical services for patients with breast cancer have an impact on tumour stage, access to treatment, treatment techniques and survival.
... Advances in the understanding of the underlying determinants of social inequalities in health might come from comparative analysis. As observed earlier, in the last decades of the twentieth century research on social inequalities in health expanded to countries beyond Britain (Leclerc et al., 1990;Costa et al., 1990;Kunst et al., 1990;Valkonen, 1992;Pappas et al., 1993;Marshall et al., 1993;Kunst et al., 1995), and more systematic attempts to compare countries using similar data sets and measures followed (Lahelma et al., 1990;Kunst & Mackenbach, 1994a;Kunst & Mackenbach, 1994b;Kunst et al., 1998b). Figure 6 in the previous section (p.37) showed that educational differences in mortality were similar across European countries. ...
Differences in morbidity and mortality between socioeconomic groups constitute one of the most consistentfindings of epidemiologic research. However, research on social inequalities in health has yet to provide acomprehensive understanding of the mechanisms underlying this association. Data from two large Europeancohorts were used to examine socioeconomic differences in all-cause and cause-specific mortality in twopopulations in early old age, as well as the role played by health behaviours and social support in shapingthose inequalities. Indicators of socioeconomic circumstances in early life were found to be related tomortality in adulthood, even though the association of the three measures examined, father’s occupationalposition, education and height, with mortality did not have the same shape and depended on the cause ofmortality being examined. Indicators of socioeconomic position in adulthood, occupational position andincome, were strongly associated with all-cause and cardiovascular mortality in both cohorts. In theWhitehall II study, health behaviours - smoking, alcohol consumption, diet and physical activity - werestrongly socially patterned, and were found to contribute to a large part of social inequalities in mortality,particularly when changes in these behaviours over time were taken into account. The same behaviourscontributed little to explaining social inequalities in mortality in the GAZEL cohort, as their socialpatterning was weak in this cohort. Of the measures of social support examined, marital status alsoaccounted for part of the socioeconomic gradient in mortality in the Whitehall II cohort but not in GAZEL,while the role of social participation and network size was negligible in both cohorts. Different mechanismsmay be driving social inequalities in health in two neighbouring European countries. This finding calls forfurther comparative research to understand the common and unique determinants of social differences inhealth within and between countries, and for additional research addressing the fundamental causes of socialinequalities in health.
... Su interpretación se refiere a cuántas veces más alta (o menos alta) es la mortalidad por cáncer del grupo de menor NE respecto de la del grupo de mayor NE (29)(30). Puede también interpretarse como una variación porcentual de la mortalidad del grupo de menor NE en relación al grupo de mayor NE (se calcula como [IDR -1] × 100) (31)(32). ...
Objetivo. Caracterizar la tendencia de la mortalidad por cáncer en Chile según diferencias por nivel educacional en el período 2000-2010 en la población mayor de 20 años. Métodos. Cálculo de las tasas de mortalidad específica por cáncer ajustadas por edad para diferentes niveles educacionales (NE), para el período 2000-2010. Las tasas obtenidas se analizaron con un modelo de regresión de Poisson, calculando el índice de desigualdad relativa (IDR) y el índice de desigualdad de la pendiente (IDP) para cada año. Resultados. Se registraron 232 541 muertes por cáncer en el período 2000-2010. Los tipos de cáncer más frecuentes fueron de mama, estómago y vesícula biliar en mujeres; y estómago, próstata y pulmón en hombres. Las tasas de mortalidad por cáncer estandarizadas por edad fueron mayores en los NE más bajos, excepto para el de mama en mujer y el de pulmón en hombres. Las mayores diferencias se encontraron en el de vesícula biliar en mujeres y el de estómago en hombres, con mayores tasas de mortalidad específica de hasta 49 y 63 veces respectivamente, para NE bajo respecto al NE alto. Entre 2000 y 2010, las diferencias en mortalidad por NE se redujeron para todos los cánceres combinados en ambos géneros, mama en mujeres, y pulmón y estómago en hombres. Conclusiones. Durante el período estudiado, la mortalidad por cáncer en Chile estuvo fuertemente asociada al NE de la población. Esta información debe ser considerada al definir estrategias nacionales para reducir la mortalidad específica por cáncer en los grupos más desprotegidos.
... Su interpretación se refiere a cuántas veces más alta (o menos alta) es la mortalidad por cáncer del grupo de menor NE respecto de la del grupo de mayor NE (29)(30). Puede también interpretarse como una variación porcentual de la mortalidad del grupo de menor NE en relación al grupo de mayor NE (se calcula como [IDR -1] × 100) (31)(32). ...
Characterize the trends in mortality from cancer in Chile according to differences in educational level in the period 2000-2010 in the population over 20 years of age.
Calculation of specific mortality from cancer, age-adjusted for different educational levels, for the period 2000-2010. The obtained rates were analyzed using a Poisson regression model, calculating the relative inequality index and the slope index of inequality for each year.
232 541 deaths from cancer were reported in the period 2000-2010. The most frequent types were breast, stomach, and gallbladder cancer in women; and stomach, prostate, and lung cancer in men. Age-standardized mortality from cancer was greater in the lower educational levels, except for breast cancer in woman and lung cancer in men. The greatest differences were found in gallbladder cancer in women and stomach cancer in men, with specific mortality rates up to 49 and 63 times higher, respectively, for low educational levels compared to higher ones. Between 2000 and 2010, the differences in mortality by educational level were smaller for all cancers combined in both genders, for breast cancer in women, and for lung and stomach in men.
During the period studied, mortality from cancer in Chile was strongly associated with the educational level of the population. This information should be considered when designing national strategies to reduce specific mortality from cancer in the most vulnerable groups.
... The "gradient effect" refers to the standardform relationship that characterizes health and developmental outcomes (of children and adults) as one ascends from the lowest levels of family socioeconomic resources (measured mostly, in various studies, by income, education, or occupation) to the highest 8 . It is standard form because it applies to a remarkably broad range of outcomes, and has been replicated in many wealthy and non-wealthy societies where this relationship has been measured [69][70][71][72][73][74][75][76][77][78][79][80][81][82][83][84][85]. Figure 2 provides an example of socioeconomic gradients in child stunting for three countries in the Andean region of South America [86]. ...
... This seems uncontroversial with respect to education and income, but social group classifications based on occupation may be somewhat more challenging because there is inherently more ambiguity in the ranking of occupations (Liberatos et al. 1988). In their international study of occupational mortality differences Kunst and Mackenbach (1994) note this difficulty as a possible explanation for the lack of consistency of their results with those of Wagstaff et al. (1991) for the size of inequality in Finland versus England and Wales. ...
... Socioeconomic position refers to the structural location, reflecting the social and economic characteristics that determine the position individuals and groups hold within society (Kunst 1997; Gadeyne 2006). In order to capture the impact of socioeconomic characteristics in industrialised countries, it is generally agreed that at least three dimensions must be considered as determinants for the socioeconomic environment both for individuals and for society: income, education and work (Kunst and Mackenbach 1994a). Some authors add wealth as a fourth dimension, because it is much more unevenly distributed than income (Hummer et al. 1998) and also it adds the intergenerational transfers of material resources. ...
The aim of this study is to determine trends in life expectancy by educational level in Belgium and to present elements of interpretation for the observed evolution. The analysis is based on census data providing information on educational level linked to register data on mortality for the periods 1991–1994 and 2001–2004. Using exhaustive individual linked data allows to avoid selection bias and numerator–denominator bias. The trends reveal a general increase in life expectancy together with a widening social gap. Summary indices of inequality based on life expectancies show, however, a more complex pattern and point to the importance to include the shifts in population composition by educational level in an overall assessment of the evolution of inequality by educational level.
... Slope indices of inequality (SIIs) were calculated for the associations between each measure of socioeconomic position and quality of life. 26 To do this, for each socioeconomic measure, a rank score was assigned to each category (or value for continuous variables) on the basis of the midpoint of their range in the cumulative population distribution (ranked from the lowest to the highest socioeconomic position). The scores were calculated separately by gender, cohort (born pre-1946 or post-1945) and country to take into account the different socioeconomic distributions. ...
Whether socioeconomic inequalities in health and well-being persist into old age and are narrower in more generous welfare states is debated. We investigated the magnitude of socioeconomic inequality in the quality of life of Europeans in early old age and the influence of the welfare regime type on these relationships.
Data from individuals aged 50-75 years (n = 16 074) residing in 13 European countries were derived from Waves 2 and 3 of the Survey of Health, Ageing and Retirement in Europe. Slope indices of inequality (SIIs) were calculated for the association between socioeconomic position and CASP-12, a measure of positive quality of life. Multilevel linear regression was used to assess the overall relationship between socioeconomic position and quality of life, using interaction terms to investigate the influence of the type of welfare regime (Southern, Scandinavian, Post-communist or Bismarckian).
Socioeconomic inequalities in quality of life were narrowest in the Scandinavian and Bismarckian regimes, and were largest by measures of current wealth. Compared with the Scandinavian welfare regime, where narrow inequalities in quality of life by education level were found in both men (SII = 0.02, 95% CI: -1.09 to 1.13) and women (SII = 1.11, 95% CI: 0.05-2.17), the difference in quality of life between the least and most educated was particularly wide in Southern and Post-communist regimes.
Individuals in more generous welfare regimes experienced higher levels of quality of life, as well as narrower socioeconomic inequalities in quality of life.
... To quantify socioeconomic inequalities in life satisfaction, slope indices of inequality (SIIs) were calculated [19]. Each measure of socioeconomic position was ranked from the least advantaged to the most advantaged (with the mid-point of their range in the cumulative distribution used for each category) [20]. ...
whether socioeconomic position over the life course influences the wellbeing of older people similarly in different societies is not known.
to investigate the magnitude of socioeconomic inequalities in life satisfaction among individuals in early old age and the influence of the welfare state regime on the associations.Design: comparative study using data from Wave 2 and SHARELIFE, the retrospective Wave of the Survey of Health, Ageing, and Retirement in Europe (SHARE), collected during 2006-07 and 2008-09, respectively.
thirteen European countries representing four welfare regimes (Southern, Scandinavian, Post-communist and Bismarckian).
a total of 17,697 individuals aged 50-75 years.
slope indices of inequality (SIIs) were calculated for the association between life course socioeconomic position (measured by the number of books in childhood, education level and current wealth) and life satisfaction. Single level linear regression models stratified by welfare regime and multilevel regression models, containing interaction terms between socioeconomic position and welfare regime type, were calculated.
socioeconomic inequalities in life satisfaction were present in all welfare regimes. Educational inequalities in life satisfaction were narrowest in Scandinavian and Bismarckian regimes among both genders. Post-communist and Southern countries experienced both lower life satisfaction and larger socioeconomic inequalities in life satisfaction, using most measures of socioeconomic position. Current wealth was associated with large inequalities in life satisfaction across all regimes.
Scandinavian and Bismarckian countries exhibited narrower socioeconomic inequalities in life satisfaction. This suggests that more generous welfare states help to produce a more equitable distribution of wellbeing among older people.
... Même si elles apparaissent globalement plus faibles qu'aux Etats-Unis (33), ces inégalités d'accès et de recours aux soins sont probablement à l'origine d'une part non négligeable des inégalités de santé constatées, et/ou les entretiennent et les accentuent. Enfin, si le recours aux soins est considéré comme un comportements de santé, on peut faire l'hypothèse que les déterminants du recours (ou du renoncement) aux soins sont aussi à rechercher parmi les caractéristiques individuelles citées plus haut, au-delà de la question des ressources financières disponibles.Ainsi, en France, où l'accès aux soins médicaux et chirurgicaux est financièrement possible pour tous (34), on observe des inégalités sociales de santé parmi les plus élevées d'Europe occidentale, pour la quasi-totalité des causes de mortalité(9,35,36) et, dans le même temps, les enquêtes annuelles représentatives sur la consommation de soins montrent qu'une part non négligeable de la population déclare « renoncer à des soins pour raisons financières ». En 2002, 16,5 % des personnes interrogées déclarent avoir renoncé au moins une fois au cours de leur vie à des soins pour raisons financières et plus de 11% au cours de l'année précédant l'enquête. ...
Contexte : L’accès aux soins est garanti pour tous en France grâce à son système de sécurité sociale. Cependant, les enquêtes nationales sur la santé et la protection sociale de l’IRDES estiment qu’environ une personne interrogée sur cinq déclare avoir déjà renoncé à des soins pour raisons financières. Notre objectif était de montrer qu’au-delà des facteurs socio-économiques classiquement étudiés, d’autres facteurs, de l’ordre des conditions de vie, des ruptures et intégrations sociales, des représentations de santé et des caractéristiques psychologiques, sont associés à un tel renoncement.
Méthode : L’enquête, réalisée en 2001, porte sur un échantillon aléatoire de 525 personnes vivant dans cinq zones urbaines sensibles d’Ile-de-France. Les associations entre le renoncement aux soins pour raisons financières et des facteurs psychosociaux ont été étudiées par une régression logistique ajustée sur l’âge, le sexe, la taille du ménage, la présence de maladies chroniques, la couverture maladie, le niveau de revenu et la situation à l’égard de l’emploi. L’adéquation du modèle a été réalisée à partir des résidus de Pearson et des résidus de la déviance. La stabilité du modèle a été estimé par une méthode de bootstrap.
Résultats : La déclaration d’un renoncement aux soins pour raisons financières est plus fréquente chez les personnes ayant vécu des évènements difficiles dans la jeunesse, des difficultés financières à l’âge adulte, des expériences d’abus sexuels, physiques ou psychologiques, les personnes ayant une faible acceptation de la maladie, celles qui portent une forte priorité à leur santé. Enfin, plus le niveau d’estime de soi est bas plus les personnes déclarent un tel renoncement.
... The Social Class Score Scale is an interval scale, where the sizes of the intervals depend on the sizes of the social classes. The dierence between the gradient before and after control for one or more of the explanatory variables was calculated by using a method suggested by Kunst and Mackenbach (1994) and Power et al. (1997). The ®ve social classes were ordered according to rank on a scale from 0 to 1, and the mid-point of each social class was then determined. ...
A representative sample of 5001 Danish employees was followed for five years. The respondents were interviewed by telephone in 1990 and again in 1995. Social class, diseases, self-rated health (SRH), and a number of psychosocial and other work environment factors were assessed in 1990, and SRH was measured again in 1995. We analyzed predictors of changes in SRH from 1990 to 1995. After control for age, gender, and disease, the following factors predicted worsening of SRH among respondents with good SRH in 1990: repetitive work, high psychological demands, low social support, high job insecurity, and high ergonomic exposures. After further control for social class, the ORs for some of these factors were reduced, but they all remained significant. Only one of the work environment factors, ergonomic exposures, predicted improvements in SRH among those respondents who had poor SRH in 1990. Many studies have shown that SRH is a powerful independent predictor for total mortality. This is the first study showing that a number of work environment factors predict worsening of SRH over time. Copyright © 2000 John Wiley & Sons, Ltd.
Previous EU sponsored projects, particularly the Eurothine project, have shown that health
inequalities were substantial throughout the European Union in the 1990s, but that there were important variations between countries in the magnitude of health inequalities. This suggests that there is great scope for reducing health inequalities. This report brings together the results of the EURO-GBD-SE project, an international collaborative project that aimed to estimate the extent to which health inequalities in Europe can realistically be reduced by policies and interventions on socioeconomic determinants as well as on specific risk factors.
We have quantified the potential for reduction and identified the most important entry-points for policies aimed at reducing health inequalities in a large number of countries in all parts of Europe.
Inequality is historically known to impact negatively on poverty reduction and economic growth. It is also known to accentuate inequality and perpetuate differentials in access to resources providing health, education and employment opportunities. Therefore, inequality of any nature and form needs to be examined, evaluated and addressed to initiate and propel positive changes. Endemic poverty, unemployment, lack of sanitation and safe drinking water; and effective healthcare determine as much as produce inequalities. The labyrinth of social relations and institutions often result in the exclusion of certain social groups on the basis of identities like gender, caste, ethnicity, region and religion. This perpetuates inequality induced marginalization and discrimination affecting access to services, goods and resources which restrict knowledge acquisition and skill development. Social exclusion, however, does not necessarily equate to poverty. Although, there is a strong correlation between socially excluded groups and high levels of poverty which influence health and its correlates. In this unequal world, there are ‘privileged’ and ‘underprivileged’ groups whose status is determined by the conducive environment for propensity to access resources and avail opportunities. A discussion on inequality in the global and national context, and how inequality affects access further perpetuating exclusion, is imperative at this time when the pandemic COVID-19 has opened new dimensions of deliberation. This paper explores the prevailing inequalities and their impact on access to healthcare in general, and vulnerabilities of people engaged in works related to cleaning and cremation.
Résumé Longtemps parent pauvre de la recherche, le champ des recherches en santé et travail a connu, depuis le début des années 2000, un important développement qui a touché l’ensemble des disciplines des sciences sociales. Cet article propose une lecture des travaux récents menés dans ce champ, afin de déterminer les avancées permises par la mobilisation de disciplines aussi diverses que l’épidémiologie, la sociologie, l’histoire ou la science politique. Le dialogue permis par le développement des travaux en santé et travail a essentiellement permis à l’épidémiologie de se faire de plus en plus sociale, enrichissant l’analyse des pathologies professionnelles de façon à prendre davantage en compte les contextes institutionnels et les jeux d’acteurs qui président à leur visibilité (ou invisibilité) sociale. En revanche, si les bouleversements de l’appareil de production ont rendu toute leur acuité aux questions de conditions et d’organisation du travail, sur ces thématiques, le dialogue interdisciplinaire semble moins développé. Enfin la volonté de tenir compte de la complexité des relations entre santé, travail et hors travail a donné naissance ces dernières années à des recherches prenant comme point d’observation les parcours de vie, suivant en cela un mouvement commun à l’ensemble des recherches en sciences humaines et sociales.
The measurement of health inequalities usually involves either estimating the concentration of health outcomes using an income-based measure of status or applying conventional inequality-measurement tools to a health variable that is non-continuous or, in many cases, categorical. However, these approaches are problematic as they ignore less restrictive approaches to status. The approach in this paper is based on measuring inequality conditional on an individual's position in the distribution of health outcomes: this enables us to deal consistently with categorical data. We examine several status concepts to examine self-assessed health inequality using the sample of world countries contained in the World Health Survey. We also perform correlation and regression analysis on the determinants of inequality estimates assuming an arbitrary cardinalisation. Our findings indicate major heterogeneity in health inequality estimates depending on the status approach, distributional-sensitivity parameter and measure adopted. We find evidence that pure health inequalities vary with median health status alongside measures of government quality.
The measurement of health inequalities usually involves either estimating the concentration of health outcomes using an income-based measure of status or applying conventional inequality-measurement tools to a health variable that is non-continuous or, in many cases, categorical. However, these approaches arc problematic as they ignore less restrictive approaches to status. The approach in this paper is based on measuring inequality conditional on an individual's position in the distribution of health outcomes: this enables us to deal consistently with categorical data. \Ve examine several status concepts to examine self-assessed health inequality using the sample of vvorld countries contained in the \Vorld Health Survey. \Ve also perform correlation and regression analysis on the determinants of inequality estimates assuming an arbitrary cardinalisation. Our findings indicate major heterogeneity in health inequality estimates depending on the status approach, distributional-sensitivity parameter and measure adopted. We find evidence that pure health inequalities vary with median health status alongside measures of government quality.
Cet article est consacré aux dispositifs épidémiologiques d'observation de la santé en relation avec le travail en France. Il se compose de deux parties principales. La première rappelle brièvement des faits essentiels, mais souvent mal connus, concernant la place des facteurs professionnels parmi les déterminants de la santé des populations. La seconde présente les sources de données disponibles à l'échelle de la France, qui sont actuellement limitées, et décrit le programme national de surveillance épidémiologique mis en place par le Département Santé Travail de l'Institut de veille sanitaire dans le but d'établir les indicateurs permettant de quantifier le poids de l'activité professionnelle sur l'état de santé de la population générale, de repérer des secteurs et des professions à risque élevé, d'alerter sur d'éventuels problèmes en relation avec le travail, connus ou émergents, et d'évaluer les dispositifs de prévention et de réparation.
Introduction:
in 2008, the British Geriatrics Society (BGS) developed the Recommended Undergraduate Curriculum in Geriatric Medicine. This was subsequently mapped to the second edition of Tomorrows' Doctors (TD2, 2003). Following the publication of the third edition of Tomorrow's Doctors in 2009 (TD3), the mapping exercise was repeated to verify the extent to which the updated General Medical Council recommendations supported teaching in ageing and geriatric medicine.
Method:
we analysed TD3 and identified 48 aspects of its general guidance that were relevant to the teaching of medicine for older people. We then mapped these to the 2009 BGS curriculum.
Results:
the BGS curriculum was supported in full by TD3. However, learning outcomes relating to the interpretation and conduct of research in TD3 had no corresponding outcomes in the BGS curriculum.
Conclusion:
the BGS curriculum for medical undergraduates continues to provide a specific and complete list of learning objectives, all of which could help to operationalise the general statements made in TD3 with relation to ageing and geriatric medicine. Learning outcomes in research in frail older patients have been added following this mapping exercise.
Equity in health has become a central issue. However, equity can mean different things to different people. Moreover, the principles underlying its definition and conceptualization may vary according to economic, medical, philosophical, political, ethical and other considerations. During the last decades, the literature on health equity has known an exponential increase. Although the majority of publications are produced in developed countries, the part devoted to developing countries is rapidly increasing This chapter is dedicated to a selection of recent papers published on equity and social determinants underlying it. Our intention is not to give an exhaustive panorama of all papers which dealt with the theme of equity, rather we have selected some of the papers that could help the reader to easily get an overview of the multidimensional aspects of equity as illustrated by the large number of publications dealing with definitions and concepts of equity, the difference between inequalities and inequities, inequity in access to health services and health status, and many other aspects. For each paper cited, we have tried to summarise the method used, the main results and the conclusion. When a detailed abstract was available, we have used it in a slightly different and concise form. The papers reviewed were grouped into sub topics: Definitions and Concepts, Social determinants of Health, Diseases and equity, Equity and children health, Maternal health and violence, Geographic disparity, Migrants and heath equity, Equity and finance.
This study compares eleven countries with respect to the magnitude of mortality differences by occupational class, paying particular attention to problems with the reliability and comparability of the data that are available for different countries. Nationally representative data on mortality by occupational class among men 30–64years at death were obtained from longitudinal and cross-sectional studies. A common social class scheme was applied to most data sets. The magnitude of mortality differences was quantified by three summary indices. Three major data problems were identified and their potential effect on inequality estimates was quantified for each country individually. For men 45–59years, the mortality rate ratio comparing manual classes to non-manual classes was about equally large for four Nordic countries, England and Wales, Ireland, Switzerland, Italy, Spain and Portugal. Relatively large ratios were only observed for France. The same applied to men 60–64years (data for only 5 countries, including France). For men 30–44years, there was evidence for smaller mortality differences in Italy and larger differences in Norway, Sweden and especially Finland (no data for France and Spain). Application of other summary indices to men 45–59years showed slightly different patterns. When the population distribution over occupational classes was taken into account, relatively small differences were observed for Switzerland, Italy and Spain. When national mortality levels were taken into account, relatively large differences were observed for Finland and Ireland. For each summary index, however, France leads the international league table. Data problems were found to have the potential to bias inequality estimates, substantially especially those for Ireland, Spain and Portugal. This study underlines the similarities rather than the dissimilarities between European countries. There is no evidence that mortality differences are smaller in countries with more egalitarian socio-economic and other policies.
The authors wish to acknowledge the contributions of the members of the Detroit Community-Academic Urban Research Center (URC), which was established in 1995 as part of the Urban Research Initiative of the CDC. The Detroit URC is a collaboration between the University of Michigan Schools of Public Health, Nursing, and Social Work, the Detroit Department of Health and Wellness Promotion, the Henry Ford Health System, and a number of community-based organizations including Communities in Schools, Community Health and Social Services, Detroit Hispanic Development Corporation, Detroiters Working for Environmental Justice, Friends of Parkside, Latino Family Services, Southwest Counseling and Development Services, and Warren/Conner Development Coalition. The authors also express gratitude to Sue Anderson for her assistance in the preparation of this chapter.
The common occurrence of chronic diseases – such as ischemic heart
diseases (IHD, stroke, and stomach cancer in most populations and the
attendant mortality, loss of independence, impaired quality of life, and social and
economic costs are compelling reasons for public health concern. Although
mortality from IHD , stroke , and stomach cancer have fallen substantially in
western Europe over recent decades, IHD and stroke remain among the leading
causes of death in Europe. Furthermore, elderly people constitute a growing
part of the population and therefore, the absolute number of deaths might
continue to increase due to ageing of European population. Together, IHD,
stroke and stomach cancer, have figured prominently in the large shifts among
causes of death, especially in industrial societies, during the 20th century. During
this period, the mortality and morbidity rates of these diseases has changed
rapidly in many countries, as a result of both increasing proportions of these
populations attaining older ages and concurrent social changes. The
epidemiology and prevention of these diseases involve the understanding of their
causes, identification of means of prevention, and monitoring of populations to
assess the changing burden of these diseases and measurable impact of
interventions to control them. This thesis monitors seven European populations –
i.e., Denmark, England and Wales, Finland, France, the Netherlands, Norway and
Sweden. It assesses the changing impact of the above mentioned diseases over
time by extrapolation of observed trends in the past. It projects the future profile
of these diseases in seven European countries.
Social inequalities in health are widely documented in the western countries including Finland, but research on Russia has so far been scarce. This article compares self-reported ill health of men and women and its social patterning in Helsinki and Moscow on the basis of a survey. The data (Helsinki N=824, Moscow N=545) were collected by mailed questionnaires in 1991. The Muscovites fared more poorly on perceived and psychological health, but the differences in self-reported morbidity (prevalence of chronic illnesses) between the cities were quite small. The sex differentials were greater in Moscow and Muscovite women had the poorest health of all. Education, family income and occupation had the most consistent associations with perceived health and morbidity among Helsinki women and the weakest among Muscovite women. With few exceptions, men of both cities fell between these groups. The differences in health between the cities were smaller in groups with low education. Thus, the role of education as a protective resource was more pronounced in Helsinki, and more notably among women. The possibility of a different impact of social stratification on health in a transitional socialist society compared to a western market economy is discussed.
The existing literature on educational inequalities in adult smoking has focused extensively on differences in current smoking and quitting, rather than on differences in never smoking regularly (initiation) by education in the adult population. Knowing the relative contribution of initiation versus quitting is critical for understanding the mechanisms that produce educational gradients in smoking because initiation and quitting occur at different points in the life course. Using data from 31 waves of the U.S. National Health Interview Survey (N = 587,174), the analyses show the relative likelihood of being a never versus former smoker by education, sex, and age from 1966 to 2010 and for birth cohorts from 1920 to 1979. The analyses also describe differences in the cumulative probability of quitting over the life course, and the role of initiation versus quitting in producing educational gaps in smoking. The results show that educational gaps in never smoking explain the bulk of the educational inequality in adult smoking. Differences in former smoking play a small and decreasing role in producing these gaps. This is true across the life course, whether measured at age 25 or age 50, and for both men and women. While the prevalence and age patterns of former smoking by education converge across birth cohorts, differences in never smoking by education increase dramatically. At the population level, educational gaps in adult smoking are produced by the combination of inequalities in initiation and quitting, with differences in initiation playing a larger role in producing the observed gaps. The portion of the gap explained by differences in quitting is itself a function of educational differences in initiation. Thus, educational gradients in adult smoking are tethered to experiences in adolescence. These findings have important implications for both understanding and addressing disparities in this important health behavior.
Objectives:
The aim was to rank coronary heart disease (CHD) risk factors according to their importance in predicting CHD morbidity and mortality using a scale-independent statistical approach.
Design:
We studied 15 515 community-dwelling adults in a population-based cohort established during 1992-93 in Western Norway. Participants were 40-42 and 65-67 years old at baseline and were followed through 2006. Endpoints were non-fatal/fatal acute myocardial infarction (AMI) and CHD death. Each factor was rank transformed and scaled to the range 0-5 before estimation of Cox models. Hazard ratios (HR) may thus be interpreted as HR per quintile increment for each factor, and the magnitude of the HR was used to rank the risk factors according to strength.
Results:
Total cholesterol and triglycerides were important risk factors for both CHD death and non-fatal/fatal AMI only in the middle-aged group. Risk factors were generally stronger in the middle-aged, except total homocysteine which was significantly associated with CHD death in the oldest group only. The only significant difference between men and women was found for single living which was an important risk factor for non-fatal/fatal AMI in middle-aged women but not in middle-aged men.
Conclusions:
We have demonstrated a simple method for direct and scale-independent comparison of the strength of both categorical and continuous risk factors. The importance of individual risk factors differed substantially between the two age groups.
Data were analysed from the Organization for Economic Cooperation and Development (OECD) Program for International Student Assessment (PISA) to examine whether the relationship between parental unemployment status and child reading literacy is modified by the level of unemployment protection provided by the nation. The sample consisted of 61,946 children, nested in 3,918 schools among 17 market economies. The results of multi-level analyses indicated that, after controlling for a range of individual, family and school covariates, children with unemployed fathers in all countries had significantly lower reading literacy scores than those of employed fathers (β = −8.84, SE = 2.01). The contextual effect of unemployment protection was not significant after accounting for fathers’ employment status (β = −18.63, SE = 16.26). However, there was a significant negative interaction between unemployment protection and fathers’ unemployment, yielding the unexpected suggestion that, in countries with higher levels of unemployment protection, children with unemployed fathers fare worse, both in relation to children with unemployed fathers in lower protection countries, and in comparison with children with employed fathers (β = −26.96, SE = 8.08). Possible explanations are advanced for this result, including the potential for a ‘discouraged child effect’ arising from the potential association between unemployment protection and higher local unemployment rates (though unemployment rates at the national level were not significant).
of Health. It represents the interests of these organizations in health disparities related to cancer, quantitative assessment and monitoring of these disparities, and interventions to remove them. NCI Project Officers for this contract are Marsha E. Reichman, Ph.D. (SRP), Bryce Reeve, Ph.D. (ARP), and Nancy Breen, Ph.D. (ARP).
In this paper we present an International Socio-Economic Index of occupational status (ISEI), derived from the International Standard Classification of Occupations (ISCO), using comparably coded data on education, occupation, and income for 73,901 full-time employed men from 16 countries. We use an optimal scaling procedure, assigning scores to each of 271 distinct occupation categories in such a way as to maximize the role of occupation as an intervening variable between education and income (in contrast to taking prestige as the criterion for weighting education and income, as in the Duncan scale). We compare the resulting scale to two existing internationally standardized measures of occupational status, Treiman's international prestige scale (SIOPS) and Goldthorpe's class categories (EGP), and also with several locally developed SEI scales. The performance of the new ISEI scale compares favorably with these alternatives, both for the data sets used to construct the scale and for five additional data sets.
Longitudinal census data from 1980, of the Norwegian population aged 20-64 years, was used to examine the relationship between intragenerational social mobility (as measured by changes in occupational group) and social inequalities in health (as measured by the standardized mortality ratio, SMR). Three propositions were derived from a theoretical model of health selection. In particular, among men the patterns of mobility turned out as expected, e.g. on aggregate those climbing up had a lower mortality than those drifting down, while 'stayers' had a lower mortality than those who moved downwards, but a higher mortality than those who moved upwards. Among men, the mobility enhanced the resultant inequality in mortality (as measured by variation coefficients) moderately, i.e. by 8.8%, due to the impact of one occupational group; low salary employees. Among women, although some mobility is in agreement with the propositions, it did not affect the resultant mortality differentials consistently. This evidence lends support to the health selection hypothesis for men, but not for women. Nevertheless, due to the modest selection effect, it may be more fruitful to focus on social and behavioural factors in order to improve the health status of disadvantaged groups, who are the first target of the World Health Organization's strategy for 'Health for All by the Year 2000'.
This paper examines the trend in social inequality in infant mortality in England and Wales between 1921 and 1980, using both class- and occupation-specific data. It employs a summary measure of inequality that uses all of the available data and can be evaluated in terms of its sensitivity to errors using accepted diagnostic techniques. Occupations that played a significant role in determining the time trend in inequality are identified and the effect of mortality among out-of-wedlock births is examined. Implications of these findings for assessing the determinants of social inequality in infant mortality and evaluating the contribution of the National Health Service in its amelioration are discussed.Cet article tudie l'volution de l'ingalit sociale face la mortalit infantile en Angleterre et au Pays de Galles entre 1921 et 1980, l'aide de donnes dcomposes selon la classe et selon la profession. L'indice global d'ingalit employ utilise toutes les donnes disponibles, et sa sensibilit aux erreurs peut tre valu au moyen de techniques de diagnostic reconnues. L'auteur identifie les professions qui ont jou un rle dterminant dans l'volution de l'ingalit au cours du temps, et examine l'effet spcifique de la mortalit des enfants illgitimes. Elle envisage ce qu'impliquent ces rsultats quant l'identification des dterminants de l'ingalit sociale face la mortalit infantile et l'valuation de la contribution du National Health Service aux progrs obtenus.
In this paper data are compared on differential mortality for working men in the United Kingdom and France, for the years 1970–1972 (U.K.) and 1966–1971 (F). Differential mortality in the United Kingdom is described in ‘occupational mortality’ published by O.P.C.S.; mortality according to ‘Catégories socio-professionnelles’ has been studied for a large cohort by INSEE (National Institute of Statistics and Economic Studies). The comparison between those two sets of data leads to the following conclusions: •social differences in death rates seem to be larger in France than in United Kingdom.•the main causes of death responsible for these inequalities differ in the two countries: respiratory diseases are the main cause in U.K.; in France, accidents and alcohol-related death lead to the largest inequalities.We discuss the difficulties of comparison between countries: some of the apparent differences may relate to the fact that, in France, mortality data concerns a cohort followed since 1954, while British data comes from a transversal survey. Another point of difference is the fact that foreigners are not included in the French study.In every country where data exist on the subject, inequalities in health are found. The reasons why these inequalities exist, and what should be done to reduce them, is a matter for discussion. The purpose of this paper is to contribute to the debate, by throwing light on some aspects of the observed differences.
This paper offers a critical appraisal of the various methods employed to date to measure inequalities in health. It suggests that only two of these--the slope index of inequality and the concentration index--are likely to present an accurate picture of socioeconomic inequalities in health. The paper also presents several empirical examples to illustrate of the dangers of using other measures such as the range, the Lorenz curve and the index of dissimilarity.
Inequalities in mortality between social classes or socioeconomic groups were compared in three European countries, using similar sources of data from large national cohort studies. People registered at a census in 1971 (1975 for France) or a sample of them, were followed until 1980 or 1981.
The Gini coefficient, a measure widely used in economics, allowed the comparison of various situations involving different numbers and group sizes. It was applied to age groups 35–44, and 45–54 for men only.
According to this measure, inequalities were of the same order in England and Wales and Finland, and greater in France. Differences between the three countries concerning the principal causes of death leading to inequalities were cardiovascular diseases in England and Wales, accidents and cardiovascular diseases in Finland, and cancer and cirrhosis in France.
The opportunities for research of socio-economic differences in mortality are best in countries where a system of personal identification numbers makes the computerised linkage of census and death records possible. The first part of this study is an example of the use of such linked records. It presents results on the development of mortality differences by level of education and occupational class in Finland in the period 1971-1985. Socio-economic mortality differences among middle-aged and elderly men increased in Finland during the study period. The increase was mainly due to the rapid decline of mortality from cardiovascular diseases among upper white-collar employees and men with more than secondary education. Relative socio-economic mortality differences were smaller among women than among men and remained unchanged in 1971-1985. The second part of the article discusses the problems in international comparisons of socio-economic mortality differences and summaries results from two comparative studies. The results are inconsistent: differences by level of education among men were found to be similar in six countries included in the comparison, whereas marked variation was found in the ratios of the mortality of manual workers to the mortality of non-manual workers.
In this paper the data on occupational and social class mortality published decennially for England and Wales are used to examine the trend in the size of class differentials in mortality from 1921 to 1972 for adult men, married women and infants. Using summary measures which take into account changes in the relative sizes of the social classes over time, it was found that absolute inequality in mortality increased among adult men and married women during the 1950s and 1960s and relative inequality increased for all three groups. Two widely recognized potential sources of error, changes in the occupational composition of the social classes over time, and discrepancies between the numerators and denominators of occupation-specific death rates are examined to determine their effect on the trend indicated, and the initial findings are confirmed. Finally, the possible causes and implications of rising inequality coincident with declining overall levels of mortality, relative affluence, and the uniform availability of basic medical services to all socio-economic sub-groups of the population are considered.