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Repercusiones de la pobreza sobre la salud de los individuos y las poblaciones
... El segundo aspecto tiene que ver con la inclusión del entorno social y humano del individuo que presenta problemas de comportamiento en la identificación de su salud mental, acorde con el carácter social de la persona y el concepto integral de salud que promueve la Organización Mundial de la Salud (1), como un estado de completo bienestar biopsicosocial del individuo. Por ello se incluye el estudio de los indicadores de salud mental en un grupo de líderes comunitarias, madres de familia desplazadas por la violencia social y en condición de pobreza, cuyos resultados fueron muy similares a la población joven escolarizada (6) y evidencian aún mayor riesgo por el reporte de diversos estudios que dan Indicadores de riesgo y comunicación en salud mental sobre consumo de sustancias psicoactivas y violencia intrafamiliar en líderes comunitarias cuenta de la relación entre pobreza y deterioro de la salud mental (7,8), los cuales explican de mejor manera por qué persisten los problemas de salud mental en la población general. En este punto fue clave conocer el escaso nivel de información y conocimiento que tienen estas líderes sobre el concepto de "salud mental" y la red de salud mental distrital, pues de ello depende la información y comunicación que dirijan a sus comunidades con el fin de atender o prevenir estos problemas; a lo cual se suma la situación de estigmatización y discriminación que sufren por su condición de desplazadas (9). ...
... Población y muestra. La población estuvo constituida por los 200 líderes de las juntas de acción comunal de la Comuna 5 del distrito de Santa Marta, caracterizada por ser población desplazada por la violencia, asentada hace más de 5 años, de escasos recursos económicos (7,8). ...
... Lo anterior es aun más preocupante si se considera que se trata de una comunidad en condición de pobreza, que incrementa su riesgo de vulnerabilidad (7,8), y que, en consecuencia, presenta diversos casos, como alcoholismo, drogadicción, violencia intrafamiliar (maltrato a la mujer, niños y jóvenes), que involucran a las líderes comunitarias y a la población joven, los cuales no están siendo afrontadas con eficiencia por parte de las entidades estatales de salud. ...
Objetivo:
Describir el nivel de comunicación ofrecido a la comunidad en el marco de la red de salud mental distrital, tomando como referente el riesgo para consumo de sustancias psicoactivas y de violencia intrafamiliar de un grupo de líderes comunitarias.
Material y métodos:
Se trata de una investigación exploratoria descriptiva, con diseño tran-seccional de campo. Participaron 20 mujeres líderes comunitarias de población vulnerable, que representan a 200 líderes comunales del distrito de Santa Marta (Colombia), con edades entre 21 a 60 años. Se les aplicaron dos pruebas, previa validación: ASSIST v3.1, para medir el consumo de sustancias psicoactivas, y la Escala de Riesgo en situación de violencia intrafamiliar -AURORA-. El análisis estadístico incluyó un análisis univariado para establecer los riesgos de consumo de las participantes; y un análisis bivariado mediante la prueba chi cuadrado para determinar la independencia de las variables. Adicionalmente se realizó una entrevista no estructurada a 4 de las líderes.
Resultados:
Se halló que la edad y escolaridad de las líderes son determinantes: a menor edad mayor riesgo de consumo de alcohol y violencia intrafamiliar; y a mayor consumo de alcohol mayor riesgo de violencia intrafamiliar. Igualmente, se halló que la mayoría sigue la ruta de salud mental hacia la Policía Nacional y no hacia los entes especializados del distrito.
Conclusiones:
Existe un riesgo significativo temprano y una deficiente comunicación sobre la ruta de salud mental en esta población, que podría estar afectando su convivencia social y salud mental.
... El segundo aspecto tiene que ver con la inclusión del entorno social y humano del individuo que presenta problemas de comportamiento en la identificación de su salud mental, acorde con el carácter social de la persona y el concepto integral de salud que promueve la Organización Mundial de la Salud (1), como un estado de completo bienestar biopsicosocial del individuo. Por ello se incluye el estudio de los indicadores de salud mental en un grupo de líderes comunitarias, madres de familia desplazadas por la violencia social y en condición de pobreza, cuyos resultados fueron muy similares a la población joven escolarizada (6) y evidencian aún mayor riesgo por el reporte de diversos estudios que dan Indicadores de riesgo y comunicación en salud mental sobre consumo de sustancias psicoactivas y violencia intrafamiliar en líderes comunitarias cuenta de la relación entre pobreza y deterioro de la salud mental (7,8), los cuales explican de mejor manera por qué persisten los problemas de salud mental en la población general. En este punto fue clave conocer el escaso nivel de información y conocimiento que tienen estas líderes sobre el concepto de "salud mental" y la red de salud mental distrital, pues de ello depende la información y comunicación que dirijan a sus comunidades con el fin de atender o prevenir estos problemas; a lo cual se suma la situación de estigmatización y discriminación que sufren por su condición de desplazadas (9). ...
... Población y muestra. La población estuvo constituida por los 200 líderes de las juntas de acción comunal de la Comuna 5 del distrito de Santa Marta, caracterizada por ser población desplazada por la violencia, asentada hace más de 5 años, de escasos recursos económicos (7,8). ...
... Lo anterior es aun más preocupante si se considera que se trata de una comunidad en condición de pobreza, que incrementa su riesgo de vulnerabilidad (7,8), y que, en consecuencia, presenta diversos casos, como alcoholismo, drogadicción, violencia intrafamiliar (maltrato a la mujer, niños y jóvenes), que involucran a las líderes comunitarias y a la población joven, los cuales no están siendo afrontadas con eficiencia por parte de las entidades estatales de salud. ...
Objetivo: Describir el nivel de comunicación ofrecido a la comunidad en el marco de la red de
salud mental distrital, tomando como referente el riesgo para consumo de sustancias psicoactivas
y de violencia intrafamiliar de un grupo de líderes comunitarias.
Material y métodos: Se trata de una investigación exploratoria descriptiva, con diseño transeccional
de campo. Participaron 20 mujeres líderes comunitarias de población vulnerable, que
representan a 200 líderes comunales del distrito de Santa Marta (Colombia), con edades entre
21 a 60 años. Se les aplicaron dos pruebas, previa validación: ASSIST v3.1, para medir el consumo
de sustancias psicoactivas, y la Escala de Riesgo en situación de violencia intrafamiliar
–AURORA–. El análisis estadístico incluyó un análisis univariado para establecer los riesgos
de consumo de las participantes; y un análisis bivariado mediante la prueba chi cuadrado para
determinar la independencia de las variables. Adicionalmente se realizó una entrevista no
estructurada a 4 de las líderes.
Resultados: Se halló que la edad y escolaridad de las líderes son determinantes: a menor edad
mayor riesgo de consumo de alcohol y violencia intrafamiliar; y a mayor consumo de alcohol
mayor riesgo de violencia intrafamiliar. Igualmente, se halló que la mayoría sigue la ruta de
1 Psicologo, Mg. en Psicologia Clinica, Dr. en Ciencias de la Educacion. Profesor Investigador, SIDI-Programa
de Psicologia, Universidad Metropolitana, Barranquilla, Colombia. roferrel@yahoo.com - fferrel@unimetro.
edu.co
2 Psicóloga, Mg. en Psicología Clínica y de la Salud. Dra. en Ciencias de la Educación. Catedrática y coordinadora
de Investigaciones, Facultad de Medicina de la Universidad Cooperativa de Colombia. Santa Marta,
Colombia. lucia.ferrelb@campusucc.edu.co; lucaferrel@hotmail.com
3 Psicologo, Mg. en Psicologia Clinica, Dr. en Psicologia. Profesor Investigador, Direccion de Investigacion,
Universidad Autonoma del Peru, Lima. luis.oblitas@autonoma.pe
4 Psicólogo, Dr. en Paz y Conflicto. Profesor investigador T. C., Grupo Estudios Sociales Interdisciplinares
(ESI), Facultad de Psicología de la Universidad Cooperativa de Colombia sede Santa Marta (Colombia).
humbertoyc@gmail.com
Correspondencia: Fernando Robert Ferrel Ortega. SIDI (Subsistema Institucional de Investigación) - Universidad
Metropolitana, Barranquilla-Colombia. fferrel@unimetro.edu.co
Salud Uninorte. Barranquilla (Col.) 2017; 33 (2): 152-167 153
Indicadores de riesgo y comunicación en salud mental sobre consumo de
sustancias psicoactivas y violencia intrafamiliar en líderes comunitarias
salud mental hacia la Policía Nacional y no hacia los entes especializados del distrito.
Conclusiones: Existe un riesgo significativo temprano y una deficiente comunicación
sobre la ruta de salud mental en esta población, que podría estar afectando su convivencia
social y salud mental.
... El segundo aspecto tiene que ver con la inclusión del entorno social y humano del individuo que presenta problemas de comportamiento en la identificación de su salud mental, acorde con el carácter social de la persona y el concepto integral de salud que promueve la Organización Mundial de la Salud (1), como un estado de completo bienestar biopsicosocial del individuo. Por ello se incluye el estudio de los indicadores de salud mental en un grupo de líderes comunitarias, madres de familia desplazadas por la violencia social y en condición de pobreza, cuyos resultados fueron muy similares a la población joven escolarizada (6) y evidencian aún mayor riesgo por el reporte de diversos estudios que dan Indicadores de riesgo y comunicación en salud mental sobre consumo de sustancias psicoactivas y violencia intrafamiliar en líderes comunitarias cuenta de la relación entre pobreza y deterioro de la salud mental (7,8), los cuales explican de mejor manera por qué persisten los problemas de salud mental en la población general. En este punto fue clave conocer el escaso nivel de información y conocimiento que tienen estas líderes sobre el concepto de "salud mental" y la red de salud mental distrital, pues de ello depende la información y comunicación que dirijan a sus comunidades con el fin de atender o prevenir estos problemas; a lo cual se suma la situación de estigmatización y discriminación que sufren por su condición de desplazadas (9). ...
... Población y muestra. La población estuvo constituida por los 200 líderes de las juntas de acción comunal de la Comuna 5 del distrito de Santa Marta, caracterizada por ser población desplazada por la violencia, asentada hace más de 5 años, de escasos recursos económicos (7,8). ...
... Lo anterior es aun más preocupante si se considera que se trata de una comunidad en condición de pobreza, que incrementa su riesgo de vulnerabilidad (7,8), y que, en consecuencia, presenta diversos casos, como alcoholismo, drogadicción, violencia intrafamiliar (maltrato a la mujer, niños y jóvenes), que involucran a las líderes comunitarias y a la población joven, los cuales no están siendo afrontadas con eficiencia por parte de las entidades estatales de salud. ...
Objective: Describe the level of communication offered to the community within the framework of the district mental health network, taking as reference the risk for psychoactive substance use and intrafamily violence of a group of community leaders. Material and methods: This is an exploratory descriptive research, with field transectional design. Twenty female vulnerable community leaders representing 200 communal leaders from the District of Santa Marta, Colombia, aged between 21 and 60, participated. Two tests were applied, after validation: ASSIST v3.1, to measure the consumption of psychoactive substances; And the Risk Scale in situations of intra-family violence -AURORA–. Statistical analysis included a univariate analysis to establish participants’ consumption risks; And a bivariate analysis using the chi-square test to determine the independence of the variables. In addition, an informal interview was conducted with 4 of the leaders. Results: It was found that the age and schooling of the leaders are determinant, at younger age greater risk of alcohol consumption and intrafamily violence; And, the higher the alcohol consumption, the higher the risk of intrafamily violence. Likewise, it was found that the majority follow the path of mental health towards the National Police and not to the specialized entities of the District. Conclusions: There is a significant early risk and poor communication about the mental health route in this population, which could be affecting their social coexistence and mental health.
... The rural housing located in the highlands of the Andes, such as the Mesoandean and Altoandean zones in the department of Puno, Peru, corresponding to bioclimatic zones 4 and 5 according to Peruvian Norm EM.110 (1), is characterized by recurrent energy poverty inside the homes, which leads to health problems for its occupants (2). Heating the home can be difficult and costly, particularly for those on low incomes (3). ...
The energy deficiency in rural housing in the Andes of Peru is recurrent. In this context, local and low environmental impact materials present an opportunity. This research evaluated the properties of five panels composed of totora and gypsum for ceiling applications. Firstly, the physical and durability properties were obtained. Then, impact and fire resistance were evaluated. Finally, thermoacoustic properties were assessed. The results showed a moisture level of 10.25%, water absorption of 354.85% which is considered high, and a dry density of 292.84 kg/m3. Adequate durability to fungus with resin on both sides. The panels’ fire resistance is superior to 60 minutes, with a safe impact criterion for 10 N and a functionality criterion for 5 N. The average values for the panels were 0.061 W/m·K for thermal insulation and 0.54 for NRC. Therefore, it is possible to produce an insulating material for thermoacoustic improvement.
... Una perspectiva que no hay que perder nunca de vista es que la salud no se juega solamente en el campo sanitario, sino que las condiciones de vida, el entorno y las conductas individuales y colectivas influyen en gran medida en ella. Cada vez son más las evidencias acumuladas sobre cómo estos distintos determinantes afectan en gran medida tanto a la esperanza de vida como a la probabilidad de enfermar 23,24 , no solo por el acceso a recursos o por la posibilidad de resolver determinados problemas de salud, sino también influyendo en los modos de expresión del material genético de cada in- dividuo, como muestran los estudios sobre epigenética desarrollados en los últimos años. Esta determinación social de la salud conlleva también otras consecuencias, ya que la diferente situación con relación a los factores clave que la determinan en nuestras sociedades conduce a la aparición de desigualdades sociales en salud: diferencias sistemáticas y por tanto injustas, potencialmente remediables en uno o más aspectos de la salud entre grupos o subgrupos de población definidos social, económica, demográfica o geográficamente. ...
... In Barcelona, much like in other cities and countries, social inequality in terms of health outcomes is not a new phenomenon (Borrell and Pasarín 2004), with a number of studies highlighting inequalities across gender, social classes, place of origin and geographical residence (Borrell et al. , 2008. Moreover, in Spain, the economic crisis and passing of austerity measures have had a significant impact on health and related inequalities across the country (Cortès-Franch and González López-Valcárcel 2014; Bartoll et al. 2015;Zapata Moya et al. 2015;Padilla and López Ruiz 2016). In the field of health, such inequalities are accompanied by the emergence of new needs resulting from, on the one hand, an increasingly ageing society with a greater prevalence of chronic conditions (Nuño et al. 2012) and, on the other hand, an increasingly migrant population with specific health needs (Malmusi et al. 2010). ...
Social welfare systems face major challenges, particularly in a context of social transformation, austerity and growing inequalities. This process is highly visible in the health sector. In this context, many voices ask for public sector reforms and community action for health as a relevant practice. However, analyses and evaluations of this kind of practices are still limited, particularly beyond the cases of single community health actions or interventions. We still need to identify key indicators for measuring and characterising what community action for health consists of, as well as to what degree this kind of intervention has been developed across a city. Based on a research about 49 neighborhoods in Barcelona, this paper creates an index to measure and characterize community action for health, using different indicators: citizen engagement programs in community health, organizational transformation of the health and social protection systems, stable participatory structures with specific teams, and urban health policies. We apply the index to the case of Barcelona and build a map of community action for health in the city using 4 categories: strong community health development (one neighbourhood), middle (9 neighborhoods), emergent (25 neighborhoods) and without specific community health promotion (14 neighbourhoods). We find that community action for health is extensive within the city of Barcelona, have great potential as a response to the need for change in the relationship between the public (health) sector and the citizenry, but is still implemented unequally across the urban territory in terms of types and methods.
Los modelos de determinantes sociales de la salud forman parte desde hace décadas de las estrategias de Salud Pública y debería ser elemento fundamental de la orientación de los sistemas sanitarios. A lo largo del tiempo, diversos estudios epidemiológicos han mostrado la relación de los determinantes sociales con enfermedades prevalentes, por lo que es necesario reducir la brecha entre este modelo y la práctica clínica de los/las profesionales de la salud. En este artículo intentaremos señalar la importancia de aplicar una visión de determinantes en el abordaje de los problemas de salud desde la organización sanitaria a la consulta individual.
In this Health Policy article, we selected and reviewed evidence synthesised by nine knowledge networks established by WHO to support the Commission on the Social Determinants of Health. We have indicated the part that national governments and civil society can play in reducing health inequity. Government action can take three forms: (1) as provider or guarantor of human rights and essential services; (2) as facilitator of policy frameworks that provide the basis for equitable health improvement; and (3) as gatherer and monitor of data about their populations in ways that generate health information about mortality and morbidity and data about health equity. We use examples from the knowledge networks to illustrate some of the options governments have in fulfi lling this role. Civil society takes many forms: here, we have used examples of community groups and social movements. Governments and civil society can have important positive roles in addressing health inequity if political will exists.
Cold homes are bad for health1—and also for the outcome of a society that doesn’t care enough about the people at the bottom. The social inequality that poor living conditions reflect is real and leads to people dying younger than they should.The UK government axed the Warm Homes Healthy People fund in 2012 despite it having been “universally popular” in helping 200 000 people a year who needed emergency boiler repairs and hot food.2 The National Institute for Health and Care Excellence (NICE) has now made recommendations including the creation of a single point of contact for vulnerable people who need help with housing conditions. This may be useful, but where is the money to help people who have poor living environments but no cash to improve their heating or insulation?NICE has told GPs that they should “at least once a year, assess the heating needs of people who use their services, whether during a home visit or elsewhere.”3 But should cold homes be seen as a medical problem rather than a political and social deficit?During routine work doctors come across all kinds of problems that are not medical. Holistic care is not merely about physical and psychological harms but also environmental ones. Truly preventive medicine concerns social equality, employment, living wages, and clean water, and it extends far into political territory. But GPs cannot take responsibility for the effects of poor housing stock without the power and resources—heating engineers and social workers, for example—to deal with it.And what of the potential harm in opportunity costs? Our patients are getting older, accumulating more diagnoses, and GPs are dealing with the resultant complexity and polypharmacy, all with fewer hospital beds available. What gets squeezed out to make way for this new work?In response to concerns about workload, NICE says that improving homes may lead to less work for GPs in the long term. This is nebulous. I remember NICE accepting expert opinion that noted “insufficient capacity within existing primary care resources to meet the increase in demand” when it lowered the recommended threshold for prescribing statins.4 But it went ahead anyway.Improving housing conditions is a moral responsibility of society. For one doctor to discuss heating for three minutes with each patient in a practice of 5000 would take five weeks. As GPs we do not have capes or wear our knickers outside our trousers. To fit this in, then, NICE, what can we stop doing instead?Follow Margaret on Twitter, @mgtmccartneyNotesCite this as: BMJ 2015;350:h1595
Objetivo: Evaluar la influencia de la desigualdad de ingresos y de la pobreza de las localidades de Bogotá-Colombia sobre la percepción de mala salud de sus residentes.
Métodos: El estudio se basó en la encuesta multipropósito aplicada en Bogotá-Colombia. Se utilizó la estructura jerárquica de los datos (individuos = nivel 1, localidades = nivel 2) para definir un modelo logístico multinivel de tipo logit. La variable dependiente fue la percepción de mala salud, y las variables de localidad fueron la desigualdad de ingresos y la pobreza. Todos los análisis se controlaron por variables sociodemográficas y se estratificaron por sexo.
Resultados: La prevalencia de reportar regular o mala salud en la población estudiada fue del 23,2%. Las mujeres mostraron mayor riesgo de mala salud, así como también los hombres y mujeres de bajo nivel educativo, con edad avanzada, sin trabajo en la última semana y afiliados al régimen subsidiado de salud. Los mayores niveles de pobreza en la localidad incrementan el riesgo de mala salud. Las interacciones transnivel mostraron que mujeres jóvenes y hombres con bajo nivel educativo son los más afectados por la desigualdad de ingresos de la localidad.
Conclusiones: En Bogotá existen diferencias geográficas en la percepción de la salud, y mayores porcentajes de pobreza y desigualdad de ingreso se mostraron asociados a un mayor riesgo de mala salud. Destacan grandes inequidades de salud entre individuos y entre localidades.
Almost all studies on the effect on health from unemployment have concluded that unemployment is bad for your health. However, only a few review articles have dealt with this relation in recent years, and none of them have focused on the analysis of subgroups such as age, gender, and marital status. The objective of our article is to review how unemployment relates to self-assessed health with a focus on its effect on subgroups.
A search was performed in Web of Science to find articles that measured the effect on health from unemployment. The selection of articles was limited to those written in English, consisting of original data, and published in 2003 or later. Our definition of health was restricted to self-assessed health. Mortality- and morbidity-related measurements were therefore not included in our analysis. For the 41 articles included, information about health measurements, employment status definitions, other factors included in the statistical analysis, study design (including study population), and statistical method were collected with the aim of analysing the results on both the population and factor level.
Most of the studies in our review showed a negative effect on health from unemployment on a population basis. Results at the factor levels were most common for gender (25 articles), age (11 articles), geographic location (8 articles), and education level (5 articles). The analysis showed that there was a health effect for gender, age, education level, household income, and geographic location. However, this effect differed between studies and no clear pattern on who benefits or suffers more among these groups could be determined. The result instead seemed to depend on the study context. The only clear patterns of association found were for socioeconomic status (manual workers suffer more), reason for unemployment (being unemployed due to health reasons is worse), and social network (a strong network is beneficial).
Unemployment affects groups of individuals differently. We believe that a greater effort should be spent on specific groups of individuals, such as men or women, instead of the population as a whole when analysing the effect of unemployment on health.
To evaluate the association between relative deprivation (lacking daily necessities) and subjective health in older Japanese adults, we performed a cross-sectional analysis using data from the Japan Gerontological Evaluation Study (JAGES). The data were obtained from functionally independent residents aged ≥65 years from 24 municipalities in Japan (n = 24,742). Thirteen items in three dimensions were used to evaluate relative deprivation of material conditions. Approximately 28% of older Japanese people indicated that they lacked some daily necessities (non-monetary poverty). A two-level Poisson regression analysis revealed that relative deprivation was associated with poor self-rated health (PR = 1.3-1.5) and depressive symptoms (PR = 1.5-1.8) in both men and women, and these relationships were stronger than those observed in people living in relative poverty (monetary poverty). The interaction effect between relative deprivation and relative poverty was not associated with poor health. As a dimension of the social determinants of health, poverty should be evaluated from a multidimensional approach, capturing not only monetary conditions but also material-based, non-monetary conditions.
Link and Phelan have proposed to explain the persistence of health inequalities from the fact that socioeconomic status is a “fundamental cause” which embodies an array of resources that can be used to avoid disease risks no matter what mechanisms are relevant at any given time. To test this theory we compared the magnitude of inequalities in mortality between more and less preventable causes of death in 19 European populations, and assessed whether inequalities in mortality from preventable causes are larger in countries with larger resource inequalities.
Aim:
To examine whether late-career job loss increased depression among older workers approaching retirement in the USA and Europe.
Methods:
Longitudinal data came from the Health and Retirement Survey and the Survey of Health, Ageing, and Retirement in Europe. Workers aged 50 to 64 years in 13 European countries and the USA were assessed biennially from 2006 to 2010. Individual fixed effects models were used to test the effect of job loss on depressive symptoms, controlling for age, sex, physical health, initial wealth and socio-demographic factors.
Results:
Job loss was associated with a 4.78% [95% confidence interval (CI): 0.823% to 8.74%] increase in depressive symptoms in the USA compared with a 3.35% (95% CI: 0.486% to 6.22%) increase in Europe. Job loss due to a worker's unexpected firm closure increased depression scores in both the USA (beta=28.2%, 95% CI: 8.55% to 47.8%) and Europe (beta=7.50%, 95% CI: 1.25% to 13.70%), but pooled models suggested significantly stronger effects for US workers (P<0.001). American workers who were poorer before the recession experienced significantly larger increases in depressive symptoms compared with wealthier US workers (beta for interaction=-0.054, 95% CI: -0.082 to -0.025), whereas pre-existing wealth did not moderate the impact of job loss among European workers.
Conclusions:
Job loss is associated with increased depressive symptoms in the USA and Europe, but effects of job loss due to plant closure are stronger for American workers. Wealth mitigates the impact of job loss on depression in the USA more than in Europe.
In this article, we analyze the extent to which an individual's socioeconomic status is inherited and how equality of opportunity could be increased to improve social mobility. Poverty and deprivation can stop being dynastic-like if the social elevator works. In Spain, income inequality, measured by the Gini coefficient, rose from 0.31 in 2006 to 0.35 in 2012 (moving away from Scandinavia and Central Europe and more closely resembling income inequality in the UK or the United States), while the degree of intergenerational mobility is half-way between that in Italy and the United States. To change this situation and make the social elevator work, primary education should be improved and the health system should be steered toward primary healthcare. This will not be feasible without an improvement in politics and the institutional framework that determine these factors.
Copyright © 2013 SESPAS. Published by Elsevier Espana. All rights reserved.
To assess whether educational class, an index of socioeconomic position, improves the accuracy of the SCORE cardiovascular disease (CVD) risk prediction equation.
In a pooled analysis of 68 455 40-64-year-old men and women, free from coronary heart disease at baseline, from 47 prospective population-based cohorts from Nordic countries (Finland, Denmark, Sweden), the UK (Northern Ireland, Scotland), Central Europe (France, Germany, Italy) and Eastern Europe (Lithuania, Poland) and Russia, we assessed improvements in discrimination and in risk classification (net reclassification improvement (NRI)) when education was added to models including the SCORE risk equation.
The lowest educational class was associated with higher CVD mortality in men (pooled age-adjusted HR=1.64, 95% CI 1.42 to 1.90) and women (HR=1.31, 1.02 to 1.68). In men, the HRs ranged from 1.3 (Central Europe) to 2.1 (Eastern Europe and Russia). After adjustment for the SCORE risk, the association remained statistically significant overall, in the UK and Eastern Europe and Russia. Education significantly improved discrimination in all European regions and classification in Nordic countries (clinical NRI=5.3%) and in Eastern Europe and Russia (NRI=24.7%). In women, after SCORE risk adjustment, the association was not statistically significant, but the reduced number of deaths plays a major role, and the addition of education led to improvements in discrimination and classification in the Nordic countries only.
We recommend the inclusion of education in SCORE CVD risk equation in men, particularly in Nordic and East European countries, to improve social equity in primary prevention. Weaker evidence for women warrants the need for further investigations.
Within the development of a regional strategy for community health engagement in Asturias (Spain), and connected to the Health Observatory, we carried out a methodology to initiate the mapping of health assets at a local level. This methodology begins with a description of the most formal resources and of the pre-existing community activities, together with a characterization of the most informal, personal and symbolic health resources. We introduce our tools, grouped for the development of mapping, and explain their connection with the theoretical models of salutogenesis, asset model and community development.
Copyright © 2012 SESPAS. Published by Elsevier Espana. All rights reserved.
Objectives:
We explored the relationship between social isolation and mortality in a nationally representative US sample and compared the predictive power of social isolation with that of traditional clinical risk factors.
Methods:
We used data on 16,849 adults from the Third National Health and Nutrition Examination Survey and the National Death Index. Predictor variables were 4 social isolation factors and a composite index. Comparison predictors included smoking, obesity, elevated blood pressure, and high cholesterol. Unadjusted Kaplan-Meier tables and Cox proportional hazards regression models controlling for sociodemographic characteristics were used to predict mortality.
Results:
Socially isolated men and women had worse unadjusted survival curves than less socially isolated individuals. Cox models revealed that social isolation predicted mortality for both genders, as did smoking and high blood pressure. Among men, individual social predictors included being unmarried, participating infrequently in religious activities, and lacking club or organization affiliations; among women, significant predictors were being unmarried, infrequent social contact, and participating infrequently in religious activities.
Conclusions:
The strength of social isolation as a predictor of mortality is similar to that of well-documented clinical risk factors. Our results suggest the importance of assessing patients' level of social isolation.
Social isolation may operate as a psychosocial stressor which disrupts functioning of the hypothalamic-pituitary-adrenocortical axis.
Using data from the MRC National Survey of Health and Development, we tested whether living alone, not being married and social network size were associated with diurnal cortisol patterns at 60-64 years. We hypothesised that recent onset compared with long-term isolation would be more strongly associated with cortisol awakening response, cortisol decline over the day and evening cortisol. Models were adjusted for sex, smoking, body mass index, alcohol intake, psychological distress and financial difficulties.
Those widowed within the last three years had a 36% (95%CI 6%, 73%) higher night time cortisol than those who were currently married. Those newly living alone also had a higher night time cortisol and flatter diurnal slope than those living with others.
Independently of multiple behavioural and psychosocial correlates, recent onset of social isolation is related to diurnal cortisol patterns that increase the risk of morbidity and mortality.
This study was motivated by a need to establish criteria for evaluating observations of moisture damage with respect to exposure and adverse health effects. The database used included information on moisture damage from 164 dwellings and questionnaire data collected from the occupants. Moisture damage observations were classified according to eleven variables characterising damage by, for example, size, duration and type of damaged material. Five health symptom scores were devised based on the questionnaire data. Visible mould associated with respiratory infections, irritative and skin symptoms. Damage 4 m2 in size associated with respiratory infections and skin symptoms. Damage of
Background:
Fuel poverty is a risk factor for ill-health, particularly among older people. We hypothesized that both the risk of fuel poverty and the strength of its detrimental effects on health would be increased in areas of colder and wetter climate.
Methods:
Individual data on respiratory health, hypertension, depressive symptoms and self-rated health were derived from the 2008/09 wave of the English Longitudinal Study of Ageing. Climate data for 89 English counties and unitary authorities were obtained from the UK Met Office. Multilevel regression models (n = 7160) were used to test (i) the association between local climate and fuel poverty risk, and (ii) the association between local climate and the effect of fuel poverty on health (adjusted for age, gender, height, smoking status and household income).
Results:
Individual risk of fuel poverty varied across counties. However, this variation was not explained by differences in climate. Fuel poverty was significantly related to worse health for two of the outcomes (respiratory health and depressive symptoms). However, there was no significant effect of climate on fuel poverty's association with these outcomes.
Conclusions:
Although there is regional variation in England in both the risk of fuel poverty and its effects on health, this variation is not explained by differences in rainfall and winter temperatures.
The health system is a social determinant of health. Although not the most important determinant of health, the health system's potential contribution to reducing social inequalities in health should not be underestimated. Due to its characteristics, primary health care is well placed to attain equity in health. To make progress in achieving this goal, the main measures to be considered are the removal of barriers to access to services, the provision of care proportionate to need, and engagement in intersectoral work. This article reviews the background and framework for action to tackle social inequalities in health and provides a summary of the primary health care actions that could help to reduce social inequalities in health and are mentioned in the most important national and international documents on health policy. We hope to stimulate debate, promote research in the field and encourage implementation. The proposals are grouped in the following five intervention lines: information systems; participation; training; intersectoral work; and reorientation of health care. Each intervention is ordered according to its targets (population and civil society; primary health team; health center and health area management; and health policy decision-makers).
Copyright © 2011 SESPAS. Published by Elsevier Espana. All rights reserved.
In previous public health surveys large differences in health have been shown between citizens living in different neighbourhoods in the Örebro municipality, which has about 125000 inhabitants. The aim of this study was to investigate the determinants of health with an emphasis on the importance of neighbourhood characteristics such as the influence of neighbourhood social cohesion and social capital. The point of departure in this study was a conceptual model inspired by the work of Carpiano, where different factors related to the neighbourhood have been used to find associations to individual self-rated health.
We used data from the survey 'Life & Health 2004' sent to inhabitants aged 18-84 years in Örebro municipality, Sweden. The respondents (n = 2346) answered a postal questionnaire about living conditions, housing conditions, health risk factors and individual health. The outcome variable was self-rated health. In the analysis we applied logistic regression modelling in various model steps following a conceptual model.
The results show that poor self-rated health was associated with social capital, such as lack of personal support and no experience of being made proud even after controlling for strong factors related to health, such as age, disability pension, ethnicity and economic stress. Also the neighbourhood factors, housing area and residential stability were associated with self-rated health. Poor self-rated health was more common among people living in areas with predominately large blocks of flats or areas outside the city centre. Moreover, people who had lived in the same area 1-5 years reported poor health more frequently than those who had lived there longer.
The importance of the neighbourhood and social capital for individual health is confirmed in this study. The neighbourhoods could be emphasized as settings for health promotion. They can be constructed to promote social interaction which in turn supports the development of social networks, social support and social capital--all important determinants of health.
One important component of social inclusion is the improvement of well-being through encouraging participation in employment and work life. However, the ways that employment contributes to wellbeing are complex. This study investigates how poor health status might act as a barrier to gaining good quality work, and how good quality work is an important pre-requisite for positive health outcomes.
This study uses data from the PATH Through Life Project, analysing baseline and follow-up data on employment status, psychosocial job quality, and mental and physical health status from 4261 people in the Canberra and Queanbeyan region of south-eastern Australia. Longitudinal analyses conducted across the two time points investigated patterns of change in employment circumstances and associated changes in physical and mental health status.
Those who were unemployed and those in poor quality jobs (characterised by insecurity, low marketability and job strain) were more likely to remain in these circumstances than to move to better working conditions. Poor quality jobs were associated with poorer physical and mental health status than better quality work, with the health of those in the poorest quality jobs comparable to that of the unemployed. For those who were unemployed at baseline, pre-existing health status predicted employment transition. Those respondents who moved from unemployment into poor quality work experienced an increase in depressive symptoms compared to those who moved into good quality work.
This evidence underlines the difficulty of moving from unemployment into good quality work and highlights the need for social inclusion policies to consider people's pre-existing health conditions and promote job quality.
Objective To provide quantitative evaluations on the association between income inequality and health.
Design Random effects meta-analyses, calculating the overall relative risk for subsequent mortality among prospective cohort studies and the overall odds ratio for poor self rated health among cross sectional studies.
Data sources PubMed, the ISI Web of Science, and the National Bureau for Economic Research database.
Review methods Peer reviewed papers with multilevel data.
Results The meta-analysis included 59 509 857 subjects in nine cohort studies and 1 280 211 subjects in 19 cross sectional studies. The overall cohort relative risk and cross sectional odds ratio (95% confidence intervals) per 0.05 unit increase in Gini coefficient, a measure of income inequality, was 1.08 (1.06 to 1.10) and 1.04 (1.02 to 1.06), respectively. Meta-regressions showed stronger associations between income inequality and the health outcomes among studies with higher Gini (≥0.3), conducted with data after 1990, with longer duration of follow-up (>7 years), and incorporating time lags between income inequality and outcomes. By contrast, analyses accounting for unmeasured regional characteristics showed a weaker association between income inequality and health.
Conclusions The results suggest a modest adverse effect of income inequality on health, although the population impact might be larger if the association is truly causal. The results also support the threshold effect hypothesis, which posits the existence of a threshold of income inequality beyond which adverse impacts on health begin to emerge. The findings need to be interpreted with caution given the heterogeneity between studies, as well as the attenuation of the risk estimates in analyses that attempted to control for the unmeasured characteristics of areas with high levels of income inequality.
Health benefits vary according to the method of reducing unemployment
The best guides we have to the possible future effects of mass unemployment are studies of previous epidemics. In men who had been continuously employed for at least five years in the late 1970s, mortality doubled in the five years after redundancy for those aged 40-59 in 1980.1 Adjustment for socioeconomic variables, previous health related behaviours, and other health indicators had almost no effect on this increase.1 The increased risk of mortality after redundancy tends to be greater in men than in women2 because men are generally affected more from a prevailing belief that when things go wrong no one will be there to help.3
The detrimental effects of unemployment were widely recognised after the great depression of the 1930s. However, by the early 1980s unemployment became viewed, as it was by some in the very early 1930s, as a “price worth paying.” We learnt through bitter experience again that it was not. By 2009 even the leader of the British Conservative Party argued that, “Unemployment is never a price worth paying and we need to take very big, bold and radical steps to help unemployed people back to work.”4
Research into mass unemployment during the early 1990s …
The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.
To assess effect of unemployment and early retirement on mortality in a group of middle aged British men.
Prospective cohort study (British Regional Heart Study). Five years after initial screening, information on employment experience was obtained with a postal questionnaire.
One general practice in each of 24 towns in Britain.
6191 men aged 40-59 who had been continuously employed for at least five years before initial screening in 1978-80: 1779 experienced some unemployment or retired during the five years after screening, and 4412 remained continuously employed.
Mortality during 5.5 years after postal questionnaire.
Men who experienced unemployment in the five years after initial screening were twice as likely to die during the following 5.5 years as men who remained continuously employed (relative risk 2.13 (95% confidence interval 1.71 to 2.65). After adjustment for socioeconomic variables (town and social class), health related behaviour (smoking, alcohol consumption, and body weight), and health indicators (recall of doctor diagnoses) that had been assessed at initial screening the relative risk was slightly reduced, to 1.95 (1.57 to 2.43). Even men who retired early for reasons other than illness and who appeared to be relatively advantaged and healthy had a significantly increased risk of mortality compared with men who remained continuously employed (relative risk 1.87 (1.35 to 2.60)). The increased risk of mortality from cancer was similar to that of mortality from cardiovascular disease (adjusted relative risk 2.07 and 2.13 respectively).
In this group of stably employed middle aged men loss of employment was associated with an increased risk of mortality even after adjustment for background variables, suggesting a causal effect. The effect was non-specific, however, with the increased mortality involving both cancer and cardiovascular disease.
Recent studies have demonstrated that income inequality is related to mortality rates. It was hypothesized, in this study, that income inequality is related to reduction in social cohesion and that disinvestment in social capital is in turn associated with increased mortality.
In this cross-sectional ecologic study based on data from 39 states, social capital was measured by weighted responses to two items from the General Social Survey: per capita density of membership in voluntary groups in each state and level of social trust, as gauged by the proportion of residents in each state who believed that people could be trusted. Age-standardized total and cause-specific mortality rates in 1990 were obtained for each state.
Income inequality was strongly correlated with both per capita group membership (r = -.46) and lack of social trust (r = .76). In turn, both social trust and group membership were associated with total mortality, as well as rates of death from coronary heart disease, malignant neoplasms, and infant mortality.
These data support the notion that income inequality leads to increased mortality via disinvestment in social capital.
To investigate the association between suicide and socioeconomic status, unemployment, and chronic illness.
Longitudinal study.
England and Wales.
Individuals from the Office for National Statistics longitudinal study for whom 1981 census data were available. The longitudinal study is a representative 1% sample of the population of England and Wales in which census variables are linked to mortality data.
Suicide and undetermined deaths occurring between 1983 and 1992. Odds ratios estimated with logistic regression adjusted for attrition of cohort members.
There was a strong independent association between suicide and individuals who were unemployed (odds ratio 2.6; 95% confidence interval 2.0 to 3.4) and permanently sick (2.5; 1.6 to 4.0). Those without access to a car had an increased risk (1.3; 1.0 to 1.5), but other measures of socioeconomic status were not associated with suicide.
The association between suicide and unemployment is more important than the association with other socioeconomic measures. Although some potentially important confounders were not adjusted for, the findings support the idea that unemployment or lack of job security increases the risk of suicide and that social and economic policies that reduce unemployment will also reduce the rate of suicide.
To assess the effects on self rated health of individual income and income distribution in Japan.
Cross sectional analysis. Data collected on household income, self rated health, and other sociodemographic characteristics at the individual level from comprehensive survey of the living conditions of people on health and welfare in a nationally representative sample from each prefecture. Setting: Prefectures in Japan.
80 899 people aged >15 years with full records in survey.
Dichotomous variable for self rated health of each respondent (0 if excellent, very good or good; 1 if fair or poor).
Inequality in income at the prefecture level measured by the Gini coefficient was comparable with that in other industrialised countries. Unadjusted odds ratios show a 14% increased risk (odds ratio 1.14, 95% confidence interval 1.02 to 1.27) in reporting poor or fair health for individuals living in prefectures with higher inequality in income. After adjustment, individual income was more strongly associated with self rated health than income inequality. Additional inclusion of regional effects showed that median income at the prefecture level was inversely related to self rated health.
Individual income, probably relative to the median prefecture income, has a stronger association with self rated health than income inequality at the prefecture level.
This study was motivated by a need to establish criteria for evaluating observations of moisture damage with respect to exposure and adverse health effects. The data base used included information on moisture damage from 164 dwellings and questionnaire data collected from the occupants. Moisture damage observations were classified according to eleven variables characteris ing damage by, for example, size, duration and type of damaged material. Five health symptom scores were devised based on the questionnaire data. Visible mould associated with respiratory infections, irritative and skin symptoms. Damage <1 m 2 in size was associated with general and skin symptoms, and >4 m2 in size associated with respiratory infections and skin symptoms. Damage of <3 years duration was associated with respiratory infections and damage that had existed for 3-10 years was associated with general, irritative and skin symp toms. Symptom scores were associated more frequently with damage to organic rather than inorganic materials. Criteria used to evaluate the association between the classification of moisture damage and symptom scores were excess risk compared to a two-category classifica tion, dose responsiveness, and biological plausibility of the findings. Despite the complexity of interpretation, the results show that more accurate models of moisture damage with respect to exposure and adverse health effects can be established.
In this paper we carry out a revision of the literature according to the measure of poverty. We describe the historic evolution that the poverty has had. We also show the different kinds of poverty lines or thresholds that we can use to assess the very complex phenomenon of poverty. Finally, we show the poverty indicators that several authors have introduced through the beginning of the twentieth century in order to analyse poverty and inequalities.
The objective of this study is to ascertain whether income inequality and per capita income of area of residence show a relationship with mortality in Spain. Data are from a nation-wide prospective study with a 7-year mortality follow-up covering all persons living in Spain's 50 provinces in 2001. In total 28,944,854 subjects aged 25 years or over at baseline were studied. Rate ratio for total mortality and cause-specific mortality, according to provincial income inequality and per capita income in two age groups, 25-64 years (adult population) and 65 years and over (elderly population). Provincial income inequality was not related to total mortality or cause-specific mortality. Total mortality rate ratios among residents of the poorest versus the richest provinces were 0.89 (95 % CI 0.95-0.93) in men and 0.91 (0.87-0.96) in women, among the adult population; and 1.02 (0.97-1.08) in men and 1.08 (1.02-1.16) in women, among the elderly population. With the exception of cardiovascular-disease mortality for which no association with per capita income was observed, adult residents of the poorest provinces registered the lowest mortality rate ratio for other causes of death. Elderly residents of the poorest provinces registered the highest mortality rate ratio for cardiovascular disease and the lowest mortality rate ratio for cancer and external causes. Aside from cardiovascular-disease mortality, the lowest mortality for most causes of death was registered by residents of the poorest provinces. Nevertheless, these findings need to be confirmed by similar studies using smaller areas as the unit of analysis.
There is substantial evidence that a number of social and behavioral factors contribute to the onset and progression of disease and affect mortality. Among these factors, only smoking and use of alcohol are commonly addressed in clinical practice. Other social and behavioral factors, including low income, low levels of education, lack of exercise, and stress, have been largely ignored by physicians because they are considered outside the scope of medical practice. However, accumulating evidence has linked these factors to the onset and progression of arthritis, asthma, and diabetes, and cardiovascular disease, as well as overall mortality. Calls have been made for organized medicine to address these factors. Several developments, including increasing use of electronic health records (EHRs), have provided the opportunity to do so. The use of EHRs has increased in recent years; more than 70% of office-based US physicians use an EHR system. Digitized information on standard measures of social and behavioral determinants can be obtained and stored. The authors of this commentary were cochairs of an expert committee of the Institute of Medicine (IOM) who were asked to recommend social and behavioral determinants that should be incorporated into EHRs and to evaluate methods to effectively include such information, as well as ways to overcome barriers to use of EHR data. Members of the committee were social scientists, clinicians, public health experts, and informatics experts. The committee reviewed data in the literature to identify social and behavioral determinants strongly associated with health that could be effectively evaluated for inclusion in EHRs. The committee developed a concise panel of measures covering 12 social and behavioral domains that can be asked by physicians and then incorporated into EHRs. The panel included questions on race or ethnic group, level of education, finance-resource strain, depression, physical activity, use of tobacco, use of alcohol, and social connection or isolation. The authors anticipate a minimal effect on physician workflow in light of the measures being primarily self-reported by patients and necessary to assess only at the initial intake visit. Special attention must be given to privacy, security, and access. The benefits of adopting and using this measurement panel are substantial; health care costs can be reduced, and patient-centered and accountable care can be provided. It is hoped that the panel of social and behavioral determinants recommended for inclusion into EHRs by the IOM Committee will be adopted by physicians and health systems.
Team-based models of care are an important way to meet the complex medical and psychosocial needs of the homebound. As part of a quality improvement project to address individual, program, and system needs, a portion of a large, physician-led academic home-based primary care practice was restructured into a team-based model. With support from an office-based nurse practitioner, a dedicated social worker, and a dedicated administrative assistant, physicians were able to care for a larger number of patients. Hospitalizations, readmissions, and patient satisfaction remained the same while physician panel size increased and physician satisfaction improved. The Team Approach is an innovative way to improve interdisciplinary, team-based care through practice restructuring and serves as an example of how other practices can approach the complex task of caring for the homebound.
There is a very large literature examining income inequality in relation to health. Early reviews came to different interpretations of the evidence, though a large majority of studies reported that health tended to be worse in more unequal societies. More recent studies, not included in those reviews, provide substantial new evidence. Our purpose in this paper is to assess whether or not wider income differences play a causal role leading to worse health. We conducted a literature review within an epidemiological causal framework and inferred the likelihood of a causal relationship between income inequality and health (including violence) by considering the evidence as a whole. The body of evidence strongly suggests that income inequality affects population health and wellbeing. The major causal criteria of temporality, biological plausibility, consistency and lack of alternative explanations are well supported. Of the small minority of studies which find no association, most can be explained by income inequality being measured at an inappropriate scale, the inclusion of mediating variables as controls, the use of subjective rather than objective measures of health, or follow up periods which are too short. The evidence that large income differences have damaging health and social consequences is strong and in most countries inequality is increasing. Narrowing the gap will improve the health and wellbeing of populations.
Copyright © 2015 Elsevier Ltd. All rights reserved.
Wilkinson and Pickett's1 (WP) theory has relative deprivation as a core mechanism for why income inequality impacts health in societies. A number of recent studies, including in JECH , have thus contrasted the health impact of relative to absolute deprivation.2 ,3 However, it is a false contrast I argue. This is because supposed absolute deprivation has its roots in a theory of relative deprivation.4 ,5 Further it is not only WP's theory that has relative deprivation as its core mechanism. Materialist/structural theory, as outlined in the very well-known Black report on health inequalities, does as well.6 Absolute deprivation is often defined as one's material standard of living up to some set level, for example, a subsistence level and as one's material standard of living independent of that of others.3 However, the Black report discusses in detail why materialist/structural theory sees the unequal access due to social class of economic and other resources as the key driver of health inequalities because it deprives people of contemporary standards of living.6 So there is a clear endorsement of deprivation as relative and a move away from notions of absolute deprivation and health in the report. There is nothing fixed about levels of physical well-being. They have improved in the past and there is every likelihood that they will improve in the future. But class inequalities persist in the distribution of health as in the distribution of income or wealth, and they persist as a form of relative deprivation. (ref. …
This study evaluates the relationship between income and mortality in Spain over a long period of declining in income inequality. The ratio between income in the richest and poorest provinces was 2.74 in 1970 and 2.10 in 2010. Pearson correlation coefficients for the association between provincial income and the measures of mortality were estimated, as well as absolute and relative differences between the mortality rates of the poorest and richest provinces. The correlation coefficient between income and infant mortality decreased from −0.59 in 1970 to −0.17 in 2010, and lost significance from 1995 onwards. The coefficient for premature all-cause mortality increased from −0.04 in 1970 to −0.40 in 2010, and acquired significance beginning in 2005. The coefficient also increased in mortality from cardiovascular, respiratory and digestive diseases. No association was found between provincial income and cancer mortality or mortality from injuries. The findings on premature mortality do not support the theory that decreasing income inequality will lead to reduced inequalities in mortality.
This article presents the findings of research conducted with social workers in primary health care teams in Ireland. Data from questionnaires and from a focus group were analyzed. The findings draw attention to the nature of the role of the primary care social worker, including both the satisfying and challenging aspects of this role. It was evident that the participants liked the generic nature of their role and the fact that they worked with non-mandated clients. However, they encountered challenges related to resources, management structures, and interdisciplinary work. The findings shed light on an area of social work that has been under-researched.
Mortality and morbidity rates are often highest during the winter period, particularly in countries with milder climates. A growing body of research has identified potential socioeconomic, housing and behavioural mediators of cold weather-related adverse health and social outcomes, but an inclusive systematic review of this literature has yet to be performed.
A systematic review, with narrative synthesis, of observational research published in English between 2001 and 2011, which quantified associations between socioeconomic, housing or behavioural factors and cold weather-related adverse health or social outcomes.
Thirty-three studies met the inclusion criteria. Average study quality was not high. Most studies failed to control for all relevant confounding factors, or to conduct research over a long enough period to ascertain causality. Low income, housing conditions and composite fuel poverty measures were most consistently associated with cold weather-related adverse health or social outcomes.
This review identified socioeconomic, housing and behavioural factors associated with a range of cold weather-related adverse health or social outcomes. Only tentative conclusions can be drawn due to the limitations of existing research. More robust studies are needed to address the methodological issues identified and uncover causal associations. A review of qualitative and intervention studies would help to inform policies to reduce the adverse health and social impacts of cold weather.
Gynecological cancers are an important cause of morbidity and mortality. Secondary prevention programmes attempt to improve their prognosis. High participation rates are needed to ensure the desired population impact. We sought to assess the use of mammography and Pap smear and analyze predictors of screening adherence. We included women surveyed in the Spanish National Health Survey 2006. Cancer screening included mammography in the last 2 years and Pap smear in the last 3 years. The target age range of the screening programmes was 50–69 years in breast cancer screening and 25–64 years in cervical cancer screening. Independent variables included: sociodemographics, chronic diseases and lifestyles. Predictors of mammography or Pap smear adherence were explored using logistic regression. The screening coverage for the target age range was 84.1% (95% confidence interval=82.9–85.2) in breast cancer and 67.4% (95% confidence interval=66.5–68.4) in cervical cancer. Mammography uptake was positively associated with age, being married, higher educational level, having visited a physician or gynecologist, supplementary private health coverage and osteomuscular disease. Some unhealthy lifestyles were associated with nonadherence to mammography. Positive predictors of Pap smear adherence behaved in the same way as for mammography and also higher monthly incomes and eating a healthy diet were associated with higher screening compliance. In conclusion, adherence to breast cancer screening in Spain is acceptable in the target age group; nevertheless Pap smear screening must be improved. In both cases, an effort must be made to recruit those women who are less likely to undergo screening, as they are those who are at higher risk of suffering these diseases.
Existing research suggests that gender differences in the effect of unemployment on mental health are related to the different positions and roles that are available for men and women in society and the family; roles that are connected with their different psychosocial and economic need for employment. The aim of this article is to analyse the role of gender in the relationship between unemployment and mental wellbeing in Sweden, representing a gender regime with a similar need for employment among women and men, and Ireland, representing a gender regime in which the need for employment differs between women and men. The results, based on longitudinal data from the two countries, show that unemployment was more negatively related to mental health among men than among women in Ireland, while men and women were equally affected by unemployment in Sweden. Factors related to the family and economic situation, as well as gendered selection into the unemployment population, explains the difference in mental health between unemployed men and women in Ireland. The overall conclusion is that the context has a major influence on the relationship between unemployment, gender and mental health.
Relative deprivation has been hypothesized as one of the pathways accounting for the link between income inequality and health. We tested this hypothesis in a large national sample of men and women in Japan. Our survey included a probability sample of 22,871 men and 24,243 women aged 25-64, from whom information was gathered on demographic variables, household income, occupation or employment status, and self-rated health. Our measure of relative deprivation was the Yitzhaki Index, which calculates the deprivation suffered by each individual as a function of the aggregate income shortfall for each person relative to everyone else with higher incomes in that person's reference group. We modeled several alternative reference groups, including others with the same occupation, others of the same age group, and others living in the same geographic area (prefecture), as well as combinations of these. Generalized estimating equations demonstrated that higher relative deprivation was associated with worse self-rated health. Even after controlling for absolute income as well as other sociodemographic factors, the odds ratio and its 95% confidence intervals (CI) for poor health ranged from 1.09 (95% CI: 1.02-1.16) to 1.18 (95% CI: 1.11-1.26) for men and from 1.10 (95% CI: 1.04-1.16) to 1.16 (95% CI: 1.09-1.23) for women per 1 million increase in the Yitzhaki Index. As such, relative income deprivation is associated with poor self-rated health independently of absolute income, and relative deprivation may be a mechanism underlying the link between income inequality and population health.
Mathers and Schofield, from the Australian Institute of Health and Welfare, review recent studies, including Australian research, on the health effects of unemployment and the mechanisms by which unemployment causes adverse health outcomes. The relationship is complex: ill-health also causes unemployment, and confounding factors include socioeconomic status and lifestyle. However, longitudinal studies with a range of designs provide reasonably good evidence that unemployment itself is detrimental to health and has an impact on health outcomes--increasing mortality rates, causing physical and mental ill-health and greater use of health services.
Social isolation confers increased risk for coronary heart disease (CHD) events and mortality. In two recent studies, low levels of social integration among older adults were related to higher levels of C-reactive protein (CRP), a marker of inflammation, suggesting a possible biological link between social isolation and CHD. The current study examined relationships among social isolation, CRP, and 15-year CHD death in a community sample of US adults aged 40 years and older without a prior history of myocardial infarction. A nested case-cohort study was conducted from a parent cohort of community-dwelling adults from the southeastern New England region of the United States (N = 2321) who were interviewed in 1989 and 1990. CRP levels were measured from stored sera provided by the nested case-cohort (n = 370), which included all cases of CHD death observed through 2005 (n = 48), and a random sample of non-cases. We found that the most socially isolated individuals had two-and-a-half times the odds of elevated CRP levels compared to the most socially integrated. In separate logistic regression models, both social isolation and CRP predicted later CHD death. The most socially isolated continued to have more than twice the odds of CHD death compared to the most socially integrated in a model adjusting for CRP and more traditional CHD risk factors. The current findings support social isolation as an independent risk factor of both high levels of CRP and CHD death in middle-aged adults without a prior history of myocardial infarction. Prospective study of inflammatory pathways related to social isolation and mortality are needed to fully delineate whether and how CRP or other inflammatory markers contribute to mechanisms linking social isolation to CVD health.
Unemployment rates in the United States remain near a 25-year high and global unemployment is rising. Previous studies have shown that unemployed persons have an increased risk of death, but the magnitude of the risk and moderating factors have not been explored. The study is a random effects meta-analysis and meta-regression designed to assess the association between unemployment and all-cause mortality among working-age persons. We extracted 235 mortality risk estimates from 42 studies, providing data on more than 20 million persons. The mean hazard ratio (HR) for mortality was 1.63 among HRs adjusted for age and additional covariates. The mean effect was higher for men than for women. Unemployment was associated with an increased mortality risk for those in their early and middle careers, but less for those in their late career. The risk of death was highest during the first 10 years of follow-up, but decreased subsequently. The mean HR was 24% lower among the subset of studies controlling for health-related behaviors. Public health initiatives could target unemployed persons for more aggressive cardiovascular screening and interventions aimed at reducing risk-taking behaviors.
There is widespread concern that the present economic crisis, particularly its effect on unemployment, will adversely affect population health. We investigated how economic changes have affected mortality rates over the past three decades and identified how governments might reduce adverse effects.
We used multivariate regression, correcting for population ageing, past mortality and employment trends, and country-specific differences in health-care infrastructure, to examine associations between changes in employment and mortality, and how associations were modified by different types of government expenditure for 26 European Union (EU) countries between 1970 and 2007.
We noted that every 1% increase in unemployment was associated with a 0.79% rise in suicides at ages younger than 65 years (95% CI 0.16-1.42; 60-550 potential excess deaths [mean 310] EU-wide), although the effect size was non-significant at all ages (0.49%, -0.04 to 1.02), and with a 0.79% rise in homicides (95% CI 0.06-1.52; 3-80 potential excess deaths [mean 40] EU-wide). By contrast, road-traffic deaths decreased by 1.39% (0.64-2.14; 290-980 potential fewer deaths [mean 630] EU-wide). A more than 3% increase in unemployment had a greater effect on suicides at ages younger than 65 years (4.45%, 95% CI 0.65-8.24; 250-3220 potential excess deaths [mean 1740] EU-wide) and deaths from alcohol abuse (28.0%, 12.30-43.70; 1550-5490 potential excess deaths [mean 3500] EU-wide). We noted no consistent evidence across the EU that all-cause mortality rates increased when unemployment rose, although populations varied substantially in how sensitive mortality was to economic crises, depending partly on differences in social protection. Every US$10 per person increased investment in active labour market programmes reduced the effect of unemployment on suicides by 0.038% (95% CI -0.004 to -0.071).
Rises in unemployment are associated with significant short-term increases in premature deaths from intentional violence, while reducing traffic fatalities. Active labour market programmes that keep and reintegrate workers in jobs could mitigate some adverse health effects of economic downturns.
Centre for Crime and Justice Studies, King's College, London, UK; and Wates Foundation (UK).
The aim of this study was to examine relationships between income and mortality, focusing on the predictive utility of single-year and multiyear measures of income, the shape of the income gradient in mortality, trends in this gradient over time, the impact of income change on mortality, and the joint effects of income and age, race, and sex on mortality risk.
Data were taken from the Panel Study of Income Dynamics for the years 1968 through 1989. Fourteen 10-year panels were constructed in which predictors were measured over the first 5 years and vital status over the subsequent 5 years. The panels were pooled and logistic regression was used in the analysis.
Income level was a strong predictor of mortality, especially for persons under the age of 65 years. Persistent low income was particularly consequential for mortality. Income instability was also important among middle-income individuals. Single-year and multiyear income measures had comparable predictive power. All effects persisted after adjustment for education and initial health status.
The issues of low income and income instability should be addressed in population health policy.
The effects of home dampness and mold exposure on adult asthma are not clear.
We aimed to investigate the associations between housing characteristics related to dampness, mold exposure, and house dust mite levels and adult asthma in 38 study centers from the European Community Respiratory Health Survey.
Data about the present home, heating and ventilation systems, double glazing, floor covers, recent water damage, and mold exposure were obtained by means of an interviewer-led questionnaire. The associations between these factors and asthma, as defined on the basis of symptoms in the last year, and of bronchial responsiveness, as determined with methacholine challenge, were evaluated. Odds ratios (ORs) were obtained by using random-effects meta-analyses adjusted within study centers for sex, age group, and smoking status.
Fitted carpets and rugs in the bedroom were related to fewer asthma symptoms and bronchial responsiveness (OR range, 0.69-0.91). This effect was consistent across centers and more pronounced among house dust mite-sensitized individuals. Reported mold exposure in the last year was associated with asthma symptoms and bronchial responsiveness (OR range, 1.14-1.44). This effect was homogeneous among centers and stronger in subjects sensitized to Cladosporium species. In centers with a higher prevalence of asthma, the prevalence of reported indoor mold exposure was also high. This association was observed for reported mold exposure by asthmatic subjects (Spearman r (s) = 0.46), as well as reported mold exposure by nonasthmatic subjects (r (s) = 0.54). Reported mold exposure was highest in older houses with recent water damage.
We conclude that indoor mold growth has an adverse effect on adult asthma.
Many developed countries have experienced a sharp rise in income inequality during the past three decades, and the United States is no exception (1). For example, the average annual salary in America in inflation-adjusted 1998 dollars increased from 35,864 in 1999, that is, a modest 10 percent increase over three decades. By contrast over the same period, the average annual compensation of the top 100 chief executive officers rose from 37.5 million (or more than 1,000 times the pay of an average worker) (2). Recent trends in wealth inequality have been equally note-worthy. The net worth of families in the top decile rose by 69 percent, to 493,400 in 1998.By contrast over the same period, the net worth of families in the lowest fifth of income earners rose 24 percent, to $7,900.The median accumulated wealth of families in the top 10 percent of the income distribution was 12 times that of lower-middle-income families through much of the 1990s, but in 2001, the median net worth of the top earners was about 22 times as great (3). It is by now widely accepted that income poverty is a risk factor for premature mortality and increased morbidity (4). It should also be noted that there exists persuasive evidence indicating the reverse pathway, from poor health status to persistent poverty and poorer economic growth (5). In this review, however, we focus on the question: Does the unequal distribution of income in a society pose an addi-tional hazard to the health of the individuals living in that society? Earlier ecologic studies, summarized elsewhere (6, 7), suggested an association between income inequality and poor health status. However, these studies have been criti-cized because of their inability to disentangle the effects of individual income (and income poverty) from the contextual effects of income inequality (6). In other words, an ecologic association between income inequality (e. g., measured by
Despite enormous advances within medical science over the past 100 years, an under-recognised but inevitable gap remains between the map of medical science and the territory of individual human suffering.1 The task of the medical generalist is to make useful connections across this constantly recurring gap. All doctors carry the medical map, albeit with patchy and varying levels of detail, but only the medical generalist uses it to try and make sense of the whole human person, transcending all the arbitrary divisions of specialist practice. Here we explore the role of the medical generalist and consider how this might be affected by current NHS reforms.
This review considers the broad area of housing and public health, one of the traditional and core areas of public health research and intervention. The review takes into account the range of factors, acting at different levels, directly and indirectly, through which housing affects health. In public health terms, housing affects health in a myriad of relatively minor ways, in total forming one of the key social determinants of health. The paper closes by considering how the improvement of housing and neighborhoods has been a core activity of public health and a central component in tackling poverty. Investment in housing can be more than an investment in bricks and mortar: It can also form a foundation for the future health and well-being of the population. Addressing poor-quality housing and detrimental neighborhoods, in the broadest sense, is thus a task that should be grasped with vigor and determination by all those involved in public health.
been repeatedly posed. Should the focus be on "absolute" poverty or "relative" poverty? Should poverty be estimated with a cut-off line that reflects a level below which people are in some sense "absolutely impoverished", or a level that reflects standards of living "common to that country" in particular? These questions-it will be presently argued do not bring out the real issues clearly enough. However, a consensus seems to have emerged in favour of taking a "relative" view of poverty in the rich countries. Wilfred Beckerman and Stephen Clark put it this way in their important recent study of poverty and social security in Britain since 1961: "we have measured poverty in terms of a 'relative' poverty line, which is generally accepted as being the relevant concept for advanced countries."' There is indeed much merit in this "relative" view. Especially against the simplistic absolute conceptualisation of poverty, the relative view has represented an entirely welcome change. However, I shall argue that ultimately poverty must be seen to be primarily an absolute notion, even though the specification of the absolute levels has to be done quite differently from the way it used to be done in the older tradition. More importantly, the contrast between the absolute and the relative features has often been confused, and I shall argue that a more general question about ascertaining the absolute standard of living lies at the root of the difficulty. In particular, it will be claimed that absolute deprivation in terms of a person's capabilities relates to relative deprivation in terms of commodities, incomes and resources. That is going to be my main theme, but before I get to that general issue, I ought to make clear the sense in which I believe that even the narrow