Health inequalities in different age groups: the case of type 2-diabetes: a study with health insurance and medication data

Summary Objectives:This study investigates social differentials in the prevalence of diabetes type 2 in women and men in a health insurance population. It is considered whether social gradients are present over different age strata. Methods:Analyses were performed with records obtained from a German statutory health insurance comprising 77294 women (31.8%) and men (68.2%) of at least 20 years. Occupational status was used as indicator of socio-economic position. Individuals with diabetes were identified using information about antidiabetic medication or by hospital diagnoses according to ICD9. The analyses were performed for the entire insurance population and for different age strata (<40yrs/40–55yrs/>55yrs). Results:The analyses revealed considerable social differences in diabetes risks. Considering the whole insurance population with the highest socio-economic category as reference group, the odds ratio (OR) for skilled non-manuals was OR=2.9, for skilled manuals it was OR=4.7, and OR=5.6 for unskilled and semi-skilled individuals. After stratifying the insurance population into three age groups the social gradients were reproduced for each stratum, but their magnitudes increased with age. Conclusions:In the health insurance population considered health inequalities with respect to diabetes are considerable, and they are persisting after stratification into age groups.     

Decreasing socioeconomic inequalities and increasing health inequalities in Spain: a case study

OBJECTIVES: We examined the evolution of income inequalities and health inequalities in Spain from the time of the country's entry into the European Union. METHODS: We estimated distributions of provincial income and household income, relations of provincial income with mortality and disability, and relations of household income with disability in 1984-1986 and 1999-2001. RESULTS: Inequalities in average provincial income and household income were lower in 2000 than in 1985. Differences in mortality and disability according to income were greater in 2000 than in 1985, in both absolute and relative terms, except for differences in mortality among individuals aged 25 to 44 years. In most cases, differences in mortality from leading causes of death and differences in major types of disabilities were also greater in 2000. CONCLUSIONS: Our results show that redistribution of income might achieve greater social justice but probably does not lead to reduced health inequalities, despite observed improvements in material circumstances as well as in most health indicators among disadvantaged population groups.     

Addressing health inequalities in the United Kingdom: a case study

Health inequalities research has a long history in the United Kingdom, and the development of government policies that are intended to explicitly address the existing health inequalities has been gathering pace since the Labour Party returned to power in 1997. In this paper, using the influential Acheson Report as a reference point, one of us (D.N.) describes how health inequalities policies have been developed, and the other (A.O.) assesses how, ideally, such policies ought to be developed. Although progress in the development of health inequalities policies has been made, the policies, and the evidence that has informed them, have been less than ideal.     

Health inequalities among persons with type 2 diabetes: the example of intermittent claudication

In Germany, high quality health care is offered to just about all socio-economic groups. The question is rarely asked, though, if there are social differences in the utilisation and quality of health care among those with similar needs. These differences are analysed by looking at a group of persons with type 2 diabetes mellitus. Another group of persons without diabetes is included as well. The data are taken from the KORA-A Study in Augsburg, southern Germany. KORA-A is a case-control study based on patients with type 2 diabetes from the MONICA surveys S2 (1989/90), S3 (1994/95) and the Myocardial Infarction Registry, and controls, matched by age and sex to the cases. In 1997/98, these persons were contacted for the KORA-A study. The dataset includes data from 378 type 2 diabetic patients. The group without diabetes comprises 438 persons. The results indicate that the prevalence of "pain while walking" increases with decreasing educational level, and that this association is stronger for persons with type 2 diabetes (OR 3.53; 95 % CI 1.32 - 9.44) than for persons without diabetes (OR 2.02; 95 % CI 0.97 - 4.23). The prevalence of intermittent claudication can serve as an indirect assessment of the quality of health care received by diabetic persons. It is concluded that health care should be improved especially for those persons with type 2 diabetes who belong to the group with low socioeconomic status.     

高尿酸血症与H型高血压之间的年龄依赖性

目的 探讨湖南省社区居民高尿酸血症与H型高血压之间年龄依赖的关联性,为H型高血压防治提供科学依据。方法 以整群抽样方法调查湖南省6个地区30 ~90岁的常住社区高血压居民,通过问卷调查、实验室检测血液生化指标及logistic回归分析统计学方法分析不同年龄层高尿酸血症与H型高血压之间的相关性。结果 本研究纳入1 395名研究对象,其中H型高血压86.6%。单因素分析结果显示,≤60岁人群,非高尿酸血症与高尿酸血症人群间H型高血压患病率、教育程度、BMI、ALT、STP、Cr、BUG、TG、VLDL的差异具有统计学意义（均P＜0.05）;＞60岁人群,非高尿酸血症与高尿酸血症人群之间ALT、STP、Cr、BUG、TG、TC、VLDL差异具有统计学意义（均P＜0.05）。logistic回归分析:伴有高尿酸血症使H型高血压事件的发生风险显著增加（P = 0.001, OR = 2.24, 95%CI = 1.37～3.67）。年龄分层,仅≤60岁人群,高尿酸血症是H型高血压事件的的独立危险因素（P = 0.007, OR = 2.36, 95%CI = 1.26～4.41）。交互作用分析结果显示:≤60岁,尿酸与性别、总蛋白、VLDL的交互作用影响H型高血压（女性:P = 0.040, OR = 0.826, 95%CI = 0.69～0.99;STP:P = 0.028, OR = 1.007, 95%CI = 1.001～1.012;VLDL: P = 0.011, OR = 1.183, 95%CI = 1.04～1.35 ）;＞60岁,尿酸仅与VLDL存在交互作用影响H型高血压（P＜0.001, OR = 1.698, 95%CI = 1.262～2.285）。结论 ≤60岁人群,高尿酸血症是H型高血压的独立危险因素。     

Measuring health inequalities between genders and age groups with realization of potential life years (RePLY)

OBJECTIVE: We propose a new method to measure health inequalities caused by conditions amenable to policy intervention and use this to identify health differences between sexes and age groups. METHODS: The lowest observed mortality rates are used as a proxy of unavoidable mortality risks to develop a new measure of health outcome - realization of potential life years (RePLY). The RePLY distribution is used to measure avoidable health inequalities between sex and age groups respectively. FINDINGS: Using RePLY we find that even those countries with very high life expectancy at birth can have substantial health inequalities across different age groups. Also, gender inequality is more pronounced among those aged < 30. Among countries with a life expectancy < 60 years, there is a much larger prevalence of gender inequality against females; countries with life expectancy > 60 years have comparable numbers of cases of inequality among females and males. Finally, high avoidable health inequality is associated with low average income, high income inequality and high population fractionalization. CONCLUSION: It is important to distinguish between unavoidable and avoidable mortality when measuring health outcomes and their distribution in society. The proposed new measure (RePLY) enables policy-makers to focus on age-sex groups with low realization of potential life years and thus high avoidable mortality risks.     

Forces promoting health insurance coverage of homebirth: a case study in Washington State

The movement of childbirth to the hospital in the early 1900s and the eventual establishments of health insurance reimbursement for hospital birth--but not for homebirth--solidified and reflected physician dominance in the area of obstetrics. Until recently, it was rare that a health insurer or a health maintenance organization (HMO) would cover a homebirth. However, in Washington State the majority of health insurance groups cover homebirths, which are generally attended by licensed midwives. In this context, our research is a case study focused on answering the question: What are the forces promoting the extensive coverage of homebirth by health insurers in Washington State? Data were gathered primarily through fourteen (14) in-depth, audiotaped interviews with key informants in relevant agencies and organizations in the state (i.e., state offices; midwife and other professional associations; and health insurance groups). Results suggest that consumer demand was an important precipitating factor without which changes to health insurance coverage would likely not have been made. Additionally, changes in state policies and professional mobilization on the part of licensed midwives were critical factors facilitating the widespread reimbursement for homebirth. Health care organizations' concerns for cost containment had little impact on this health insurance trend. Our study concludes that jurisdictional openings in the system of professions can be facilitated by a small number of strategically positioned individuals.     

Health care by a DMP for diabetes mellitus type 2—results of a survey of participating insurance customers of a health insurance company in Germany

Since the late 1990s, intensive efforts have been made in Germany to enhance integration within the fragmented health care sector. Disease management programmes (DMPs) represent an attempt to improve the care for the chronically ill, which is known to be deficient in particular for diabetics. A representative telephone survey was carried out of participants in the DMP for diabetics (customers of the BARMER Health Insurance, Neubrandenburg) to investigate preferences, motives and assessments of participants (random sample, net = 124, June 2005). The interviewees were generally aged 61 years or older (77.4%), and two-thirds of them had suffered from diabetes or received treatment for more than 5 years. During the programme, the proportion consulting a specially trained diabetology physician doubled to 31%. The assessment of the quality of care improved markedly; 19% of the participants reported an improvement in their health status. The main reasons given for participating in the DMP were anticipated improvement in the quality of care and the activation of the patient role. Analyses indicate that those who reported the most benefit from the programme are the core group of the elderly chronically ill. However, as this group was particularly well informed about their own disease, attention should always be paid to the possibility of social selection processes in such health programmes. Quality studies in the past have not provided a comprehensive picture, so quality assurance studies should be carried out in order to validate surveys addressing participants in DMPs, and conversely surveys of DMP participants should be conducted to validate quality assurance findings. Surveys of health insurance customers can provide valuable information about the opinions of the patients themselves and allow the investigation of social influences. Considerable work remains necessary in Germany to develop appropriate methodologies.     

Socio-economic health inequalities in Brazil: gender and age effects

This paper analyses Brazilian socio-economic inequalities in health by measuring the concentration indices for the following variables: health expectancy, self-assessed health status and chronic health problems. Data used were taken from the 1996/1997 Living Standard Measurement Study (LSMS). In summary, as far as gender distinction is concerned, the results showed that up to 5 years of age the mortality rates, reported appearance of chronic health problems as well as the self-assessed health indicated that the boys were in worse health condition than the girls. After this age group there was a tendency for differences to disappear until adulthood, when the situation changed and the women consistently considered themselves less healthy. With reference to the socio-economic inequalities, one generally finds larger differences within the women's groups. The analysis for the different age groups indicated that the pro-rich inequalities increased with age. Both results were clearly proved, especially for the health expectancy variable, by adopting an adjustment of the dominance concept derived from literature on economic inequalities, consisting of comparing concentration curves.     

Health sector reform and equity: a study at a family health center affiliated to health insurance organization in Alexandria

The 1990's witnessed a wave of reform in health systems of many countries. Health sector reform (HSR) initiatives aimed at improving health status, utilizers' satisfaction, as well as equity and accessibility of care. This study aims at exploring the question of whether there is a socioeconomically- based differential access to services provided by a family health center applying HSR. A total of 248 utilizers were randomly selected and interviewed. An access index comprised of eight elements was developed to measure access and its corollary equity. Results demonstrated that the majority belonged to the low middle socio-economic class and one- quarter belonged to the low class. Approximately 9/10 of utilizers had high access to the services offered. Mean access index score for all utilizers was above the 90% mark. ANOVA analysis of mean access index according to socio-economic class revealed that there is no statistically significant disparity among various socio-economic classes regarding their access to care. However, it was demonstrated that higher classes had a higher opinion concerning the completeness of physical examination during the initial visit than lower classes. It was recommended to establish an appropriate policy framework to assure optimal standards of equity, preferably a 100% of high access as measured through the access index devised in this study.     

Health, health risks and inequalities: an exploratory study of women's perceptions

Recent theoretical and empirical research has highlighted the importance of understanding the relationship between social structure and health beliefs. The empirical study described here explores the relationships between occupational social class and two dimensions of health beliefs which were concepts of health and perception of vulnerability to disease. Both the dimensions are claimed to be associated with decisions to carry out health behaviour and thus one of the aims was to shed some light on the social class gradient in patterns of preventive health behaviour and risk-taking behaviour. The findings showed a more marked social class differentiation in concepts of health when they were defined in the abstract compared with when they were defined in relation to personal health. The concept of personal vulnerability itself was shown to be problematic and theories about vulnerability were similar for both classes. Explanations for the findings are discussed.     

Health promotion, advocacy and health inequalities: a conceptual framework

Advocacy has often been described as a key strategy for theachievement of health promotion aims, but multiple and conflictingdefinitions and usages exist. The concept itself may be unnecessarilyintimidating. Advocacy work can take place at the level of both‘cases’ and ‘causes’. Two main goalsunderpin health advocacy—protection of the vulnerable(representational advocacy) and empowerment of the disadvantaged(facilitational advocacy). This paper attempts to integrateexisting models and definitions into a conceptual frameworkfor considering the role of advocacy in addressing health inequalities.It argues that we need to pay some attention to the diversityof values and goals of health promotion if we are to understandwhich models and approaches to health advocacy apply and inwhat context. This paper concludes that advocacy for healthfulfils two functions: as a form of practice and as a usefulstrategy for a discipline which has to be self-promoting aswell as health-promoting in order to survive in the competitivepolitical environment of contemporary health work.     

Socioeconomic health inequalities in Latvia: a cross-sectional study

AIMS: Socioeconomic health differences have been studied elaborately for many Western societies. Relatively little is know about the social variations in health in the former communist states of Eastern Europe. This study investigated socioeconomic health inequalities in Latvia. METHODS: Cross-sectional analysis was undertaken of the 1999 Norbalt-II Living Conditions Survey, a random population-based sample in Latvia, and included males and females aged 25 to 70. RESULTS: Lower educated subjects had higher rates of self-assessed poor health than those with tertiary education (men OR 2.21; 1.31-3.71 95% CI, and women OR 2.48; 1.74-3.54 95% CI). After adjusting for income, educational differences were significant only for women. Income differences were larger than educational differences in self-assessed poor health for both genders (OR of highest vs. lowest quintile for men: 5.10; 2.26-11.5 95% CI, women: OR 3.26; 1.92-5.51 95% CI). For long-standing health problems socioeconomic differences were smaller. After adjusting for income no educational differences were found, but income differences were significant (men: OR 2.06; 1.15-3.69 95% CI, women: OR 1.42; 1.12-2.63 95% CI). The economically non-active were in worse health than the (self-)employed subjects (men: OR 6.12; 3.65-10.3 95% CI, women: OR 2.79; 1.66-3.39 95% CI). CONCLUSIONS: Substantial social inequalities in self-assessed poor health and longstanding health problems exist in Latvia for both sexes. Inequalities by material circumstances, as measured by income, appear to be larger than educational differences. Economic activity was also strongly associated with health. There were no inequalities with regard to urbanization and ethnic differences were found only for long-standing health problems among women.     

Diffusion of new medication across different income groups under a universal health insurance program: an example involving newly enlisted nonsteroidal anti-inflammatory drugs for elderly osteoarthritis patients

Objectives  

The aim of this research was to determine whether socioeconomic status, as measured by income level, impacts on the diffusion to patients of newly reimbursed nonsteroidal anti-inflammatory drugs (NSAIDs) under the National Health Insurance program in Taiwan.     

Racial inequalities in health: a challenge to the British National Health Service

The existence of racial inequalities in health in the United Kingdom is examined using both indirect and direct data. The evidence strongly supports the view that the health experience of black and other ethnic minority groups is worse than that of the indigenous white population. Ways of improving this situation are outlined; they indicate the need for a coordinated Health service response incorporating planning, training, and equal opportunities in both service provision and employment practices.     

Health insurance and subjective health status: data from the 1987 National Medical Expenditure survey.

OBJECTIVES. The relationship between health insurance and subjective health status was investigated. It was hypothesized that persons without health insurance would have lower levels of subjective health status than those with health insurance and that this relationship would hold for both poor and nonpoor persons. METHODS. Data from the 1987 National Medical Expenditure Survey were analyzed to examine the relationship between health insurance and self-reported health status. The analysis controlled for sociodemographic and attitudinal variables and medical conditions. RESULTS. Persons without health insurance had significantly lower levels of subjective health status than did persons with insurance. This adverse effect persisted after adjustments were made for the effects of age, sex, race, income, attitude toward the value of medical care and health insurance, and medical conditions. The detrimental effect of lacking health insurance on subjective health status was present for persons at all income levels and was greater than the effect on subjective health status found for 2 of the 11 reported medical conditions. CONCLUSIONS. Lacking health insurance is associated with clinically significant lower levels of subjective health status in both poor and non-poor persons.     

Individualization and inequalities in health: a qualitative study of class identity and health

It has been argued that social class, if not dead, is at least a 'zombie category' in contemporary Western society. However, epidemiological evidence shows that class-based inequalities have either persisted or widened, despite overall improvements in the health of Western populations. This article presents an exploratory qualitative study of the individualization of class identity and health conducted in a southern English city. Findings are presented in consideration of two competing argumentative positions around which participants worked to negotiate class identity and health. The first of these positions denied the significance of class for identity and health and was associated with the individualised heroic and stoic narratives of working class identity. The second position acknowledged the reality of class relations and their implications for health and identity, being associated with structurally and politically orientated narratives of middle class identity. In sum, resistance to class was associated with talk about individual, private experience whereas the acceptance of class was linked to discussion of health as a wider social or political phenomenon. This evidence lends qualified support to the individualization thesis: inequalities in health existing on structural or material levels are not simply reproduced, and indeed in some contexts may even juxtapose, accounts of social identity in interview and focus group contexts. Class identity and health are negotiated in lay talk as participants shift argumentatively back and forth between competing positions, and public and private realms, in the attempt to make sense of health and illness. The promotion of greater awareness and interest in health inequalities within wider public discourse may well help support attempts to tackle these injustices.