Advancing the income inequality – health hypothesis

The notion that income inequality exerts an influence on health status (over and above the long-known effects of individual or household income) has received a great deal of attention in social epidemiology, medical sociology and economics in the past 20 years. And although a clear consensus on the hypothesis is yet to emerge, a new wave of empirical studies has strengthened the case for seeing income inequality as a social determinant of health. This article examines the current trajectory of the income inequality – health literature, and explores two issues that will be critical to its development in the coming years: (1) the need to re-examine the epistemological grounding of this research area, with a corresponding shift towards blurring the division between positivism and critical realism, and (2) the value of re-considering the geo-political ‘frame’ of studies in this field, with a move towards a truly global analysis of the health effects of income inequality.     

Vitamin D for the prevention of preeclampsia? A hypothesis

Preeclampsia has been suggested to result from a partial breakdown of tolerance to the developing fetus after maternal immune maladaptation. Several of the proposed immunomodulatory properties of the hormonal vitamin D system could potentially have beneficial effects for successful maintenance of pregnancy. Preeclampsia is characterized by marked changes in vitamin D metabolism. This paper reviews the evidence suggesting that the immunomodulatory properties of 1,25(OH)2D may play a key role in maintaining immunological tolerance in pregnancy, and proposes that ensuring adequate vitamin D status/intake may help in the prevention and management of preeclampsia.     

Exploring relative deprivation: is social comparison a mechanism in the relation between income and health?

During the last decade there has been a growing interest in the relation between income and health. The discussion has mostly focused on the individual's relative standing in the income distribution with the implicit understanding that the absolute level of income is not as relevant when the individual's basic needs are fulfilled. This study hypothesises relative deprivation to be a mechanism in the relation between income and health in Sweden: being relatively deprived in comparison to a reference group causes a stressful situation, which might affect self-rated health. Reference groups were formed by combining indicators of social class, age and living region, resulting in 40 reference groups. Within each of these groups a mean income level was calculated and individuals with an income below 70% of the mean income level in the reference group were considered as being relatively deprived. The results showed that more women than men were relatively deprived, but the effect of relative deprivation on self-rated health was more pronounced among men than among women. In order to estimate the importance of the effect of relative income versus the effect of absolute income, some analyses on the effect of relative deprivation on self-rated health were also carried out within different absolute income levels. When restricting the analysis to the lowest 40% of the income span the effect of relative deprivation almost disappeared. Relative deprivation may have a significant relation to health among men. However, for the 40% with the lowest income in the population the effect of relative deprivation on health is considerably reduced, possibly due to the more prominent relation between low absolute income and poor health.     

Childhood tuberculosis: out of sight,out of mind?

Despite significant improvements in tuberculosis (TB) management under the WHO directly observed treatment, short course (DOTS) strategy, childhood TB has been relatively neglected. Children are at high risk of severe disease, and reactivation of latent infection in adulthood perpetuates the epidemic. Almost a million cases of childhood TB are estimated to occur annually, but good-quality epidemiological data are scarce due to inherent difficulties diagnosing paediatric TB. There remains an urgent need both for better diagnostic tests and for robust regional data on the true burden of disease, otherwise childhood TB will remain an essentially 'invisible' and therefore neglected disease.     

A higher prevalence of health problems in low income groups: does it reflect relative deprivation?

STUDY OBJECTIVE: Although it has frequently been suggested that income affects health, there is hardly any research in which this issue has been explored directly. The aim of this study was, firstly, to examine whether income is independently associated with health, secondly, to assess the extent to which this association reflects high levels of deprivation in low income groups, and thirdly, to examine which specific components of deprivation contribute most to the link between income and health. Health indicators used were the prevalence of chronic conditions, health complaints and less than "good" perceived general health. SETTING: Region in the south east of the Netherlands. PARTICIPANTS: A population of 2567 men and women who participated in an oral interview, aged 15-74. DESIGN: Data were obtained from the baseline of a prospective cohort study aimed at the explanation of socioeconomic inequalities in health. RESULTS: Large inequalities in health by (equivalent) income after differences in other socioeconomic indicators had been controlled for were observed. For example, among those in the lowest income group the risk of bad perceived health was three times as high as among people in the highest income group. The prevalence of deprivation (basic, housing, social) increased with decreasing income to approximately 50-60% in the lowest income group. A substantial part of the increased health risks of the lowest income groups could statistically be accounted for by the higher prevalence of deprivation in these groups. The components that are likely to influence health indirectly, through a psychological or behavioural mechanism, accounted for most of the effect. CONCLUSIONS: These analyses provide evidence to suggest that a low income has detrimental health effects through relative deprivation. Moreover, the results indicate an indirect link between deprivation and health problems involving psychological or behavioural factors.     

The analysis of tobacco consumption in Croatia--are we successfully facing the epidemic?

Tobacco is the largest cause of morbidity and mortality. The aim of this study is to analyse several health and economically related indicators of tobacco consumption: smoking prevalence, standardized death rates (SDRs) from lung cancer and the proportion of GDP spent on tobacco in Croatia and other transitional countries--the Czech Republic, Slovakia, Poland, Hungary, Slovenia, Romania, and Bulgaria. The overall smoking prevalence in Croatia decreased by 5.2% during 1994-2005, more among females (-9.9%) than males (-0.3%). There is no significant difference in the smoking prevalence between Croatia (27.4%) and other countries. However, 33.8% of Croatian males smoked during 2002-2005, more than in Romania and the Czech Republic, and less than in Hungary and Poland. The prevalence of female smoking (21.7%) in Croatia is similar to the female smoking prevalence in Poland, the Czech Republic, and Hungary, but male smoking is predominant in all countries. The proportion of smokers among youth is above 20% and it is the highest in the Czech Republic (29.7%), followed by Hungary (26.7%), Slovenia (24.9%), Croatia (24.1%), and Poland (21.5%). The proportion of smokers among girls is higher than among boys in Slovenia, Hungary, the Czech Republic, and Croatia, contrary to Slovakia, Bulgaria, and Poland where boys smoke slightly more. There is no significant difference between the prevalence of smoking among girls in Croatia and Bulgaria, Poland, the Czech Republic, Hungary, Slovenia, and Slovakia. According to the SDR from lung cancer in males (70.3/100,000), Croatia is ranked high assuming the 3rd place, after Hungary (99.7) and Poland (72.0). With a SDR of 15.9/100,000 for females, Croatia is ranked slightly better--5th place. Tobacco consumption continues to be a major public health problem in transitional countries. Croatia conducted several campaigns and programmes in the past. However, results reveal that current anti-tobacco strategies are ineffective in reducing the smoking prevalence among men and youth. Men do not smoke less than a decade ago and, despite the observed decline among women, increasing trends are observed among teenage girls. Croatia should apply a comprehensive approach that would include raising awareness of health risks, restriction of smoking in public places, higher taxing, implementing stricter bans on advertising and promotion of tobacco as well as supporting smoking cessation. This last measure is believed to bring about some results in the medium term in targeted population groups, provided that it is supported by all health professionals. Otherwise, we may expect progress at the population level in the field of social stigmatization of smoking and wider intolerance to second-hand smoke. The full impact of smoking on the population health is yet to be seen and in the future it will undoubtedly remain one of the major contributors to the poor public health situation in Croatia.     

Are the nation's hospitals facing a capital crisis?

Are hospitals facing a capital crisis? Wall Street is taking a long, hard look at hospitals' bottom lines--and many analysts don't like what they see. Hospitals' increasing reliance on long-term debt, lower debt-service coverage ratios, and weakening performance indicators all signal a potentially volatile situation for some sectors of the field. Which hospitals are at risk? Experts point to hospitals in Southern California and New York. But others say that hospitals in moderate-size cities with 250 beds and $40 million or more in long-term debt are vulnerable. However, 40 percent of the 600 CEOs who responded to our Hamilton/KSA survey agree that the continued erosion of reimbursement will require a government bailout similar to the savings and loan industry. "A great deal depends on public policy," says Darrel Brownell, executive vice-president and chief financial officer, Memorial Health Services, a two-hospital system based in Long Beach, CA. "The government has the ability to maintain the industry in a stable condition, or it has the ability to force it into a bailout situation."     

Uncharitable and out of control?

This article explores the current state of the law governing partnerships and other collaborations between tax-exempt health care organizations and private health care providers. The author sets out the regulatory maze through which exempt entities and private parties must navigate in attempting to maintain Internal Revenue Code (IRC) Section 501(c)(3) status for the exempt entity in these relationships. The article discusses and comments on general principles through an examination of case law, statutes, regulations, revenue rulings, revenue procedures, and information letters, as well as state law issues, with an emphasis on maintaining charitable purposes, effecting control, and dealing with ownership and compensation issues.     

Compared to whom? An investigation of the relative health comparisons of well people

OBJECTIVES: Responses to the self-reported health (SRH) question, "In general how would you rate your health? Excellent, very good, good, fair or poor", have been repeatedly demonstrated to predict mortality. Survival curves plotted for each response category show that the likelihood of death increases in a stepped fashion with each progressively negative response category and the relationship persists for up to 12 years following initial measurement. To whom do people compare themselves when answering the self-reported health question? METHODS: Twenty-one interviews with people who selected the better-health response choices (i.e., good, very good, or excellent) were conducted in a Canadian city. Qualitative content analysis was undertaken and the interviews were approached with no pre-conceived ideas about what the participants would say. RESULTS: Analysis of the interviews suggested that there are three key features in making a health comparison: the type (i.e., with whom), direction (i.e., upward or downward), and magnitude of the comparison (i.e., with a few people or an ideal person vs. many other people). These key features varied in a systematic way with the chosen response. DISCUSSION: The findings related to the direction of comparison contradict, somewhat, the theories of social psychologists but these differences may have occurred because the participants were well. Healthy people may use different factors than ill people when making social comparisons as they select a self-reported health question response category. The nature of the comparisons are complex and the responses indicate that they are affected by age, gender, and life experience.     

Income as mediator of the effect of occupation on the risk of myocardial infarction: does the income measurement matter?

AIM: To investigate whether the effect of occupational grade on the risk of myocardial infarction (MI) is mediated by income with different aspects of income taken into account. METHODS: Data were used from three prospective population studies conducted in Copenhagen. A total of 16 665 employees, 43% women, aged 20-75 years, with an initial examination between 1974 and 1992 were followed up until 1999 for incident (hospital admission or fatal) MI. Register based information on job categories and income was used. RESULTS: During follow up, 855 subjects were diagnosed with a MI: 708 men and 147 women (in total 47% fatal). The hazards by household and individual income showed a graded effect with a hazard ratio (HR) of 1.43 (95% CI 1.12 to 1.83) for the lowest household income group compared with the highest, whereas equivalent income showed an inverse "J shape" effect with a HR of 1.55 (95% CI 1.25 to 1.82) for the third income group compared with the highest. HR for unskilled workers as compared with executive managers was reduced from 1.55 (95% CI 1.24 to 1.93) to 1.42 (95% CI 1.12 to 1.81) after adjustment for household income. CONCLUSIONS: Occupation and income are not mutually exclusive, but at least partly explained by or mediated through the other on the risk of MI. The mediating effect of income is independent of the choice of an income indicator. Income is not a big contributor to inequality in MI; probably because of the rather even income distribution in Denmark.     

Does the disbursement of income increase psychiatric emergencies involving drugs and alcohol?

OBJECTIVE: To determine if the incidence of psychiatric emergencies involving drugs or alcohol supports the argument that mentally ill persons contribute to elevated mortality during the days following disbursement of private earnings and public income transfers. STUDY DESIGN: Interrupted time-series using Box-Jenkins methods. DATA COLLECTION/EXTRACTION METHODS: Daily counts of adults admitted to psychiatric emergency services in San Francisco after using drugs or alcohol were derived from medical records for the period January 1 through June 30, 1997. PRINCIPAL FINDINGS: Psychiatric emergencies among males who had used drugs or alcohol were elevated in the early days of the month. Such emergencies among females were not similarly elevated. Emergencies among females who had not used drugs or alcohol were elevated in the early days of the month. CONCLUSION: Elevated mortality in the first week of the month may be attributable, in part, to the "check effect" or use of drugs and alcohol by mentally ill males in the days after they receive income. The contribution of women is more complex and may be induced by drug or alcohol abuse among persons in their social networks. The check effect suggests that persons with a history of substance abuse and mental illness should be offered the opportunity to have their income managed by someone who can monitor and influence how the money is being spent. The fact that drug- or alcohol-related admissions among males exhibit temporal patterns suggests that the provision of preventive as well as treatment services may be strategically scheduled.