The wider determinants of inequalities in health: a decomposition analysis

Background  

The common starting point of many studies scrutinizing the factors underlying health inequalities is that material, cultural-behavioural, and psycho-social factors affect the distribution of health systematically through income, education, occupation, wealth or similar indicators of socioeconomic structure. However, little is known regarding if and to what extent these factors can assert systematic influence on the distribution of health of a population independent of the effects channelled through income, education, or wealth.     

Epidemiology and social determinants of health inequalities

BACKGROUND: The general approach of social epidemiology is based on the observation of a strong social stratification of health outcomes within populations: a similar stratification of factors associated with health must therefore also exist according to social status. To explain social differences in health, the natural approach for epidemiologists is to consider an imbalanced distribution of established risk factors according to the social position of individuals. As this approach has largely failed, two main other research areas were recently explored: (i) identification of "new" social risk factors; (ii) research of possible mechanisms of social differences in health. METHODS AND RESULTS: Identification of social risk factors: early events and life course, occupational factors, social relationships (social networks and support, discrimination, neighborhood characteristics), health care. Research of possible mechanisms of social differences in health in the context of specific theoretical frameworks: the materialist model, the psychosocial model and the eco-social model integrating the interaction between individuals'characteristics and their environment. COMPLEX METHODOLOGICAL PROBLEMS: definition and measurement of variables characterizing the social situation of individuals; quantification of social inequalities at population level. Observational methods must often rely on very long-lasting cohorts, and imply statistical methods that account for longitudinal data or are able to manage simultaneously individual and contextual data.     

Health disparities between racial groups in South Africa: a decomposition analysis

This article explores the sources of self-rated health status inequalities among South Africans. We propose a decomposition of observed health disparities between racial groups using a procedure based on an extended version of Oaxaca-Blinder decomposition methods which addresses explicitly the specificities associated with the analysis of subjective measures. This method allows for a decompositions of differences in self-rated health status between races and isolates what may be due to observed socioeconomic inequality between racial groups, i.e. an "indirect racial effect" (Whites and Africans with different socio-economical characteristics have different health), from what could be due to unexplained racial differences, i.e. a "direct racial effect" (Whites and Africans with similar socio-economical characteristics have different health). Unsurprisingly, we find a strong indirect racial effect in favor of Whites. However, our analysis tends to show that the issue of direct racial discrimination on health is more complex and closely linked with that of economical inequality and discrimination. Our results thus stress the necessity not only to open access for Africans to the more sophisticated sector of health care but also to provide them with the economical opportunity to use it.     

The social epidemiology of tuberculosis in South Africa: a multilevel analysis

Increased risk of tuberculosis is widely recognized to be associated with increased poverty, yet there have been few analyses of the social determinants of tuberculosis, particularly in high-burden settings. We conducted a multilevel analysis of self-reported tuberculosis disease in a nationally representative sample of South Africans based on the 1998 Demographic and Health Survey (DHS). Individual and household-level demographic, behavioral and socioeconomic risk factors were taken from the DHS; data on community-level socioeconomic status (including measures of absolute wealth and income inequality) were derived from the 1996 national census. Of the 13,043 DHS respondents, 0.5% reported having been diagnosed with tuberculosis disease in the past 12 months and 2.8% reported having been diagnosed with tuberculosis disease in their lifetime. In a multivariate model adjusting for demographic and behavioral risk factors, tuberculosis diagnosis was associated with cigarette smoking, alcohol consumption and low body mass index, as well as a lower level of personal education, unemployment and lower household wealth. In a model including individual- and household-level risk factors, high levels of community income inequality were independently associated with increased prevalence of tuberculosis (adjusted odds ratio for lifetime tuberculosis comparing the most unequal quintile to the middle quintile of inequality: 2.37, 95% confidence interval: 1.59-3.53). These results provide novel insights into the socioeconomic determinants of tuberculosis in developing country settings, although the mechanisms through which income inequality may affect tuberculosis disease require further investigation.     

HIV prevention in sub-Saharan Africa: a multilevel analysis of message frames and their social determinants

In light of the great threat that HIV/AIDS poses in sub-Saharan Africa, the current study assesses HIV/AIDS posters from this region with specific reference to health message frames, including HIV sources, consequences, self-efficacy, preventive means, and barriers and benefits to employing such means of prevention. There is a two-step methodology. First, the content of HIV/AIDS posters from 15 sub-Saharan African countries was coded for the six health message frames. Second, relationships between the health message frames and four social determinants (HIV rate, HIV awareness, condom use and uncertainty avoidance (UAI)) were assessed with hierarchical linear modeling (HLM). Analysis indicates that self-efficacy is the most common frame, but that almost one-quarter of the posters has none of the six health message frames. HLM indicates some favorable findings, including that health message frames are used most often in countries with the most troubling levels of HIV awareness and condom use. Less favorably, health message frames are used least common in countries that have high levels of UAI and high HIV rates. Improvements for related media practices and policy are articulated.     

Social determinants and inequalities in urban health

Social and environmental factors are health determinants, in association with behavior, biological factors, and health services. Whereas socioeconomic characteristics (age, gender, ethnicity, social status) describe individuals, social determinants work through broader policies that are influenced by governments. The relation between health and four social areas is discussed. Social capital, measured as social networks and social support, appears to be protective in developing some heart disease and mental illnesses; job control at work is also found to protect against heart disease; early life experiences affect both biological and social development; and the degree of income inequality within societies correlates with health status. The Independent Report on Inequalities in Health, published in the United Kingdom in 1998, is also reviewed. The report (a) briefly describes inequalities in health by social class, sex, and ethnicity; (b) reviews the literature on policy areas that affect health; (c) includes a section indicating relatively little inequality of access or provision in the National Health Service; and (d) makes 132 recommendations. Social determinants is a new area of research having the potential to link epidemiology and environmental sciences at small area level.     

Assessing the social class of children from parental information to study possible social inequalities in health outcomes

PURPOSE: When the subjects are children, the assessment of social class must be made indirectly from parental data. We propose correspondence analysis as a method for combining parental information. METHODS: Four assessment methods were used: father's occupation, mother's occupation, dominant occupation of both, and both combined by means of a correspondence analysis. The results were used to explore social inequalities in dental health. We used data from a survey performed on school children (12- and 15-16-year olds) in the Comunitat Valenciana (Spain). Dental health was measured through prevalence of caries, number of teeth with caries, number of caries in permanent teeth, decayed, missing, and filled teeth score (DMF-T), decayed, missing, and filled surface score (DMF-S), prevalence of DMF>0, community periodontal index of treatment needs (CPITN) and prevalence of CPITN>0. RESULTS: Correspondence analysis methods reflect the impact of social class on health indicators. They were able to assign a social group to all individuals. The association between social class and oral health was found to be sensitive to the method used. CONCLUSIONS: Pooling information from both parents is important. Evidence of social inequalities in oral health may or may not be obtained depending on the method used.     

HIV infection in women: social inequalities as determinants of risk

Social inequalities lie at the heart of risk of HIV infection among women living in poor countries and among poor women living in wealthy countries. As of December 1996, UNAIDS estimated that 12.1 million women have developed AIDS-defining diagnoses. These women have been disproportionately poor, and in the US, African-American and Latina. Their neighborhoods and villages have been burdened by poverty, civil unrest, structural adjustment, racism, drugs and violence. To explain which women are at risk and why, this article reviews the epidemiology of HIV and AIDS among women in light of four conceptual frameworks linking health and social justice: feminism, social production of disease/political economy of health, ecosocial, and human rights. The article applies these alternative theories to describe sociopolitical contexts for AIDS' emergence and spread in the US, and reviews evidence linking inequalities of class, race/ethnicity, gender and sexuality, as well as strategies of resistance to these inequalities, to the distribution of HIV among women.     

Revisiting the social determinants of health agenda from the global South

ABSTRACT

In an effort to provide an overview of the conceptual debates shaping the mobilisation around social determinants of health and health inequities and challenge the apparent consensus for equity in health, this essay compares two of the most influential approaches in the field: the WHO Commission on Social Determinants of Health approach (CSDH), strongly influenced by European Social Medicine, and the Latin American Social Medicine and Collective Health (LASM-CH) ‘Social determination of the health-disease process’ approach, hitherto largely invisibilized. It is argued that the debates shaping the equity in health agenda do not merely reflect conceptual differences, but essentially different ethical-political proposals that define the way health inequities are understood and proposed to be transformed. While the health equity agenda probably also gained momentum due to the broad political alliance it managed to consolidate, it is necessary to make differences explicit as this allows for an increase in the breadth and specificity of the debate, facilitating the recognition of contextually relevant proposals towards the reduction of health inequities.     

The social determinants of health: a contribution to the analysis of gender differences in health and illness

While it is established that socioeconomic status and social integration influence the distribution of health and illness among men and women, little attention has been paid to the different ways in which women and men experience socioeconomic opportunities and social attachments to others. Drawing on evidence from the literature, the position developed in this article is that gender mediates the influence of both socioeconomic status and social integration on health, and for women, these are intricately linked. Women's relationship to the labour market establishes and perpetuates their socioeconomic inequality relative to men, and may produce contradictory influences on women's health. Furthermore, for women, the marital relationship is paradoxical: marriage may at once improve economic and social support opportunities, while diminishing control over paid and unpaid work--potentially increasing as well as compromising the health status of women. The article is intended to contribute to the growing body of literature on gender and the determinants of health.     

A discourse analysis of the social determinants of health

The social determinants of health (SDH) concept is common to Canadian policy documents and reports. Yet, little effort is undertaken to strengthen their quality and promote their more equitable distribution through public policy action. Much of this has to do with the SDH concept conflicting with current governmental approaches of welfare state retrenchment and deference to the dominant societal institution in Canada, the marketplace. In addition, many SDH researchers and implementers of SDH-related concepts are reluctant to identify the public policy implications of the SDH concept. The result is a variety of SDH discourses that differ greatly in their explication of the SDH concept and their implications for action. This article identifies these various SDH discourses with the goal of noting their contributions and limitations in the service of advancing the SDH agenda in Canada and elsewhere.     

Viewing primary mental health care at a time of social transition in South Africa.

As South Africa shifts from a social structure based on the principles of apartheid to a democratic society, social policies must be developed that are consonant with the ideals of the "new" society. These must, however, take into account the current realities of the South African context. This article suggests that the application of the principles of primary mental health care is the approach most likely to meet mental health needs in the future South Africa, but that difficulties are likely to arise in the transition to this approach. These difficulties must be identified and dealt with. The authors discuss the problems in providing competent curative care to all and in shifting emphasis to prevention and promotion in mental health care. The discussion covers both practical and political complications. The authors conclude that though the process to primary mental health care will be a long one, the problems are unlikely to be insurmountable.     

Personal, social and environmental determinants of educational inequalities in walking: a multilevel study

OBJECTIVE: To investigate the contribution of personal, social and environmental factors to mediating socioeconomic (educational) inequalities in women's leisure-time walking and walking for transport. METHODS: A community sample of 1282 women provided survey data on walking for leisure and transport; educational level; enjoyment of, and self-efficacy for, walking; physical activity barriers and intentions; social support for physical activity; sporting/recreational club membership; dog ownership; and perceived environmental aesthetics and safety. These data were linked with objective environmental data on the density of public open space and walking tracks in the women's local neighbourhood, coastal proximity and street connectivity. RESULTS: Multilevel modelling showed that different personal, social and environmental factors were associated with walking for leisure and walking for transport. Variables from all three domains explained (mediated) educational inequalities in leisure-time walking, including neighbourhood walking tracks; coastal proximity; friends' social support; dog ownership; self-efficacy, enjoyment and intentions. On the other hand, few of the variables examined explained educational variations in walking for transport, exceptions being neighbourhood, coastal proximity, street connectivity and social support from family. CONCLUSIONS: Public health initiatives aimed at promoting, and reducing educational inequalities in, leisure-time walking should incorporate a focus on environmental strategies, such as advocating for neighbourhood walking tracks, as well as personal and social factors. Further investigation is required to better understand the pathways by which education might influence walking for transport.     

Embedded gender and social changes underpinning inequalities in health: An ethnographic insight into a local Spanish context

Despite growing interest in the social determinants of health and contributions from studies focussing on the analysis of explanations to enhance our understanding of the interactions between gender identities, embodied experiences and structural inequalities between men and women, few research papers have devoted attention to this perspective in the Spanish context. This study is an empirical exploration of lay knowledge, for an enhanced understanding of health inequalities in this context, from an ethnographic standpoint based on a phenomenological approach. Specifically, our aim is to study the lay perceptions of men and women regarding their gender identity and living conditions as health determinants within different "contexts" of their everyday lives, namely: the personal context; the home context; and the neighbourhood context. Fifty eight in-depth interviews and three focus groups were held between January 2005 and January 2007, and analysed using a hermeneutic method. Our findings show how disease-coping strategies or the perceived loss of social cohesion are linked to the gender system. They also point to how the dynamics of social change have developed around a strong division between the productive and reproductive arenas. Approaching these issues from different "contexts" provides insights into the explanations for the gendered patterning of mortality and morbidity, as well as furthering our understanding of the basis for social embodiment of gender differences and health inequalities in the context studied. In the discussion of our findings, we place emphasis on the implications that informal caring has for these processes and also take into account contributions of the "lay approach" to study and understand social determinants and health inequalities.     

Measuring inequalities in health: an analysis of mortality patterns using two social classifications

The paper investigates relationship between mortality and social class as measured by the Erikson-Goldthorpe schema, a validated measure of employment conditions, and compares this with differentials found using the Registrar General's social classes. Two cohorts of men aged 15/16–64 were drawn from the OPCS Longitudinal Study for 1971 and 1981. Mortality differences between social classes were estimated using deaths occurring between 1976 and 1980 in the first cohort and 1986 and 1989 in the second. The two classification were formally compared by means of the Relative Index of Dissimilarity and a likelihood-based statistic. Similar mortality differentials were found using both classifications in the two time periods. The Erikson-Goldthorpe schema showed a clear pattern of higher mortality in those groups without a career structure and with lower discretion over their work. The paper concludes that inequalities in health are seen when a validated social class schema based on employment conditions is used. The use of validated measures will make it possible for health differences to be more clearly interpreted in policy terms.