Access to health care in relation to socioeconomic status in the Amazonian area of Peru

Background  

Access to affordable health care is limited in many low and middle income countries and health systems are often inequitable, providing less health services to the poor who need it most. The aim of this study was to investigate health seeking behavior and utilization of drugs in relation to household socioeconomic status for children in two small Amazonian urban communities of Peru; Yurimaguas, Department of Loreto and Moyobamba, Department of San Martin, Peru.     

Smoking habits in relation to socioeconomic factors

Smoking habits are analyzed by SEG for men and women, aged 15-74. The SEGs are constructed using education and income and here only the middle-class, with three sub-groups, is considered. Over-achievers are more often smokers. There are less quitters and more heavy smokers in this sub-group than among under-achievers. Smoking habits of female over- and middle-achievers are similar to those of male over-achievers. Female and male under-achievers show similar smoking habits. These observations are consistent with the hypothesis that socio-economic factors are influential in determining smoking habits.     

Survival of breast cancer patients in Connecticut in relation to socioeconomic and health care access indicators

The purpose of this study of 16,931 black and white Connecticut women diagnosed with invasive breast cancer in 1988–1995 was to examine survival in relation to surrogate or proxy indicators of both socioeconomic status (SES) and access to primary care. Patients were followed through 1998, and the risk of death was elevated for the lowest (vs. highest) SES category independent of stage at diagnosis and other characteristics, especially among patients diagnosed before age 65 years. The health care access indicator was not associated with risk of death when other patient characteristics (including the SES variable and stage at diagnosis) were taken into account. Unexplained elevations, relative to the rest of the state, in risk of death were found for patients diagnosed while living in two of the state’s four largest cities.     

The relation of widows' needs and resources to perceived health and depression

The study investigated the relationship of widowhood-related needs and resources to physical health and to depressed affect. Participants were 246 widowed women of all ages, who were widowed from 1 to 7 years, and who were drawn by stratified-random sampling from widows living in urban areas in Israel, and receiving social insurance payments. The findings show that although there was a significant added contribution by resources, the unique contribution of needs to the health and depression variance was generally maintained. Length of widowhood was not related either to health or depression, while widows' age was significantly related to both. The findings suggest that needs, as well as resources are necessary concepts for a fuller understanding of the coping process of widows.     

Trypanosomiasis control in relation to other public health services

The authors describe the aims and principles of trypanosomiasis control and discuss the individual techniques of control and the ways in which these can be channelled through a general rural health service. They argue that, given the circumstances at present prevailing in rural Africa, a broad-based general public health service should be established before specific campaigns for control or eradication of sleeping-sickness, or indeed any other specific diseases, are instituted. They emphasize the necessity of international co-operation for effective trypanomiasis control.     

Bilharziasis control in relation to water resources development in Africa and the Middle East

As part of its world-wide programme for the control of bilharziasis, the World Health Organization has set up a Bilharziasis Advisory Team, composed of an epidemiologist and an engineer, to investigate in different countries the prevalence of the disease and its relationship to irrigation, agriculture and a variety of factors associated with the development of water resources. This paper is an appraisal of the situation in 15 countries in Africa and the Middle East, based largely on surveys conducted by the Bilharziasis Advisory Team in the period 1958-60.     

Trauma,socioeconomic resources,and self-rated health in an ethnically diverse adult cohort

Objectives. To evaluate ethnic group differences in the association between trauma exposure and health status among an ethnically diverse sample originating in Hawai‘i.

Design. Across a 10-year period (1998–2008), participants (N=833) completed five waves of questionnaire assessments. Trauma exposure was measured retrospectively at the most recent assessment (wave 5), socioeconomic resources (educational attainment and employment status) were measured at wave 1, and self-rated health was measured at each of the five waves.

Results. Results indicated that greater exposure to trauma was associated with poorer self-rated health, as were lower educational attainment and lower work status. In addition, there was ethnic group variation in health ratings, as well as in how strongly trauma exposure predicted health status. Specifically, within Filipino American and Native Hawaiian ethnic groups, there was a stronger negative association between trauma exposure and self-rated health.

Conclusion. These results suggest complex interrelations among trauma, ethnicity, socioeconomic status, and physical health. Further understanding these relations may have implications for medical and behavioral interventions in vulnerable populations.     

Anthropometric measures in relation to Schistosomiasis mansoni and socioeconomic variables

A cross-sectional study of anthropometric measures and their association with socioeconomic variables, infection by Schistosoma mansoni, intensity of infection and splenomegaly was carried out in an endemic area for schistosomiasis in Brazil (Comercinho), using multiple logistic regression methods. Eighty-seven per cent of all 1.5-14.4 year-old children in the area participated in the study. Children below the 5th percentile (USA Ten State Survey) for height-for-age, weight-for-age and arm muscle area-for-age were compared to those greater than the 5th percentile. There was no association between low anthropometric measures and schistosomiasis or socioeconomic variables in children under five years of age. For the 4.4-14.4 year-old children, poor condition of the heads of family and poorer housing were independently associated with low height and arm muscle area. Heavy excretion of S. mansoni eggs (greater than or equal to 500 epg) was related to low height, and splenomegaly was the variable which showed the strongest association with low height, weight and arm muscle area (odds ratios adjusted for socioeconomic variables were 6.4, 3.5 and 3.7 respectively). This indicates that there is a biological component for low anthropometric measures in the severe form of schistosomiasis and this reinforces the need for public health measures to prevent the development of splenomegalies in endemic areas.     

Geographic variation in sarcoidosis in South Carolina: its relation to socioeconomic status and health care indicators.

Geographic patterns of sarcoidosis have been detected and studied on a global scale. However, the associations between these disease patterns and population characteristics have not been determined. The authors studied the geographic pattern of sarcoidosis in South Carolina and its relation to socioeconomic status (SES) and health status indicators. Hospitalization rates for the period 1985-1995 were used as geographic indicators of sarcoidosis. Rates were assessed for the 46 counties in South Carolina, adjusting for differences in SES, availability/accessibility of health care, diagnostic practices, and hospital utilization. Patterns in geographic variation were assessed based on physiographic characteristics and proximity to the Atlantic coastline. Significant variation was identified with an increase in sarcoidosis rates proximal to the Atlantic coastline. Population characteristics were identified that appeared to explain regional variation in sarcoidosis in Caucasians; however, regression analysis was unable to explain the regional differences in disease distribution by variation in SES, diagnostic practices, accessibility/availability, or hospital utilization in African Americans. These results suggest that the development of sarcoidosis is associated with a geographically linked risk factor in African Americans. This work supports the need for additional studies that will identify this risk factor(s).     

Lifetime socioeconomic position in relation to onset of perimenopause

STUDY OBJECTIVE: To assess the association between lifetime socioeconomic position and onset of perimenopause. DESIGN: Prospective cohort study. SETTING: Boston, Massachusetts. PARTICIPANTS: 603 premenopausal women aged 36-45 years at baseline who completed a cross sectional survey on childhood and adult socioeconomic position. MAIN OUTCOME MEASURES: Time to perimenopause, defined as time in months from baseline interview to a woman's report of (1) an absolute change of at least seven days in menstrual cycle length from baseline or subjective report of menstrual irregularity; (2) a change in menstrual flow amount or duration; or (3) cessation of periods for at least three months, whichever came first. Main results: Incidence of perimenopause was 1.75 times higher (95%CI 1.10 to 2.79) and median age at onset was 1.2 years younger (44.7 v 45.9 years) for women reporting childhood and adult economic distress compared with women reporting no lifetime economic distress. After adjustment for age, race/ethnicity, age at menarche, parity, oral contraceptive use, family history of early menopause, depression, smoking, and body mass index, the association weakened (incidence rate ratio (IRR)=1.59; 95%CI 0.97 to 2.61). Inverse associations were observed for most, but not all, measures of educational level. Measures of current household income were not associated with risk of perimenopause. CONCLUSIONS: This study suggests that adverse socioeconomic conditions across the lifespan, when measured in terms of economic hardship and low educational attainment, may be associated with an increased rate of entry into perimenopause.     

Dual source support and control at work in relation to poor health

BACKGROUND AND AIM: Social support and decision authority in relation to health has been examined in extensive research. However, research on the role of different constellations of support sources is conspicuously lacking. The aim of the present study is to describe the health of employees in eight contrasting situations that differ with regard to support from superiors and from workmates and with regard to decision authority. Men and women were studied separately. STUDY SAMPLE AND METHODS: A large sample of Swedish employees (n = 53,371, after exclusion of supervisors) who participated in a national work environment survey was utilized. In addition prospective long-term sick leave data (60 days or more during the 12 months after questionnaire completion) were collected from the national insurance register. RESULTS: Employees who reported below median decision authority had higher prevalence of pains after work and general physical symptoms as well as a higher incidence of long-term sick leave than those with higher decision authority in all subgroups. Those with good support from both workmates and superiors had lower symptom prevalence and long-term sick leave incidence than those with poor support. The groups with either poor support from superiors or from workmates were in an intermediate category with regard to symptom prevalence. The group with good support from superiors but weak support from workmates, however, had as high long-term sick leave incidence as the group with poor support from both superiors and workmates. The patterns were similar for men and women. CONCLUSION: Long-term sick leave was related mainly to poor support from workmates. Prevalence of symptoms, on the other hand, was related to both sources of support and absence of both sources was associated with particularly high prevalence of physical symptoms. This illustrates that it is meaningful to separate the social support sources.     

Socioeconomic position and self-rated health: the contribution of childhood socioeconomic circumstances, adult socioeconomic status, and material resources

OBJECTIVES: We examined socioeconomic inequalities in self-rated health by analyzing indicators of childhood socioeconomic circumstances, adult socioeconomic position, and current material resources. METHODS: We collected data on middle-aged adults employed by the City of Helsinki (n=8970; 67% response rate). Associations between 7 socioeconomic indicators and health self-ratings of less than "good" were examined with sequential logistic regression models. RESULTS: After adjustment for age, each socioeconomic indicator was inversely associated with self-rated health. Childhood economic difficulties, but not parental education, were associated with health independently of all other socioeconomic indicators. The associations of respondents' own education and occupational class with health remained when adjusted for other socioeconomic indicators. Home ownership and economic difficulties, but not household income, were the material indicators associated with health after full adjustment. CONCLUSIONS: Own education and occupational class showed consistent associations with health, but the association with income disappeared after adjustment for other socioeconomic indicators. The effect of parental education on health was mediated by the respondent's own education. Both childhood and adulthood economic difficulties showed clear associations with health and with conventional socioeconomic indicators.     

Time perspective and socioeconomic status: A link to socioeconomic disparities in health?

Time perspective is a measure of the degree to which one's thinking is motivated by considerations of the future, present, or past. Time perspective has been proposed as a potential mediator of socioeconomic disparities in health because it has been associated with health behaviors and is presumed to vary with socioeconomic status. In this cross-sectional community-based survey of respondents recruited from hair salons and barber shops in a suburb of Washington DC, we examined the association between time perspective and both education level and occupation. We asked participants (N = 525) to complete a questionnaire that included three subscales (future, present-fatalistic, and present-hedonistic) of the Zimbardo Time Perspective Inventory. Participants with more formal education and those with professional occupations had higher scores on the future time perspective subscale, and lower scores on the present-fatalistic subscale, than participants with less formal education or a non-professional occupation. Present-fatalistic scores were also higher among participants whose parents had less formal education. Present-hedonistic scores were not associated with either education level or professional occupation. Time perspective scores were not independently associated with the likelihood of obesity, smoking, or exercise. In this community sample, future time perspective was associated with current socioeconomic status, and past-fatalistic time perspective was associated with both current and childhood socioeconomic status.     

Social determinants of health: a veil that hides socioeconomic position and its relation with health

The emergence of theoretical models of social determinants of health has added conceptual ambiguity to the understanding of social inequalities in health, as it is often not possible to clearly distinguish between socioeconomic position and these determinants. Whether the existence of social inequalities in health is based on differences in health or on differences in social determinants of health that are systematically associated with socioeconomic position, policymakers should be clearly informed of the importance of socioeconomic position for health. Thus, the following three basic requirements are proposed: to reach a consensus about the dimensions that reflect socioeconomic position; to agree about what are to be considered the social determinants of health and whether or not these determinants are a construct that can be distinguished from socioeconomic position; and finally, to establish which dimensions and measures of socioeconomic position are most appropriate for the evaluation of interventions that aim to reduce these inequalities.     

Hospital injury rates in relation to socioeconomic status and working conditions

Objectives

To describe the risk of work injury by socioeconomic status (SES) in hospital workers, and to assess whether SES gradient in injury risk is explained by differences in psychosocial, ergonomic or organisational factors at work.

Methods

Workforce rosters and Occupational Safety and Health Administration injury logs for a 5‐year period were obtained from two hospitals in Massachusetts. Job titles were classified into five SES strata on the basis of educational requirements and responsibilities: administrators, professionals, semiprofessionals, skilled and semiskilled workers. 13 selected psychosocial, ergonomic and organisational exposures were assigned to the hospital jobs through the national O*NET database. Rates of injury were analysed as frequency records using the Poisson regression, with job title as the unit of analysis. The risk of injury was modelled using SES alone, each exposure variable alone and then each exposure variable in combination with SES.

Results

An overall annual injury rate of 7.2 per 100 full‐time workers was estimated for the two hospitals combined. All SES strata except professionals showed a significant excess risk of injury compared with the highest SES category (administrators); the risk was highest among semiskilled workers (RR 5.3, p<0.001), followed by nurses (RR 3.7, p<0.001), semiprofessionals (RR 2.9, p = 0.006) and skilled workers (RR 2.6, p = 0.01). The risk of injury was significantly associated with each exposure considered except pause frequency. When workplace exposures were introduced in the regression model together with SES, four remained significant predictors of the risk of injury (decision latitude, supervisor support, force exertion and temperature extremes), whereas the RR related to SES was strongly reduced in all strata, except professionals.

Conclusions

A strong gradient in the risk of injury by SES was reported in a sample population of hospital workers, which was greatly attenuated by adjusting for psychosocial and ergonomic workplace exposures, indicating that a large proportion of that gradient can be explained by differences in working conditions.Main indicators of socioeconomic status (SES) include education, income and occupational class (position in hierarchy).¹ These variables tend to be highly correlated empirically and there is little consensus on which indicator would represent a more valid measure of SES.^2,3Two main theoretical approaches are present in the sociological literature, one considering social stratification due to inequalities in resources distribution and the other due to inequalities in power distribution. The first one identifies social status with social prestige, which would be best described by the access individuals have to limited resources in society, such as goods, services and knowledge.¹ Researchers adopting this theoretical model have mainly used educational attainment or social prestige associated with occupation as measures of SES, because of their direct or indirect influence on access to all these types of resources. According to the second approach, the social status of individuals is best represented by their economic and political power in society, which would be the actual determinant of the distribution of resources. In this view, power is intended as control over the means of production, investments, decision making, other people''s work and one''s own work.⁴ The SES indicator mostly used by this line of research is occupational social class, constructed by reclassifying occupations on the basis of the different aspects of control over work.Although educational level and occupational class are in general strongly correlated, some studies have found them to exert independent effects on mortality and morbidity in multivariate analyses,^2,5,6 suggesting that using either SES classification alone probably results in some misclassification of the social position of individuals. Other authors have stressed the importance of developing more complete SES indicators, which should include different social features, such as social network, income and wealth, apart from occupation and education.^3,7,8Occurrence of injury at work is higher in those with lower education^9,10,11 and lower occupational class.¹² This inverse relationship has been attributed largely to the fact that people in higher SES strata are mainly employed in jobs with less hazardous working conditions. Many of the known risk factors for occupational injury are in fact predominant in lower status jobs; these include ergonomic exposures such as high physical workload, lifting and bending,^11,13,14,15 psychosocial,^10,16 and organisational features such as shiftwork, understaffing, overcrowding, work pressure, overtime level, safety climate and subcontracted work.^{10,17,18,19,20}However, it has also been suggested that lower education could act as an independent risk factor, through lower risk perception, which could lead to unsafe work practices,^21,22 or through less access to information on hazardous jobs.²³ Other individual risk factors, not apparently related to the workplace, include exercise level,^24,25 marital status,¹⁸ smoking,^24,26 family conflicts,¹⁸ stressful life events²⁷ and daily hassles.²⁸ Although some of these may also show a socioeconomic gradient, it is not clear that they exercise causal effects on workplace injury that are independent of occupational conditions.The healthcare sector is one of the industries in the US at highest risk, with yearly rates of 9.7 recordable injury and illness cases per 100 workers in hospitals and 12.6 in nursing homes.²⁹ There were almost 14 million healthcare workers in 2003, representing nearly 10% of the US working population, with a substantial proportion of women (more than 75% of the workers) and racial/ethnic minorities (30% in the US).³⁰ Of these, almost six million were employed in hospitals.³⁰ The wide range of jobs, such as nurses, aides, laundry and food workers, health technicians, clerks, administrators, doctors and clinical scientists, involve very different socioeconomic positions and working conditions. This highly diverse workforce offers an opportunity, at least in principle, to disentangle the respective influences of SES, working conditions and demographic characteristics on injury rates. For this purpose, a new SES classification specific for the healthcare industry, which was explicitly based on power distribution—namely, the responsibility level typical of each job title, but also included education as a prestige‐based measure was developed.Therefore, the objectives of this study were:

• to evaluate the predictive value of SES on the risk of Occupational Safety & Health Administration (OSHA)‐recordable workplace injuries in a sample of the Massachusetts hospital workforce and
• to assess whether any differences in the risk of injury by SES could be explained by psychosocial, physical or organisational factors at work.

     

Deliberation to enhance awareness of and prioritize socioeconomic interventions for health

Health disparities are, to a large extent, the result of socio-economic factors that cannot be entirely mitigated through the health care system. While an array of social services are thought to be necessary to address the social determinants of health, budget constraints, particularly in difficult economic times, limit the availability of such services. It is therefore necessary to prioritize interventions through some fair process. While it might be appropriate to engage in public deliberation to set priorities, doing so requires that the public accept such a deliberative process and appreciate the social determinants of health. We therefore analyzed the results of a study in which groups deliberated to prioritize socio-economic interventions to examine whether these two requirements can possibly be met and to explore the basis for their priorities. A total of 431 residents of Washington, D.C. with incomes under 200% of the federal poverty threshold participated in 43 groups to engage in a hypothetical exercise to prioritize interventions designed to ameliorate the social determinants of health within the constraints of a limited budget. Findings from pre- and post-exercise questionnaires demonstrate that the priority setting exercise was perceived as a fair deliberative process, and that following the deliberation, participants became more likely to agree that a broad number of determinants contribute to their health. Qualitative analysis of the group discussions indicate that participants prioritized interventions that would provide for basic necessities and improve community conditions, while at the same time addressing more macro-structural factors such as homelessness and unemployment. We conclude that engaging small groups in deliberation about ways to address the social determinants of health can both change participant attitudes and yield informed priorities that might guide public policy aimed at most affordably reducing health disparities.     

The relation of socioeconomic status to oral and pharyngeal cancer

We assessed the relation between socioeconomic status and risk of oropharyngeal cancer in a population-based interview study of 762 male cases and 837 male controls in four areas of the United States. Three primary indicators of socioeconomic status were evaluated: education, occupational status, and percentage of potential working life spent in employment. With adjustment for the effects of established risk factors, such as use of tobacco products, alcohol consumption, and poor dentition, a relatively low percentage of years worked was also a risk factor. Educational attainment and occupational status were not independently related to risk of oropharyngeal cancer. These results are consistent with the hypothesis that behaviors that lead to social instability, and/or social instability itself, are linked to an increased risk of oral and pharyngeal cancers.     

Healthy eating index in southern brazilian older adults and its association with socioeconomic,behavioral and health characteristics

Objective  

The objective of this study was to assess factors associated with the diet quality of brazilian older adults.