Welfare state matters: a typological multilevel analysis of wealthy countries

Building on the social science literature, we hypothesized that population health indicators in wealthy industrialized countries are 'clustered' around welfare state regime types. We tested this hypothesis during a period of welfare state expansion from 1960 to 1994. We categorized data from 19 wealthy countries into 4 different types of welfare state regimes (Social Democratic, Christian Democratic, Liberal and Wage Earner Welfare States). Outcome variables were the infant mortality rate (IMR) and the low birth weight rate (LBW), obtained from the Organization of Economic Co-operation and Development (OECD) Health Data 2000 and from the United Nations Common Statistical Database (UNCSD). A two-level multilevel model was constructed, and fixed effects of welfare state were tested. Through the 39 years analyzed, Social Democratic countries exhibited a significantly better population health status, i.e., lower infant mortality rate and low birth weight rate, compared to other countries. Twenty percent of the difference in infant mortality rate among countries could be explained by the type of welfare state, and about 10% for low birth weight rate. The gap between Social Democracies and other countries widened over the 1990s. Our results confirm that countries exhibit distinctive levels of population health by welfare regime types even when adjusted by the level of economic development (GDP per capita) and intra-country correlations. It implies that countries, as groups, adopt similar policies or through any other ways, achieve similar level of health status. Proposed mechanisms of such process and suggestions for future research directions are presented in the discussion.     

Changes in socioeconomic determinants of health: comparing the effect of social and economic indicators through European welfare state regimes

Aim

This study is aimed at comparing the effect of different measures of socioeconomic status on self-rated health throughout European welfare state regimes during the period 2002–2008, in order to study how diverse socioeconomic inequalities can vary our health over time.

Subjects and methods

This study uses the European Social Survey to compare the impact of three specific socioeconomic measures (income, education and occupational status) on self-rated health.

Results

The main finding to be highlighted is that the importance of education-related inequalities surpasses differences in income and occupational status, especially in southern and eastern countries. The relationship between income and self-rated health is stronger in liberal and social-democratic regimes, where labour market regulation is characterized by its flexibility and high liberalization. The impact of occupational status is moderate among liberal, social-democratic and conservative regimes, but lower in southern and eastern ones.

Conclusion

These findings support the existence of a contextual effect among welfare states that varies the impact of social and economic indicators in self-rated health over time.     

Wage inequality, the health system, and infant mortality in wealthy industrialized countries, 1970-1996

This pooled, cross-sectional, time-series study assesses the impact of health system variables on the relationship between wage inequality and infant mortality in 19 OECD countries over the period 1970-1996. Data are derived from the OECD, World Value Surveys, Luxembourg Income Study, and political economy databases. Analyses include Pearson correlation and fixed-effects multivariate regression. In year-specific and time-series analyses, the Theil measure of wage inequality (based on industrial sector wages) is positively and statistically significantly associated with infant mortality rates--even while controlling for GDP per capita. Health system variables--in particular the method of healthcare financing and the supply of physicians--significantly attenuated the effect of wage inequality on infant mortality. In fixed effects multivariate regression models controlling for GDP per capita and wage inequality, variables generally associated with better health include income per capita, the method of healthcare financing, and physicians per 1000 population. Alcohol consumption, the proportion of the population in unions, and government expenditures on health were associated with poorer health outcomes. Ambiguous effects were seen for the consumer price index, unemployment rates, the openness of the economy, and voting rates. This study provides international evidence for the impact of wage inequalities on infant mortality. Results suggest that improving aspects of the healthcare system may be one way to partially compensate for the negative effects of social inequalities on population health.     

Community indicators of child health

Summary Indicators of health in child populations are critically reviewed and the potential for routinely collected morbidity and life quality data discussed. A short list of currently available, routinely collected child health data is proposed which, if available for all European countries, would form the basis of a useable and comparable European child health data base. A European consensus group on child health indicators is proposed and further research into morbidity and life quality measures relevant to children recommended.

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Zusammenfassung Bestehende Indikatoren für Gesundheit bei Kindern werden kritisch überprüft und die Möglichkeiten für routinemässig erhobene Daten über Morbidität und Lebensqualität werden diskutiert. Eine kurze Liste von momentan erhältlichen regelmässig erhobenen Daten über Gesundheit von Kindern wird vorgestellt, die-vorausgesetzt sie ist für alle europäischen Länder vorhanden die Grundlage für eine brauchbare und vergleichbare Datenbank für Gesundheitsdaten von Kindern in Europa bilden wird. Vorgeschlagen wird eine europäische Studiengruppe zur Koordination von Indikatoren über Gesundheit von Kindern und weitere Forschungsprojekte über Morbidität und Lebensqualität werden empfohlen.

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Résumé Les indicateurs permettant de juger l'état de santé d'une population d'enfants sont examinés de manière critique et les possibilités de collecter des données de morbidité et de qualité de vie sont discutées. Une courte liste de données actuellement collectées de routine est présentée qui, si elle devenait disponible dans tous les pays européens, formerait le socle d'une base de données européenne, utilisable et comparable, concernant la santé des enfants. La création d'un groupe de consensus européen sur les indicateurs de santé chez l'enfant est proposée, et de nouvelles recherches sur la mesure de la morbidité et de la qualité de vie sont recommandées.

     

Children as a zone of peace: A framework for promoting child health and welfare in developing countries

Abstract

Children as a Zone of Peace (CZOP) is a strategy that aims to provide humanitarian aid during conflict by prioritising the rights of children. This desk review considers CZOP implementation in countries across five regions of the world. The strategy is found to have achieved results both in terms of stated objectives, such as immunisation coverage and disease control, and other benefits, such as a break from violence and a sense of national purpose. Implementation challenges relate to the political and logistical realities of conflict. Five elements are identified for successful execution of CZOP: (1) an initial proposal from a respected third party; (2) high level negotiations; (3) resourceful planning; (4) targeted communication; and (5) broad partnerships among diverse stakeholders. The CZOP is found to have proven value as a basis for negotiation and humanitarian intervention. Further potential is suggested, both in conflict settings and non-conflict environments, where children's rights are not being met.     

Sociocultural determinants of infant and child mortality in Turkey

This paper is an attempt to review and integrate international and Turkish research on infant and child mortality. Recent research and multivariate analyses in African, Latin American and Asian countries have revealed that in many countries mother's education is a powerful predictor of child survival. The present review of research in Turkey has indicated that urban/rural and regional differentials in infant mortality have been clearly established as by-products of fertility, contraception, and health surveys covering nationally representative samples. However, there are only a few multivariate explanatory models of infant/child mortality in Turkey to isolate and measure the effects of mother's education in relation to other variables. Nevertheless, existing studies in Turkey seem to suggest that mother's and father's education might link socio-economic, psychocultural, and biomedical variables with each other at community, household, and individual levels, providing clue for the formulation of future research designs and policy decisions.     

The determinants of infant and child mortality in Tanzania

This paper investigates the determinants of infant and child mortality in Tanzania using the 1991/92 Tanzania Demographic and Health Survey. A hazards model is used to assess the relative effect of the variables hypothesized to influence under-five mortality. Short birth intervals, teenage pregnancies and previous child deaths are associated with increased risk of death. The Government of the United Republic of Tanzania should therefore maintain its commitment to encouraging women to space their births at least two years apart and delay childbearing beyond the teenage years. Further, this study shows that there is a remarkable lack of infant and child mortality differentials by socioeconomic subgroups of the population, which may reflect post-independence health policy and development strategies. Whilst lack of socioeconomic differentials can be considered an achievement of government policies, mortality remains high so there is still a long way to go before Tanzania achieves its stated goal of 'Health for All'.     

The welfare state: a glossary for public health

Recently, there has been a surge in comparative social epidemiology, and a sizeable amount of this has examined the relation between different aspects of the welfare state and population health. Such research draws strongly, though usually implicitly, on welfare state theories and concepts. In this glossary, we explicitly define these concepts in order to enable more researchers, practitioners and policy-makers to engage with and contribute to this exciting and fruitful area of public health research.     

Occupational health indicators for tracking work-related health effects and their determinants

Experts in various fields of public health have developed proposed indicators to enhance public health surveillance. These indicators have been published in Indicators for Chronic Disease Surveillance, June 2000, State Injury Indicator Report January 2002; and Draft Environmental Public Health Indicators, August 2002. The indicators are measures of health or factors associated with health in specified populations.     

The determinants of infant and child morbidity in Lagos,Nigeria

Analysis of the structure of real morbidity among children in Lagos, Nigeria, reveals that the leading diseases were of hygienic, nutritional and perinatal origin. These diseases were highly concentrated in infancy and early childhood; in the case of the former, the concentration was greater among boys than girls. During the 1970s, a decline is noticed in the frequency of infective and parasitic diseases particularly among male infants. Simultaneously, a slightly rising trend of diseases related to birth complications and perinatal nature afflicting predominantly early infancy occurred, off-setting, to some extent, the effect of the diminishing trend in infective diseases. The rising trend of perinatal diseases should be seen in conjunction with a likely increase in gravidity of women and the resultant increase of pregnancies and birth complications, which affected the health of the mother as well as that of the child.The findings seem to suggest that although both medical and non-medical factors contributed to the change in morbidity pattern in the decade 1968–1978, the role of factors of socio-economic nature was significant. The implication is that without socio-economic epidemiology, biomedical epidemiology could make a limited contribution to the reduction of morbidity.     

Spatial distribution and self-correlation of mother and child health indicators in the state of Parana, Brazil

Aiming to analyze the spatial distribution and self-correlation of data of mother-child health in Parana, Brazil, variables were selected from the Information System on Live Births, grouped into socioeconomic indicators: teenage mother, low education, high parity, race/color black of newborn; healthcare indicators: the prenatal coverage, prematurity and cesarean delivery and result indicators: low birth weight. The indicators were distributed in thematic maps and spatial self-correlation was measured using Moran's index that quantifies the degree of self-correlation. There was significant spatial self-correlation of teenage mother, low education and high parity of the "high-high" type in the macro-regions East, Campos Gerais and South; of low coverage of antenatal care in Campos Gerais, Central-south and North and of cesarean delivery in the Northwest. Elevated proportions of indicators of risk to the health of mother and child were found in the regions East, Campos Gerais and South. These results support the evaluation and planning of health services.     

Public health surveillance of fatal child maltreatment: analysis of 3 state programs

Objectives. We sought to describe approaches to surveillance of fatal child maltreatment and to identify options for improving case ascertainment.Methods. Three states—California, Michigan, and Rhode Island—used multiple data sources for surveillance. Potential cases were identified, operational definitions were applied, and the number of maltreatment deaths was determined.Results. These programs identified 258 maltreatment deaths in California, 192 in Michigan, and 60 in Rhode Island. Corresponding maltreatment fatality rates ranged from 2.5 per 100000 population in Michigan to 8.8 in Rhode Island. Most deaths were identified by child death review teams in Rhode Island (98%), Uniform Crime Reports in California (56%), and child welfare agency data in Michigan (44%). Compared with the total number of cases identified, child welfare agency (the official source for maltreatment reports) and death certificate data underascertain child maltreatment deaths by 55% to 76% and 80% to 90%, respectively. In all 3 states, more than 90% of cases ascertained could be identified by combining 2 data sources.Conclusions. No single data source was adequate for thorough surveillance of fatal child maltreatment, but combining just 2 sources substantially increased case ascertainment. The child death review team process may be the most promising surveillance approach.Child maltreatment causes a significant number of fatalities in the United States, and accurately determining the number of maltreatment-related deaths each year remains a challenge. With data from child protective services agencies, the National Child Abuse and Neglect Data System estimated there were nearly 1500 child abuse–related or neglect-related deaths in 2004 (2.0 per 100 000 children).1 However, child protective services data are known to underestimate maltreatment deaths for a variety of reasons including difficulties identifying, investigating, and reporting deaths to child protective services; lack of standard definitions of child maltreatment; and differing legal standards for substantiation of maltreatment.2^,3In the United States, a death certificate is the official record of death. Death certificates include a determination of the cause and manner of death and are often used to summarize the mortality burden of injuries and diseases. It is, however, well documented that these vital records underestimate the magnitude of fatal child maltreatment.3^–6 In fact, 50% to 60% of all child maltreatment deaths are not identified as such by death certificates,3^,5^,6 with 1 report estimating that 85% of deaths related to child maltreatment are recorded on the death certificate as attributable to other causes.7The combination of data from multiple sources to obtain more accurate identification of individuals with the condition under surveillance (i.e., case ascertainment) has enhanced public health surveillance of injuries and violence8^–11 and has shown promise as a method for obtaining more accurate estimates of mortality related to child maltreatment.3^,6 In September 2001, the Centers for Disease Control and Prevention (CDC) funded programs in 3 states—California, Michigan, and Rhode Island—to develop and evaluate public health surveillance of fatal child maltreatment through the use of multiple data sources for case ascertainment. We describe the approaches taken in these programs and summarize the epidemiology of fatal child maltreatment. Because underascertainment of fatal child maltreatment by both child protective services and death certificate data are well documented, we focused on the relative utility of additional data sources available for surveillance and explored various options for improving case ascertainment. Four of the authors took part in the state programs (T. M. C. and V. J. P. in Michigan, S. J. W. in California, and W. V-O. in Rhode Island). By summarizing options for surveillance based on their experiences, we hope to provide useful information to other states interested in establishing surveillance for fatal child maltreatment.