Does area-based social capital matter for the health of Australians? A multilevel analysis of self-rated health in Tasmania

BACKGROUND: Material circumstances and collective psychosocial processes have been invoked as potential explanations for socioeconomic inequalities in health; and, linking social capital has been proposed as a way of reconciling these apparently opposing explanations. METHODS: We conducted multilevel logistic regression of self-rated health (fair or poor vs excellent, very good, or good) on 14 495 individuals living within 41 statistical local areas who were respondents to the 1998 Tasmanian Healthy Communities Study. We modelled the effects of area-level socioeconomic disadvantage and social capital (neighbourhood integration, neighbourhood alienation, neighbourhood safety, social trust, trust in public/private institutions, and political participation), and adjusted for the effects of individual characteristics. RESULTS: Area-level socioeconomic disadvantage was associated with poor self-rated health (beta = 0.0937, P < 0.001) an effect that was attenuated, but remained significant, after adjusting for individual characteristics (beta = 0.0419, P < 0.001). Social trust was associated with a reduction in poor self-rated health (beta = -0.0501, p = 0.008) and remained significant when individual characteristics (beta = -0.0398, P = 0.005) were included. Political participation was non-significant in the unadjusted model but became significant when adjusted for individual characteristics (beta = -0.2557, P = 0.045). The effects of social trust and political participation were attenuated and became non-significant when area-level socioeconomic disadvantage was included. CONCLUSION: Area-based socioeconomic disadvantage is a determinant of self-rated health in Tasmania, but we did not find an independent effect of area-level social capital. These findings suggest that in Tasmania investments in improving the material circumstances in which people live are likely to lead to greater improvements in population health than attempts to increase area-level social capital.     

An analysis of perceived access to health care in Europe: How universal is universal coverage?

The objective of this paper is to examine variations in perceptions of access to health care across and within 29 European countries. Using data from the 2008 round of the European Social Survey, we investigate the likelihood of an individual perceiving that they will experience difficulties accessing health care in the next 12 months, should they need it (N = 51,835). We find that despite most European countries having mandates for universal health coverage, individuals who are low income, in poor health, lack citizenship in the country where they reside, 20–30 years old, unemployed and/or female have systematically greater odds of feeling unable to access care. Focusing on the role of income, we find that while there is a strong association between low income and perceived access barriers across countries, within many countries, perceptions of difficulties accessing care are not concentrated uniquely among low-income groups. This implies that factors that affect all income groups, such as poor quality care and long waiting times may serve as important barriers to access in these countries. Despite commitments to move towards universal health coverage in Europe, our results suggest that there is still significant heterogeneity among individuals’ perceptions of access and important barriers to accessing health care.     

Do welfare regimes matter for oral health? A multilevel analysis of European countries

While the role of political factors on population health has recently received increasing attention, relatively little is known in that respect for oral health. We aimed to assess the influence of welfare state regimes on the variation in adult oral health between European countries, building on the existing literature by using a multilevel approach. Our analysis also explored how the oral health of people with different socioeconomic position was influenced by living in five different welfare state regimes. We analysed data from the Eurobarometer survey 2009. The main outcome was no functional dentition, defined as having fewer than 20 natural teeth. Age, gender, marital status, education and occupational social class were the individual-level explanatory variables, while welfare regimes, GDP per capita and GDP annual growth were the country-level variables. Multilevel logistic regression models were fitted with individuals nested within countries. Results revealed that country-level characteristics accounted for 8.1% of the variation in oral health. Adults in all welfare regimes were more likely to have poorer oral health than their counterparts in the Scandinavian regime, with those in Eastern countries being 6.94 (95% CI: 3.62–12.67) times as likely to lack a functional dentition as adults in Scandinavian countries. The variation at country-level reduced significantly when welfare regimes were introduced into the model (from 0.57 to 0.16; 72% reduction), indicating that welfare regime explained much of the variation in the outcome among European countries. Finally, adults with less education and lower occupational level were more likely to have no functional dentition, especially in the Eastern and Bismarckian welfare regimes.     

Does increased gender equality lead to a convergence of health outcomes for men and women? A study of Swedish municipalities

This study examines associations between indicators of gender equality and public health. We compare Swedish municipalities on nine indicators in both the private and public sphere, and an additive index, and study the correlations with indicators of morbidity and mortality. The hypothesis that a higher level of gender equality is associated with a convergence of health outcomes (life expectancy, sickness absence) between men and women was supported for equality of part-time employment, managerial positions and economic resources for morbidity, and for temporary parental leave for mortality. Our main finding is that gender equality was generally correlated with poorer health for both men and women. Our conclusions are tentative due to the methodological uncertainties. However, the results suggest an unfortunate trade-off between gender equality as we know it and public health. Sweden may have reached a critical point where further one-sided expansion by women into traditionally male roles, spheres and activities will not lead to positive health effects unless men also significantly alter their behaviour. Negative effects of this unfinished equality might be found both for women, who have become more burdened, and men, who as a group have lost many of their old privileges. We propose that this contention be confronted and discussed by policymakers, researchers and others. Further studies are also needed to corroborate or dispute these findings.     

Saturday night fever? Reasons for referral from health centres to hospitals during weekends in Finland

OBJECTIVE: We aimed to examine the reasons for referral from health centres to hospitals during the weekend in Finland. METHOD: We conducted a survey of all referrals from general practice on two weekends (30 November to 6 December 1992 and 28 November to 4 December 1994) in central and northern Finland, which covered 72% of the area of the country and one-third of the population. The participants were 178 GPs from public health centres and who made 530 referrals during these weekends. The outcome measures were reasons for referrals by ICPC codes with respect to the characteristics of patients, GPs and practices. RESULTS: During the weekends studied, 530 patients were referred from out-of-hours work. More male (53%) than female patients (47%) were referred. Out of a total of 530 patients, 213 (40%) were referred to surgery, 139 (26%) to internal medicine, 48 (9%) paediatric medicine, 32 (6%) to neurology, 28 (5%) to both ear, nose and throat (ENT) and psychiatry, 25 (5%) to gynaecology and 18 (4%) to other specialities (ophthalmology, lung disease and cancer departments). Fractures requiring surgery, angina pectoris for which patients were sent to internal medicine and stroke for which patients were sent to other specialities were the most commonly reported reasons for referral. Male patients were referred 12 times more often than females for arrhythmia (atrial fibrillation or tachyarrhythmia); males experienced dislocations eight times more often and fractures three times more often than females. CONCLUSION: Our results point out the need to train GPs about those complaints that most often require a referral to specialist care during the weekend. Future research should focus on those patients who are responsible for the huge gender gap of reasons for referral during weekends.     

Is universal health coverage the practical expression of the right to health care?

Background

Public stigma against family members of people with mental illness is a negative attitude by the public which blame family members for the mental illness of their relatives. Family stigma can result in self social restrictions, delay in treatment seeking and poor quality of life. This study aimed at investigating the degree and correlates of family stigma.

Methods

A quantitative cross-sectional house to house survey was conducted among 845 randomly selected urban and rural community members in the Gilgel Gibe Field Research Center, Southwest Ethiopia. An interviewer administered and pre-tested questionnaire adapted from other studies was used to measure the degree of family stigma and to determine its correlates. Data entry was done by using EPI-DATA and the analysis was performed using STATA software. Unadjusted and adjusted linear regression analysis was done to identify the correlates of family stigma.

Results

Among the total 845 respondents, 81.18% were female. On a range of 1 to 5 score, the mean family stigma score was 2.16 (±0.49). In a multivariate analysis, rural residents had significantly higher stigma scores (std. β?=?0.43, P?<?0.001) than urban residents. As the number of perceived signs (std. β?=?-0.07, P?<?0.05), perceived supernatural (std. β?=?-0.12, P?<?0.01) and psychosocial and biological (std. β?=?-0.11, P?<?0.01) explanations of mental illness increased, the stigma scores decreased significantly. High supernatural explanation of mental illness was significantly correlated with lower stigma among individuals with lower level of exposure to people with mental illness (PWMI). On the other hand, high exposure to PWMI was significantly associated with lower stigma among respondents who had high education. Stigma scores increased with increasing income among respondents who had lower educational status.

Conclusions

Our findings revealed moderate level of family stigma. Place of residence, perceived signs and explanations of mental illness were independent correlates of public stigma against family members of people with mental illness. Therefore, mental health communication programs to inform explanations and signs of mental illness need to be implemented.     

Is social capital the key to inequalities in health?

There has been vigorous debate between the "social capital" and "neomaterialist" interpretations of the epidemiological evidence regarding socioeconomic determinants of health. We argue that levels of income inequality, social capital, and health in a community may all be consequences of more macrolevel social and economic processes that influence health across the life course. We discuss the many reasons for the prominence of social capital theory, and the potential drawbacks to making social capital a major focus of social policy. Intervening in communities to increase their levels of social capital may be ineffective, create resentment, and overload community resources, and to take such an approach may be to "blame the victim" at the community level while ignoring the health effects of macrolevel social and economic policies.     

A will to health? Drinking,risk and social class

This article explores risk conceptions related to alcohol use among Danes who drink ‘too much’ (based on the National Health Board’s standards for safe drinking). It analyses drinking patterns and risk management strategies among interviewees from different socio-economic backgrounds, and explores the differences between the behaviours and conceptions of these individuals and the risk advice and definitions provided by health agencies. The article shows that people from different socio-economic backgrounds respond differently to the neo-liberal strategy of alcohol risk minimisation, with middle- and upper-class participants being more in tune with the public health ethos of alcohol consumer ‘autonomisation’ and ‘responsibilisation’. Cutting across socio-economic differences, though, are risk conceptions that clash with the public health model of risk prevention. While the risk communication of the health agencies builds on the logic of ‘a will to health’, drinkers at relatively high consumption levels tend to prefer other rationales, associating alcohol use with socialisation, pleasure and relaxation, and defining alcohol risks in terms of ‘addiction’ rather than detrimental health effects. The article contributes to the discussion of the ‘prevention paradox’, showing that rational initiatives at a general population level are not always comprehended as such at the individual level.     

What happens to our ideas? A bibliometric analysis of articles in social work in health care in the 1990s

Scholars spend a considerable amount of time reflecting upon their professional work. When individuals decide to communicate their professional thoughts beyond informal venues, the penultimate expression of their reflection is the peer reviewed journal article. The study reported here entailed a bibliometric analysis of articles appearing in the journal Social Work in Health Care during the 1990s, in order to better understand what happens to our ideas after they appear in a peer reviewed journal article.     

How close have universal health systems come to achieving equity in use of curative services? A systematic review.

Most governments in established market economies have developed universal systems of health care, but these are being increasingly threatened by widespread health sector reforms. Hence, it is more important than ever to monitor the effects of policy changes on the ability of universal systems to achieve their equity goals. This article provides evidence for such monitoring. The authors present the results of a systematic review of equity in use of curative health services in universal systems, together with a critical appraisal of the essential components of studies to address this question. Of the 79 studies identified that addressed the review question, only 26 met the inclusion criteria and adjusted for differential health need across socioeconomic groups. The authors found a pro-rich bias in use of specialist hospital services and a reasonably equitable access to primary health care by different socioeconomic groups. There was a wide inter-study variation in the difference in utilization rates between people of high and low socioeconomic groups. Improvements are needed in the way that equity in universal systems is monitored, with particular attention to how "need" is defined and to the impact on patients of indirect costs.     

How should governments respond to the social determinants of health?

The notion of the social determinants of health is now prominent in international and national health policy discussions. However, action on the social determinants primarily lies outside the sphere of influence of Ministries of Health. Here it is proposed that Ministries of Health use part of their budgets to sponsor initiatives by other government departments that address the social determinants of health, and, in particular, reduce chronic stress or improve individual prospects of healing.     

How much does social capital add to individual health? A survey study of Russians

Some Russians are healthier than others. To what extent does their health vary with involvement or exclusion from social capital networks? The first section reviews alternative theories: human capital as the primary determinant; social capital, whether generic, situation-specific or simply a new label for old measures of social integration; or a composite theory--both human and social capital are major determinants of health. The evidence to test hypotheses consists of individual-level data about self-assessed physical and emotional health from the special-purpose social capital questionnaire used in the 1998 New Russia Barometer survey, a nationwide representative sample of the adult Russian population. Multiple regression analysis shows that on their own human capital and social capital each account for a notable amount of variance in health. When both forms of capital are combined in a composite model, each retains major influence, demonstrating that social capital does make an independent contribution to health. Significant social capital influences include involvement or exclusion from formal and informal networks; friends to rely on when ill; control over one's own life; and trust. Significant human capital influences besides age include subjective social status, gender and income. Regression-based estimates of impact show that social capital increases physical and emotional health more than human capital; together they can easily raise an individual's self-reported health from just below average on a five-point scale to approaching good health.     

Do risk factors explain more of the social gradient in self-reported health when adjusting for baseline health?

BACKGROUND: It has often been debated the extent to which known risk factors explain socio-economic differences in health. While common in mortality studies, few studies of morbidity adjust for baseline health. In this study, we argue that there are sound reasons to do so, and examine whether a set of risk factors explain a larger part of social gradients in men and women's self-rated health (SRH) in Denmark when controlling for previous health. METHODS: We use interval regression models on longitudinal survey data from 1990 and 1995 separately for Danish male and female workers aged 18-59. RESULTS: Large social gradients are found in SRH for both men and women. The included risk factors (smoking, body mass index, high blood pressure and job satisfaction) reduce the educational gradient in SRH by 40% (based on highest versus no education), the wage gradient by 18% and leaves occupational gradients (based on no employment versus white collar workers) unaltered for men. For women, similar gradients are altered by 6 and 22 and 14% in cross-sectional models. Controlling for baseline health 5 years earlier, the risk factors reduce the education, occupation and wage gradients by 45, -15 and 17% for men and by 5, 25 and 15% for women. CONCLUSION: The findings suggest that common risk factors do not explain a larger fraction of social health inequalities in dynamic than in static models of self-reported health.     

Are social comparisons of homes and cars related to psychosocial health?

BACKGROUND: It has been suggested that perceiving oneself to be inferior to those around one is a psychosocial risk factor associated with ill health. The aim of this study was to examine whether negative social comparisons of the worth of two common assets (homes and cars) were related to psychosocial health (i.e. lower self-esteem and mastery, higher anxiety, and depression). METHODS: A postal questionnaire was sent to a random sample of adults in the West of Scotland (sampling from the 1997 electoral roll, response rate was 50%, achieved sample 2838). RESULTS: Having adjusted for socio-demographic variables, rating one's house/flat as worth less than others was associated with lower self-esteem (P < 0.001) and mastery (P < 0.001) and higher depression (P < 0.007) and anxiety (P < 0.012). Rating one's car as worth less than others was not significantly associated with these psychosocial variables. CONCLUSIONS: Our findings lend some support, but only in relation to the home, to the hypothesis that perceiving oneself to be worse off in relation to those around is related to poorer psychosocial health.     

Achieving universal health insurance in Korea: a model for other developing countries?

As developing countries explore alternative methods to provide universal health insurance coverage, one potential model is South Korea. In twelve years (from 1977 to 1989), Korea was able to achieve universal health insurance coverage first by mandating employer based health insurance coverage for medium and large firms and then by establishing regional health insurance systems for small firms, farmers and the self-employed. A government medical aid insurance program was instituted for low income citizens. The specifics of the plan and some of the issues encountered in implementing the plan may be of interest to developing countries who want to achieve universal health insurance while maintaining a significant role for the private sector.