Women's status and child well-being: a state-level analysis

We conducted an ecologic analysis of the relation between women's status and child well-being in the 50 United States. State-level women's status was assessed via four composite indices: women's political participation, economic autonomy, employment and earnings, and reproductive rights. Child well-being was measured via five outcomes: percentage of low birthweight babies, infant mortality, teen mortality, high school dropout rate, and teen birth rate. Higher state-level women's status on all indicators was associated with significantly better state-level child well-being in unadjusted analyses. Several associations remained significant after adjusting for income inequality and state racial composition. Women's political participation was associated with a significantly lower percentage of low birthweight babies (p<.001) and lower teen birth rates (p<.05). Women's employment and earnings was associated with lower infant mortality (p<.05) and teen birth rates (p<.05). More economic and social autonomy for women was associated with better child outcomes on all measures (p<.01 all). Greater reproductive rights were associated with significantly lower infant mortality (p<.01). We conclude that child well-being is worse in states where women have lower political, economic, and social status. Women's status is an important aspect of children's social context which may impact their well-being. Multi-level analyses of the association between state-level women's status and child well-being are needed.     

Women's status and depressive symptoms: a multilevel analysis

The effects of state-level women's status and autonomy on individual-level women's depressive symptoms were examined. We conducted a multi-level analysis of the 1991 longitudinal follow up of the 1988 National Maternal Infant Health Survey (NMIHS), with 7789 women nested within the fifty American states. State-level women's status was assessed by four composite indices measuring women's political participation, economic autonomy, employment & earnings, and reproductive rights. The main outcome measure was symptoms of depression (Center for Epidemiologic Studies Depression Scale, CES-D). The participants were a nationally representative stratified random sample of women in the USA aged between 17 and 40 years old who gave birth to live babies in 1988, were successfully contacted again in 1991 and provided complete information on depressive symptoms. Women who were younger, non-white, not currently married, less educated or had lower household income tended to report higher levels of depressive symptoms. Compared with states ranking low on the employment & earnings index, women residing in states that were high on the same index scored 0.85 points lower on the CES-D (p<0.01). Women who lived in states that were high on the economic autonomy index scored 0.83 points lower in depressive symptoms (p<0.01), compared with women who lived in states low on the same index. Finally, women who resided in states with high reproductive rights scored 0.62 points lower on the CES-D (p<0.05) compared with women who lived in states with lower reproductive rights. Gender inequality appears to contribute to depressive symptoms in women.     

Ecological analysis of the health effects of income inequality in Argentina

OBJECTIVES: Despite a large body of empirical literature, a consensus has not been reached concerning the health effects of income inequality. This study contributes to ongoing debates by examining the robustness of the income inequality-population health relationship in Argentina, using five different income inequality indexes (each sensitive to inequalities in differing parts of the income spectrum) and five measures of population health. STUDY DESIGN: Cross-sectional, ecological study. METHODS: Income and self-reported morbidity data from Argentina's 2001 Encuesta de Condiciones de Vida (Survey of living conditions) were analysed at the provincial level. Provincial rates of male/female life expectancy and infant mortality were drawn from the Instituto Nacional de Estadistica y Censos database. RESULTS: Life expectancy was correlated in the expected direction with provincial-level income inequality (operationalized as the Gini coefficient) for both males (r=-0.55, P<0.01) and females (r=-0.61, P<0.01), but this association was not robust for all five income inequality indexes. In contrast, infant mortality, self-reported poor health and self-reported activity limitation were not correlated with any of the income inequality indexes. CONCLUSIONS: This study adds further complexity to the literature on the health effects of income inequality by highlighting the important effects of operational definitions. Mortality and morbidity data cannot be used as reasonably interchangeable variables (a common practice in this literature), and the choice of income inequality indicator may influence the results.     

Mortality,inequality and race in American cities and states

A number of studies have found that mortality rates are positively correlated with income inequality across the cities and states of the US. We argue that this correlation is confounded by the effects of racial composition. Across states and Metropolitan Statistical Areas (MSAs), the fraction of the population that is black is positively correlated with average white incomes, and negatively correlated with average black incomes. Between-group income inequality is therefore higher where the fraction black is higher, as is income inequality in general. Conditional on the fraction black, neither city nor state mortality rates are correlated with income inequality. Mortality rates are higher where the fraction black is higher, not only because of the mechanical effect of higher black mortality rates and lower black incomes, but because white mortality rates are higher in places where the fraction black is higher. This result is present within census regions, and for all age groups and both sexes (except for boys aged 1-9). It is robust to conditioning on income, education, and (in the MSA results) on state fixed effects. Although it remains unclear why white mortality is related to racial composition, the mechanism working through trust that is often proposed to explain the effects of inequality on health is also consistent with the evidence on racial composition and mortality.     

Socioeconomic inequality in voting participation and self-rated health

OBJECTIVES: This study tested the hypothesis that disparities in political participation across socioeconomic status affect health. Specifically, the association of voting inequality at the state level with individual self-rated health was examined. METHODS: A multilevel study of 279,066 respondents to the Current Population Survey (CPS) was conducted. State-level inequality in voting turnout by socioeconomic status (family income and educational attainment) was derived from November CPS data for 1990, 1992, 1994, and 1996. RESULTS: Individuals living in the states with the highest voting inequality had an odds ratio of fair/poor self-rated health of 1.43 (95% confidence interval [CI] = 1.22, 1.68) compared with individuals living in the states with the lowest voting inequality. This odds ratio decreased to 1.34 (95% CI = 1.14, 1.56) when state income inequality was added and to 1.27 (95% CI = 1.10, 1.45) when state median income was included. The deleterious effect of low individual household income on self-rated health was most pronounced among states with the greatest voting and income inequality. CONCLUSIONS: Socioeconomic inequality in political participation (as measured by voter turnout) is associated with poor self-rated health, independently of both income inequality and state median household income.     

Women at risk: Gender inequality and maternal health

Gender inequality has been documented as a key driver of negative health outcomes, especially among women. However, studies have not clearly examined the role of gender inequality in maternal health in an African setting. Therefore, the authors of this study examined the role of gender inequality, indicated by lack of female autonomy, in exposing women to maternal health risk. Data were obtained from the 2007 Zambia Demographic and Health Survey on a weighted sample of 3,906 married or partnered women aged 15–49 years. Multivariable analyses revealed that low autonomy in household decision power was associated with maternal health risk (Odds Ratio (OR) = 1.52, p < .001). Autonomy interacted with household wealth showed that respondents who were in the wealthier households and had low autonomy in household decision power (OR = 2.03, p < .05) were more likely to be exposed to maternal health risk than their counterparts who had more autonomy. Efforts to lower women’s exposure to maternal mortality and morbidity in Zambia should involve interventions to alter prevailing gender norms that limit women’s active participation in decisions about their own health during pregnancy and delivery.     

Community level effects of gender inequality on intimate partner violence and unintended pregnancy in Colombia: testing the feminist perspective

Violence against women, especially by intimate partners, is a serious public health problem that is associated with physical, reproductive, and mental health consequences. The effect of intimate partner violence on women's ability to control their fertility and the mechanisms through which these phenomena are related merit further investigation. Building on findings from a previous analysis in which a statistically significant relationship between intimate partner violence and unintended pregnancy in Colombia was found, this analysis examines the effect of gender inequality on this association using data from the 2000 Colombian Demographic and Health Survey. Specifically, the objective of this analysis is to explore whether gender inequality (as measured by women's autonomy, women's status, male patriarchal control, and intimate partner violence) in municipalities partially explains the association between intimate partner violence and unintended pregnancy in Colombia. Results of logistic regression analysis with multi-level data show that living in a municipality with high rates of male patriarchal control significantly increased women's odds of having an unintended pregnancy by almost four times. Also, living in a municipality with high rates of intimate partner violence increased one's odds of unintended pregnancy by more than 2.5 times, and non-abused women living in municipalities with high rates of intimate partner violence were at a significantly increased risk of unintended pregnancy. In addition, abused women living in a municipality with high personal female decision-making autonomy had more than a fourfold increased risk of having an unintended pregnancy. These findings demonstrate the need for reproductive health programs to target areas at particularly high risk for unintended pregnancy by reducing intimate partner violence and gender inequality.     

Wide range of socioeconomic factors associated with mortality among cities in Japan

The aim of this study was to identify socioeconomic factors associated with mortality among cities in Japan. Sex-specific and age-adjusted mortality rates for 1990 and 1995 were calculated by 779 local administrative units across the nation. One hundred indicators related to socioeconomic factors were compiled and divided into eight categories: economy, education, living conditions, vegetation and open space, transport, preventive activities, medical care and demography. Composite socioeconomic indices were formulated using factor analysis of the socioeconomic indicators by category, and the association between the indices and mortality rates was examined by correlation analysis and multiple regression analysis. Nineteen composite socioeconomic indices were obtained from factor analysis, and all indices except educational expenditure-related index were significantly correlated with mortality rates. Unemployment, old housing, primary health resources and density were independently positively associated, and higher education, public library activity, health check-up participation and population growth were independently negatively associated with both 1990 and 1995 male mortality rates. For female mortality, higher income, unemployment, spacious dwelling, old housing, less vegetation, road facility, numbers of cars per population, primary health resources and density were independently positively associated, and higher education, public library activity and health check-up participation were independently negatively associated. The relationship between mortality and socioeconomic conditions was stronger in males than in females, and higher income and less vegetation were associated with higher mortality only for females. The present study demonstrated a close link between mortality and a wide range of socioeconomic conditions by using a number of indicators compiled from various data sources. The results promote a deeper understanding of socioeconomic health determinants and development of multi-sectoral health policy to improve population health.     

Is inequality at the heart of it? Cross-country associations of income inequality with cardiovascular diseases and risk factors

Despite a number of cross-national studies that have examined the associations between income inequality and broad health outcomes such as life expectancy and all-cause mortality, investigations of the cross-country relations between income inequality and cardiovascular disease (CVD) morbidity, mortality, and risk factors are sparse. We analyzed the cross-national relations between income inequality and age-standardized mean body mass index (BMI), serum total cholesterol, systolic blood pressure (SBP), obesity prevalence, smoking impact ratio (SIR), and age-standardized and age-specific disability-adjusted life-years (DALYs) and mortality rates from coronary heart disease (CHD) and stroke, controlling for multiple country-level factors and specifying 5- to 10-year lag periods. In multivariable analyses primarily limited to industrialized countries, countries in the middle and highest (vs. lowest) tertiles of income inequality had higher absolute age-standardized obesity prevalences in both sexes. Higher income inequality was also related to higher mean SBP in both sexes, and higher SIR in women. In analyses of larger sets of countries with available data, positive associations were observed between higher income inequality and mean BMI, obesity prevalence, and CHD DALYs and mortality rates. Associations with stroke outcomes were inverse, yet became positive with the inclusion of eastern bloc and other countries in recent economic/political transition. China was also identified to be an influential data point, with the positive associations with stroke mortality rates becoming attenuated with its inclusion. Overall, our findings are compatible with harmful effects of income inequality at the national scale on CVD morbidity, mortality, and selected risk factors, particularly BMI/obesity. Future studies should consider income inequality as an independent contributor to variations in CVD burden globally.     

National female literacy, individual socio-economic status, and maternal health care use in sub-Saharan Africa

The United Nations Millennium Development Goals have identified improving women's access to maternal health care as a key target in reducing maternal mortality in sub-Saharan Africa (sSA). Although individual factors such as income and urban residence can affect maternal health care use, little is known about national-level factors associated with use. Yet, such knowledge may highlight the importance of global and national policies in improving use. This study examines the importance of national female literacy on women's maternal health care use in continental sSA. Data that come from the 2002-2003 World Health Survey. Multilevel logistic regression was used to examine the association between national female literacy and individual's non-use of maternal health care, while adjusting for individual-level factors and national economic development. Analyses also assessed effect modification of the association between income and non-use by female literacy. Effect modification was evaluated with the likelihood ratio test (G(2)). We found that within countries, individual age, education, urban residence and household income were associated with lack of maternal health care. National female literacy modified the association of household income with lack of maternal health care use. The strength of the association between income and lack of maternal health care was weaker in countries with higher female literacy. We conclude therefore that higher national levels of female literacy may reduce income-related inequalities in use through a range of possible mechanisms, including women's increased labour participation and higher status in society. National policies that are able to address female literacy and women's status in sub-Saharan Africa may help reduce income-related inequalities in maternal health care use.     

Aggregation and the measurement of income inequality: effects on morbidity

This is a cross-sectional study using records from the National Health Interview Survey linked to Census geography. The sample is restricted to white males ages 25-64 in the United States from three years (1989-1991) of the National Health Interview Survey. Perceived health is used to measure morbidity. Individual covariates include income-to-needs ratio, education and occupation. Contextual level measures of income inequality, median household income and percent in poverty are constructed at the US census county and tract level. The association between inequality and morbidity is examined using logistic regression models. Income inequality is found to exert an independent adverse effect on self-rated health at the county level, controlling for individual socioeconomic status and median income or percent poverty in the county. This corresponding effect at the tract level is reduced. Median income or percent poverty and individual socioeconomic status are the dominant correlates of perceived health status at the tract level. These results suggest that the level of geographic aggregation influences the pathways through which income inequality is actualized into an individuals' morbidity risk. At higher levels of aggregation there are independent effects of income inequality, while at lower levels of aggregation, income inequality is mediated by the neighborhood consequences of income inequality and individual processes.     

Income inequality and health. Coastal communities in British Columbia,Canada

OBJECTIVE: An imbalance in the distribution of economic resources, i.e., income inequality, is a characteristic of a community that may influence the aggregate health of the population. In North America, income inequality seems to be strongly related to mortality rates among American communities such as states and metropolitan areas but largely irrelevant for health at similar levels of geopolitical aggregation in Canada. This article summarizes relevant international and North American evidence and then explores relationships between income inequality and mortality rates among coastal communities in the province of British Columbia, Canada. METHODS: Cross-sectional analysis was conducted among twenty-four coastal communities in British Columbia, utilizing four measures based on the 1996 Census to measure income inequality and crude, age-standardized and age- and gender-specific mortality rates averaged over the five-year period 1994-98 to measure health. RESULTS: The three valid measures of income inequality were positively and significantly related to the crude mortality rate but were not significantly related to the age-standardized mortality rate. Two of the inequality measures were related to mortality rates for males aged 0-44 and for males aged 45-64 before but not after controlling for mean household income. DISCUSSION: Health researchers have yet to report a meaningful relationship between income inequality and population health within Canada. At the risk of committing the ecological fallacy, these findings provisionally support a psycho-social interpretation of the individual-level relationship between income and health wherein members of these communities compare themselves to an encompassing community, e.g., all Canadians.     

Low socioeconomic status of the opposite sex is a risk factor for middle aged mortality

OBJECTIVES: To examine the relations between subjective social status, and objective socioeconomic status (as measured by income and education) in relation to male/female middle aged mortality rates across 150 sub-regions in Hungary. DESIGN: Cross sectional, ecological analyses. SETTING: 150 sub-regions of Hungary. PARTICIPANTS AND METHODS: 12,643 people were interviewed in the Hungaro-study 2002 survey, representing the Hungarian population according to sex, age, and sub-regions. Independent variables were subjective social status, personal income, and education. MAIN OUTCOME MEASURE: For ecological analyses, sex specific mortality rates were calculated for the middle aged population (45-64 years) in the 150 sub-regions of Hungary. RESULTS: In ecological analyses, education and subjective social status of women were more significantly associated with middle aged male mortality, than were male education, male subjective social status, and income. Among the socioeconomic factors female education was the most important protective factor of male mid-aged mortality. Subjective social status of the opposite sex was significantly associated with mid-aged mortality, more among men than among women. CONCLUSION: Pronounced sex interactions were found in the relations of education, subjective social status, and middle aged mortality rates. Men seem to be more vulnerable to the socioeconomic status of women than women to the effects of socioeconomic status of men. Subjective social status of women was an important predictor of mortality among middle aged men as was female education. The results suggest that improved socioeconomic status of women is protective for male health as well as for female health.     

Income inequality and mortality: a multilevel prospective study of 521 248 individuals in 50 US states

BACKGROUND: Some of the most consistent evidence in favour of an association between income inequality and health has been among US states. However, in multilevel studies of mortality, only two out of five studies have reported a positive relationship with income inequality after adjustment for the compositional characteristics of the state's inhabitants. In this study, we attempt to clarify these mixed results by analysing the relationship within age-sex groups and by applying a previously unused analytical method to a database that contains more deaths than any multilevel study to date. METHODS: The US National Longitudinal Mortality Study (NLMS) was used to model the relationship between income inequality in US states and mortality using both a novel and previously used methodologies that fall into the general framework of multilevel regression. We adjust age-sex specific models for nine socioeconomic and demographic variables at the individual level and percentage black and region at the state level. RESULTS: The preponderance of evidence from this study suggests that 1990 state-level income inequality is associated with a 40% differential in state level mortality rates (95% CI = 26-56%) for men 25-64 years and a 14% (95% CI = 3-27%) differential for women 25-64 years after adjustment for compositional factors. No such relationship was found for men or women over 65. CONCLUSIONS: The relationship between income inequality and mortality is only robust to adjustment for compositional factors in men and women under 65. This explains why income inequality is not a major driver of mortality trends in the United States because most deaths occur at ages 65 and over. This analysis does suggest, however, the certain causes of death that occur primarily in the population under 65 may be associated with income inequality. Comparison of analytical techniques also suggests coefficients for income inequality in previous multilevel mortality studies may be biased, but further research is needed to provide a definitive answer.     

Primary care, income inequality, and self-rated health in the United States: a mixed-level analysis.

Using the 1996 Community Tracking Study household survey, the authors examined whether income inequality and primary care, measured at the state level, predict individual morbidity as measured by self-rated health status, while adjusting for potentially confounding individual variables. Their results indicate that distributions of income and primary care within states are significantly associated with individuals' self-rated health; that there is a gradient effect of income inequality on self-rated health; and that individuals living in states with a higher ratio of primary care physician to population are more likely to report good health than those living in states with a lower such ratio. From a policy perspective, improvement in individuals' health is likely to require a multi-pronged approach that addresses individual socioeconomic determinants of health, social and economic policies that affect income distribution, and a strengthening of the primary care aspects of health services.     

Socioeconomic status and mortality in Swedish women: opposing trends for cardiovascular disease and cancer

We examined relations between socioeconomic status and cardiovascular disease, cancer, and diabetes mellitus in a 24-year prospective study of 1,462 Swedish women. Two socioeconomic indicators were used: the husband's occupational category for married women and a composite indicator combining women's educational level with household income for all women. The husband's occupational category was strongly associated with cardiovascular disease and cancer mortality in opposite directions, independent of age and other potential confounders. Women with husbands of lower occupational categories had an increased risk of cardiovascular disease mortality [relative risk (RR) = 1.60; 95% confidence interval (95% CI) = 1.09-2.33] while experiencing lower rates of all-site cancer mortality (RR = 0.69; 95% CI = 0.50-0.96). A similar relation was seen with the composite variable: women with low socioeconomic status had an increased risk of cardiovascular disease (RR = 1.37; 95% CI = 1.01-1.84) but a somewhat lower risk for cancer of all sites (RR = 0.86; 95% CI = 0.66-1.11). Finally, morbidity data (diabetes mellitus, stroke, and breast cancer) yielded results that were consistent with the mortality trends, and breast cancer appeared to account for a major part of the association between total cancer and high socioeconomic status. In summary, higher socioeconomic status was associated with decreased cardiovascular disease mortality and excess cancer mortality, in such a way that only a weak association was seen for all-cause mortality.     

Income inequality and population health: correlation and causality

A large literature now exists on the cross-national correlation between income inequality and population health, but existing studies suffer from sparse data, poor operationalization of income inequality, and the use of low-power statistical models. This paper sets out to estimate the ecological correlation between income inequality and indicators of population health in a very broad panel of countries, to demonstrate that this relationship is largely non-artifactual, and to test whether this relationship might be causal. Gini coefficients of national income inequality in 1970 and 1995 are correlated with life expectancy, infant mortality rates, and murder rates, controlling for national income per capita. In cross-sectional analyses, inequality is significantly correlated with life expectancy, infant mortality, and (inconsistently) the murder rate. The health correlations are shown to be not primarily due to the "convexity effect" of the non-linear relationship between individual income and individual health, which seems to account for no more than one-third of the relationship between inequality and health, and likely much less. Change in inequality 1970-1995 is significantly related to change in life expectancy and infant mortality, suggesting a causal relationship, but these correlations are not robust with respect to sample or controls. It can be concluded that there is a strong, consistent, statistically significant, non-artifactual correlation between national income inequality and population health, but though there is some evidence that this relationship is causal, the relative stability of income inequality over time in most countries makes causality difficult to test.     

State-level income inequality and individual mortality risk: a prospective, multilevel study

OBJECTIVES: Previous studies have linked state-level income inequality to mortality rates. However, it has been questioned whether the relationship is independent of individual-level income. The present study tests whether state-level income inequality is related to individual mortality risk, after adjustment for individual-level characteristics. METHODS: In this prospective, multilevel study design, the vital status of National Health Interview Survey (NHIS) respondents was ascertained by linkage to the National Death Index, with additional linkage of state-level data to individuals in the NHIS. The analysis included data for 546,888 persons, with 19,379 deaths over the 8-year follow-up period. The Gini coefficient was used as the measure of income inequality. RESULTS: Individuals living in high-income-inequality states were at increased risk of mortality (relative risk = 1.12; 95% confidence interval = 1.04, 1.19) compared with individuals living in low-income-inequality states. In stratified analyses, significant effects of state income inequality on mortality risk were found, primarily for near-poor Whites. CONCLUSIONS: State-level income inequality appears to exert a contextual effect on mortality risk, after income is adjusted for, providing further evidence that the distribution of income is important for health.     

Macro-level gender equality and alcohol consumption: a multi-level analysis across U.S. States

Higher levels of women's alcohol consumption have long been attributed to increases in gender equality. However, only limited research examines the relationship between gender equality and alcohol consumption. This study examined associations between five measures of state-level gender equality and five alcohol consumption measures in the United States. Survey data regarding men's and women's alcohol consumption from the 2005 Behavioral Risk Factor Surveillance System were linked to state-level indicators of gender equality. Gender equality indicators included state-level women's socioeconomic status, gender equality in socioeconomic status, reproductive rights, policies relating to violence against women, and women's political participation. Alcohol consumption measures included past 30-day drinker status, drinking frequency, binge drinking, volume, and risky drinking. Other than drinker status, consumption is measured for drinkers only. Multi-level linear and logistic regression models adjusted for individual demographics as well as state-level income inequality, median income, and % Evangelical Protestant/Mormon. All gender equality indicators were positively associated with both women's and men's drinker status in models adjusting only for individual-level covariates; associations were not significant in models adjusting for other state-level characteristics. All other associations between gender equality and alcohol consumption were either negative or non-significant for both women and men in models adjusting for other state-level factors. Findings do not support the hypothesis that higher levels of gender equality are associated with higher levels of alcohol consumption by women or by men. In fact, most significant findings suggest that higher levels of equality are associated with less alcohol consumption overall.     

Democracy and growth in divided societies: A health-inequality trap?

Despite a tremendous increase in financial resources, many countries are not on track to achieve the child and maternal mortality targets set out in the Millennium Development Goals 4 and 5. It is commonly argued that two main social factors - improved democratic governance and aggregate income - will ultimately lead to progress in reducing child and maternal mortality. However, these two factors alone may be insufficient to achieve progress in settings where there is a high level of social division. To test the effects of growth and democratisation, and their interaction with social inequalities, we regressed data on child and maternal mortality rates for 192 countries against internationally used indexes of income, democracy, and population inequality (including income, ethnic, linguistic, and religious divisions) covering the period 1970-2007. We found that a higher degree of social division, especially ethnic and linguistic fractionalisation, was significantly associated with greater child and maternal mortality rates. We further found that, even in democratic states, greater social division was associated with lower overall population access to healthcare and lesser expansion of health system infrastructure. Perversely, while greater democratisation and aggregate income were associated with reduced maternal and child mortality overall, in regions with high levels of ethnic fragmentation the health benefits of democratisation and rising income were undermined and, at high levels of inequality reversed, so that democracy and growth were adversely related to child and maternal mortality. These findings are consistent with literature suggesting that high degrees of social division in the context of democratisation can strengthen the power of dominant elite and ethnic groups in political decision-making, resulting in health and welfare policies that deprive minority groups (a health-inequality trap). Thus, we show that improving economic growth and democratic governance are insufficient to achieve child and maternal health targets in communities with high levels of persistent social inequality. To reduce child and maternal mortality in highly divided societies, it will be necessary not only to increase growth and promote democratic elections, but also empower disenfranchised communities.