Morbidity Experiences and Disability Among Canadian Women

HEALTH ISSUE: Women are more frequently affected by chronic conditions and disability than men. Although some of these sex differences have been in part attributed to biological susceptibility, social determinants of health and other factors, these gaps have not been fully explained in the current literature. This chapter presents comparisons of hospitalization rates, and the prevalence of chronic conditions and physical disability between Canadian women and men and between various subgroups of women, adjusting for selected risk factors. The Canadian Hospital Morbidity Database (2000-2001) and Canadian Community Health Survey (2000-2001) were used to examine inpatient hospital morbidity, prevalence of chronic conditions and disability. KEY FINDINGS: Hospitalization rates were 20% higher among women than men. This was due to the large number of hospitalizations for pregnancies and childbirth. When "normal" deliveries were excluded, hospitalization rates remained higher among women. Women had slightly lower rates of hospitalizations for ambulatory-care sensitive conditions than men. Prevalence of activity limitation (mild and severe) was higher among women than men, and differences remained after adjusting for age, chronic conditions, socio-economic status, and smoking. Women who reported a disability were less likely than men to be in a partnered relationship, have less tangible social support, and have lower income and employment rates. DATA GAPS AND RECOMMENDATIONS: The impact of morbidity and disability on Canadian women is substantial. These results identify areas for interventions among more vulnerable subgroups, and point to the need for further research in the area of risk factors for the prevention of morbidity and disability in the population.     

Women's health status in Poland in the transition to a market economy

Since 1989 Poland has been experiencing large-scale social and economic changes as a result of the reforms associated with the transition to a market economy. This study uses a 1996 Health Survey of over 20,000 women to examine the impact of the new socio-economic situation and of women's multiple roles on their health at the early stage of transition. We investigated the importance of selected economic, socio-demographic and cultural determinants in explaining differences in women's health status in Poland, focusing on education level, (un)employment, living conditions, marital status, smoking and life style. There are health inequalities between men and women in Poland based on life expectancy, chronic diseases and health self-assessment. Some of these, especially the large differences between life expectancy at working ages, may be attributed to the difficult socio-economic situation. The multivariate analysis of women's self-assessed health and morbidity from selected chronic diseases indicated substantial inequalities in health. Together with the behavioural and cultural risk factors recognized by medicine, such as obesity, lack of physical exercise and smoking, the paper shows the crucial role of economic factors in influencing Polish women's health. Women whose financial position is poor are more likely to assess their health as less than good, to suffer from respiratory and circulatory systems' diseases and report neurotic problems. Other factors, strongly connected with the transition process in Poland, which contribute to health problems are lack of employment and low educational level, particularly for younger women. Women's marital and parental status are also important predictors of some categories of health problems; however, their influence varies for women of different ages. Our survey also supports the thesis that loneliness in old age, defined on the basis of living in a one-person household, may be negatively correlated with health status.     

Integrating Ethnicity and Migration As Determinants of Canadian Women's Health

HEALTH ISSUE: This chapter investigates (1) the association between ethnicity and migration, as measured by length of residence in Canada, and two specific self-reported outcomes: (a) self-perceived health and (b) self-reports of chronic conditions; and (2) the extent to which these selected determinants provide an adequate portrait of the differential outcomes on Canadian women's self-perceived health and self-reports of chronic conditions. The 2000 Canadian Community Health Survey was used to assess these associations while controlling for selected determinants such as age, sex, family structure, highest level of education attained and household income. KEY FINDINGS: * Recent immigrant women (2 years or less in Canada) are more likely to report poor health than Canadian-born women (OR = 0.48 CI: 0.30-0.77). Immigrant women who have been in Canada 10 years and over are more likely to report poor health than Canadian-born women (OR = 1.31 CI: 1.18-1.45).* Although immigrant women are less likely to report chronic conditions than Canadian-born women, this health advantage decreased over time in Canada (OR from 0.35 to 0.87 for 0-2 years to 10 years and above compared with Canadian born women). DATA GAPS AND RECOMMENDATIONS: * Migration experience needs to be conceptualized according to the results of past studies and included as a social determinant of health above and beyond ethnicity and culture. It is expected that the upcoming longitudinal survey of immigrants will help enhance surveillance capacity in this area.* Variables need to be constructed to allow women and men to best identify themselves appropriately according to ethnic identity and number of years in the host country; some of the proposed categories used as a cultural group may simply refer to skin colour without capturing associated elements of culture, ethnicity and life experiences.     

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

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

Indicadores para monitorizar la evolución de la crisis económica y sus efectos en la salud y en las desigualdades en salud. Informe SESPAS 2014

The economic crisis has adverse effects on determinants of health and health inequalities. The aim of this article was to present a set of indicators of health and its determinants to monitor the effects of the crisis in Spain. On the basis of the conceptual framework proposed by the Commission for the Reduction of Social Health Inequalities in Spain, we searched for indicators of social, economic, and political (structural and intermediate) determinants of health, as well as for health indicators, bearing in mind the axes of social inequality (gender, age, socioeconomic status, and country of origin). The indicators were mainly obtained from official data sources published on the internet. The selected indicators are periodically updated and are comparable over time and among territories (among autonomous communities and in some cases among European Union countries), and are available for age groups, gender, socio-economic status, and country of origin. However, many of these indicators are not sufficiently reactive to rapid change, which occurs in the economic crisis, and consequently require monitoring over time. Another limitation is the lack of availability of indicators for the various axes of social inequality. In conclusion, the proposed indicators allow for progress in monitoring the effects of the economic crisis on health and health inequalities in Spain.     

Social relations and self-reported health: a prospective analysis of the French Gazel cohort

Social networks and social support are strongly associated with health, yet the pathways between social relations and health are not well understood. In one of the very few studies on this issue conducted in France, we used data from the French GAZEL cohort of employees of the national gas and electricity company, to (1) explore the relationship between the structure and function of the social environment upon self-reported health and (2) test the hypothesis that social relations directly affect health. In a prospective analysis over a 12-month follow-up period, we found that a lack of social support and dissatisfaction with social relations are predictive of poor health status, while weak social networks are not. Thus, functional aspects of social relations are better predictors of poor health than the structure of social interactions. Low social support was an independent risk factor for poor health in men and women: for men the effect was strongest among individuals who held a high occupational status, for women among those in high and low occupational groups. This study suggests that in France social relations exert an independent effect on health, modified by gender and socio-economic factors. Our results indicate that both clinicians in their practice and researchers may do well to focus increased attention on the health impact of social support.     

Investigating socio-economic explanations for gender and ethnic inequalities in health

This paper examines inequalities in the self-reported health of men and women from white and minority ethnic groups in the UK using representative data from the Health Survey for England, 1993-1996. The results show substantially poorer health among all minority ethnic groups compared to whites of working-age. The absence of gender inequality in health among white adults contrasts with higher morbidity for many minority ethnic women compared to men in the same ethnic group. The analysis addresses whether socio-economic inequality is a potential explanation for this pattern of health inequality using measures of educational level, employment status, occupational social class and material deprivation. There are marked socio-economic differences according to gender and ethnic group: high morbidity is concentrated among adults who are most socio-economically disadvantaged, notably Pakistanis and Bangladeshis. Logistic regression analyses show that socio-economic inequality can account for a sizeable proportion of the health disadvantage experienced by minority ethnic men and women, but gender inequality in minority ethnic health remains after adjusting for socio-economic characteristics.     

The social determinants of substance use for aboriginal women: A systematic review

ABSTRACT

Although women who use substances are often also facing severe economic and social problems, little is known about the relationship between social determinants of health and substance use among women. Furthermore, despite their increased visibility in substance use programs and policies in Canada, little is known about the social contexts of substance use among Aboriginal women. I systematically reviewed empirical research published from 1997 through March 2013 that examined the relationship between social determinants of health and substance use among Aboriginal women. Studies that were peer-reviewed, published in English, and had an abstract were included. Of an initial 261 studies, only sixteen studies met the inclusion criteria (fourteen quantitative, one qualitative, one mixed methods). The social determinants of health that were explored in these studies were socio-demographics factors, trauma, gender, social environments, colonialism, culture, and employment. The studies identified significant relationships between the social determinants of health and substance use among Aboriginal women. The almost exclusive use of quantitative methods and the prioritization of certain social determinants of health over others prevented a comprehensive and contextual understanding of substance use among Aboriginal women. Further research is needed to understand these significant relationships, particularly in relation to Aboriginal-specific determinants of health.     

Gender differences in health: a Canadian study of the psychosocial, structural and behavioural determinants of health

Gender-based inequalities in health have been frequently documented. This paper examines the extent to which these inequalities reflect the different social experiences and conditions of men's and women's lives. We address four specific questions. Are there gender differences in mental and physical health? What is the relative importance of the structural, behavioural and psychosocial determinants of health? Are the gender differences in health attributable to the differing structural (socio-economic, age, social support, family arrangement) context in which women and men live, and to their differential exposure to lifestyle (smoking, drinking, exercise, diet) and psychosocial (critical life events, stress, psychological resources) factors? Are gender differences in health also attributable to gender differences in vulnerability to these structural, behavioural and psychosocial determinants of health? Multivariate analyses of Canadian National Population Health Survey data show gender differences in health (measured by self-rated health, functional health, chronic illness and distress). Social structural and psychosocial determinants of health are generally more important for women and behavioural determinants are generally more important for men. Gender differences in exposure to these forces contribute to inequalities in health between men and women, however, statistically significant inequalities remain after controlling for exposure. Gender-based health inequalities are further explained by differential vulnerabilities to social forces between men and women. Our findings suggest the value of models that include a wide range of health and health-determinant variables, and affirm the importance of looking more closely at gender differences in health.     

Mechanisms for the social gradient in health: results from a 14-year follow-up of the Northern Swedish Cohort

Objective

Although numerous studies have demonstrated a socio-economic gradient in health, there is still a lack of research about the mechanisms behind this gradient. The aim of this study was to analyse possible mechanisms from adolescence to adulthood to explain the socio-economic gradient in somatic symptoms among men and women in the Northern Swedish Cohort.

Study design

A prospective cohort study was performed, in which all pupils (n = 1083) in the last year of compulsory school were followed for 14 years. The response rate was high, with 96.6% still participating after 14 years. The data were mainly collected through repeated comprehensive self-administered questionnaires.

Methods

The main dependent variable was a combination of socio-economic position and somatic health at 30 years of age. Multivariate multinomial and bivariate logistic regression analyses were undertaken.

Results

After controlling for parental working-class position and health-related selection, the authors identified mechanisms from adolescence to adulthood for the socio-economic gradient in health that were related to social relations (poor relationship with father and unemployed friends among men, violence among women), labour market experiences (unemployment among men and women, physically heavy work among women), economic hardship (among women) and poor health behaviour.

Conclusion

These analyses contribute to the development of epidemiological methods for analysing mechanisms for the socio-economic gradient in health.     

Social background, adult body-height and health

STUDY OBJECTIVE: To study the socio-demographic determinants of body-height and the bearing of these determinants on the association between body-height and health among Finnish adults. DATA AND METHOD: Cross-sectional population survey including questions on social background, body-height and health, and retrospective questions on childhood living conditions. The data derive from a representative Survey on Living Conditions collected by Statistics Finland in 1994. The response rate was 73%. Male and female respondents > or =20 years were included in the analysis (N = 8212). Statistical methods include regression analysis and logistic regression analysis. RESULTS: Body-height was strongly associated with year of birth, region, childhood living conditions and education among adult men and women. Body-height was also associated with limiting long-standing illness and perceived health as below good. Tall men had the best health and short men the poorest health. Among women the association of body-height with health differed from men, as tall women showed high levels of limiting long-standing illness, notably musculo-skeletal diseases. Adjusting for the background variables weakened but did not abolish the association between poor health and short stature among men and women. CONCLUSIONS: Short stature is associated with poor health among Finnish men and women. A non-linear association among women was found for musculo-skeletal diseases. The studied social background factors explained only little of the association between body-height and health.     

Socio-economic position and health: what you observe depends on how you measure it

BACKGROUND: A number of different socio-economic classifications have been used in relation to health in the United Kingdom. The aim of this study was to compare the predictive power of different socio-economic classifications in relation to a range of health measures. METHODS: A postal questionnaire was sent to a random sample of adults in the West of Scotland (sampling from 1997 electoral roll, response rate 50 percent achieved sample 2,867). RESULTS: Associations between social position and health vary by socio-economic classification, health measure and gender. Limiting long-standing illness is more socially patterned than recent illness; income, Registrar General Social Class, housing tenure and car access are more predictive of health than the new National Statistics Socio Economic Classification; and men show steeper socio-economic gradients than women. CONCLUSION: Although there is a consistent picture of poorer health among more disadvantaged groups, however measured, in seeking to explain and reduce social inequalities in health we need to take a more differentiated approach that does not assume equivalence among social classifications and health measures.     

Perceived health as related to income, socio-economic status, lifestyle, and social support factors in a middle-aged Japanese

BACKGROUND: Few studies have examined the association of perceived health with socio-economic status, especially income, and social isolation and support in Japan. The purpose of this study is to clarify the associations among perceived health, lifestyle, and socio-economic status, as well as social isolation and support factors, in middle-aged and elderly Japanese. METHODS: Subjects were 9,650 participants aged 47-77 years who completed a self-administered questionnaire in 2000 in the second survey of a population-based cohort (the Komo-Ise study). The questionnaire included items on sociodemographic and socio-economic factors, social isolation and support, lifestyle, past history of chronic disease and perceived health. Perceived health was dichotomized into excellent or good health and fair or poor health. A logistic regression analysis was used to determine the odds ratios of socio-economic status, social characteristics and lifestyle in relation to self-reported fair or poor health. RESULTS: We found that household income, physical activity, sleeping, smoking habit, and BMI had a strong association with self-reported fair or poor health in middle-aged and elderly Japanese men and women. Male subjects tended to report fair or poor health as household income decreased. The results for women differed in that social isolation and low social support had a stronger association for self-reported fair or poor health than low household income. CONCLUSIONS: The results indicated that perceived health was associated with socio-economic and social characteristics among middle-aged and elderly residents in Japan.     

Household income is strongly associated with health-related quality of life among Japanese men but not women

OBJECTIVES: As socio-economic status (SES) strongly reflects individual economic status, evaluating the association between SES and health could provide information that is important for planning integrated economic and public health policies. We examined the association between annual household income as a measure of SES and the eight scale scores of the Medical Outcomes Study Short Form-36 Health Survey (SF-36) as a quantifier of health-related quality of life (HRQOL) in Japan. STUDY DESIGN: Cross-sectional survey. METHODS: Data were from the SF-36 national survey in Japan. A total of 4500 people aged 16 years or older were selected from the entire population of Japan using stratified-random sampling, and 3395 responded to the survey. RESULTS: Men with lower levels of annual household income had lower scores in all SF-36 domains. However, only 'general health perceptions' and 'social functioning' showed statistically significant trends among the women surveyed. In the subgroup of women working full-time, there were no domains that showed significant trends. CONCLUSIONS: A strong association exists between annual household income and SF-36 scores among men, but there is only a limited association among women. The employment and economic policies that affect annual household income potentially influence HRQOL.     

Increasing inequalities in all-cause and cardiovascular mortality among US adults aged 25-64 years by area socioeconomic status, 1969-1998

BACKGROUND: This study examined the extent to which areal socio-economic gradients in all-cause and cardiovascular disease (CVD) mortality among US men and women aged 25-64 years increased between 1969 and 1998. METHODS: Using factor analysis 17 census tract variables were used to develop an areal index of socio-economic status that was used to stratify all US counties into five socio-economic categories. By linking the index to county-level mortality data from 1969 to 1998, we calculated annual age-adjusted mortality rates for each area socio-economic group. Poisson regression models were fitted to estimate areal socio-economic gradients in mortality over time. RESULTS: Areal socio-economic gradients in all-cause and cardiovascular mortality have increased substantially over the past three decades. Compared to men in the highest area socio-economic group, rates of all-cause and CVD mortality among men in the lowest area socio-economic group were 42% and 30% greater in 1969-1970 and 73% and 79% greater in 1997-1998, respectively. The gradients in mortality among women were steeper for CVD than for all causes. Compared to women in the highest area socio-economic group, rates of all-cause and CVD mortality among women in the lowest area socio-economic group were 29% and 49% greater in 1969-1970 and 53% and 94% greater in 1997-1998, respectively. CONCLUSIONS: Although US all-cause and cardiovascular mortality declined for all area socio-economic groups during 1969-1998, the gradient increased because of significantly larger mortality declines in the higher socio-economic groups. Increasing areal inequalities in mortality shown here may be related to increasing temporal differences in the material and social living conditions between areas.     

Socio-economic influences on self-rated health in Russian men and women--a life course approach

Socio-economic differentials in health in Russia are not well understood and the life course approach has been relatively neglected. This paper examines the influence of socio-economic risk factors over the life course on the self-rated health of older Russian men and women. A random sample (response rate 61%) of the general population of the Russian Federation in 2002 included 1004 men and 1930 women aged 50 years and over in a cross-sectional study. They provided information concerning their childhood circumstances, including going to bed hungry; education; current social conditions, including per capita household income; health behaviours and self-rated health. There was considerable tracking of adverse social conditions across the life course with men and women who reported hunger in childhood having lower educational achievements, and current household income was strongly influenced by educational attainment. The effect of these socio-economic risk factors on health accumulated with an odds ratio of poor health of 1.87 [1.07-3.28] for men with one risk factor, 3.64 [2.13-6.22] for two risk factors and 4.51 [2.57-7.91] for all three compared to men with no risk factors. For women, the odds ratios were 1.44 [1.05-2.01], 2.88 [2.10-3.93] and 4.27 [3.03-6.00] for one, two and three risk factors, respectively. Current income was the strongest individual predictor for men, and education for women. Adjustment for health behaviours reduced the odds ratios only marginally. The results suggest that self-rated health in older Russians reflects social exposures accumulated over the life course, with the differentials observed only partially explained by current social conditions. Health behaviours were not involved in mediating social differences in self-rated health. Our results indicate that a life course approach may contribute to the understanding of health in Russia.     

The impact of a reduced fertility rate on women's health

HEALTH ISSUE: Total fertility rates (TFRs) have decreased worldwide. The Canadian fertility rate has gone from 3.90 per woman in 1960 to 1.49 in 2000. However, not many studies have examined the impact on women's health of reduced fertility rates, delayed fertility and more births to unmarried women. This paper presents information on the relation between family size and specific determinants of health. KEY FINDINGS: The rate of TFR decline varies considerably by geographic location and socio-demographic subgroup. Further, the associations between family size and selected determinants of health are different for women and men. For example a woman with one child is almost four times more likely to be "coupled" than a childless woman, and if she has two children she is significantly more likely to be "coupled" than if she had only one child. However, a man with one or more children is over six times more likely to be "coupled" than his childless counterpart, and this does not vary with family size. DATA GAPS AND RECOMMENDATIONS: There is a paucity of data on the impact of reduced fertility rates on women's health in general and on how women's roles affect their decision to have children. While it would be useful to examine longer-term health outcomes by parity and age of first birth, as well as socio-economic and role-related variables these longitudinal and detailed "role related" data are not available. Given the differing profiles of women and men with children, further health policies research is needed to support vulnerable women with children.     

Social disadvantage and cardiovascular disease: development of an index and analysis of age, sex, and ethnicity effects

BACKGROUND: Social disadvantage is defined by adverse socio-economic characteristics and is distributed unequally by age, sex, and ethnicity. We studied the relationship between social disadvantage, cardiovascular risk factors, and cardiovascular disease (CVD) among men and women from diverse ethno-racial backgrounds. METHODS: A total of 1227 men and women of South Asian, Chinese, Aboriginal, and European ancestry were randomly selected from four communities in Canada to undergo a health assessment. Socio-economic factors, conventional and novel CV risk factors, atherosclerosis, and CVD were measured. A social disadvantage index was generated and included employment status, income, and marital status. Social disadvantage was examined in relation to risk factors for CVD, atherosclerosis, and prevalent CVD. RESULTS: Social disadvantage was higher among older people, women, and non-white ethnic groups. Cigarette smoking, glucose, overweight, abdominal obesity, and CRP were higher among individuals with higher social disadvantage, whereas systolic blood pressure, lipids, norepinephrine, and atherosclerosis were not. Social disadvantage is an independent predictor of CVD after adjustment for conventional and novel risk markers for CVD (OR for 1 point increase = 1.25; 95% CI 1.06-1.47). CONCLUSION: The social disadvantage index combines social and economic exposures into a single continuous measure. Significant variation in social disadvantage by age, sex, and ethnic group exists. Increased social disadvantage is associated with an increased burden of some CV risk factors, and is an independently associated with CVD.     

Social determinants of sex differences in disability among older adults: a multi-country decomposition analysis using the World Health Survey

ABSTRACT: INTRODUCTION: Women represent a growing proportion of older people and experience increasing disability in their longer lives. Using a universally agreed definition of disability based on the International Classification of Functioning, Disability and Health, this paper examines how, apart from age, social and economic factors contribute to disability differences between older men and women. METHODS: World Health Survey data were analyzed from 57 countries drawn from all income groups defined by the World Bank. The final sample comprises 63638 respondents aged 50 and older (28568 males and 35070 females). Item Response Theory was applied to derive a measure of disability which ensured cross country comparability. Individuals with scores at or above a threshold score were those who experienced significant difficulty in their everyday lives, irrespective of the underlying etiology. The population was then divided into "disabled" vs. "not disabled". We firstly computed disability prevalence for males and females by socio-demographic factors, secondly used multiple logistic regression to estimate the adjusted effects of each social determinant on disability for males and females, and thirdly used a variant of the Blinder-Oaxaca decomposition technique to partition the measured inequality in disability between males and females into the "explained" part that arises because of differences between males and females in terms of age and social and economic characteristics, and an "unexplained" part attributed to the differential effects of these characteristics. RESULTS: Prevalence of disability among women compared with men aged 50+ years was 40.1% vs. 23.8%. Lower levels of education and economic status are associated with disability in women and men. Approximately 45% of the sex inequality in disability can be attributed to differences in the distribution of socio-demographic factors. Approximately 55% of the inequality results from differences in the effects of the determinants. CONCLUSIONS: There is an urgent need for data and methodologies that can identify how social, biological and other factors separately contribute to the health decrements facing men and women as they age. This study highlights the need for action to address social structures and institutional practices that impact unfairly on the health of older men and women.     

Social determinants of health – A question of social or economic capital? Interaction effects of socioeconomic factors on health outcomes

Social structures and socioeconomic patterns are the major determinants of population health. However, very few previous studies have simultaneously analysed the "social" and the "economic" indicators when addressing social determinants of health. We focus on the relevance of economic and social capital as health determinants by analysing various indicators. The aim of this paper was to analyse independent associations, and interactions, of lack of economic capital (economic hardships) and social capital (social participation, interpersonal and political/institutional trust) on various health outcomes. Data was derived from the 2009 Swedish National Survey of Public Health, based on a randomly selected representative sample of 23,153 men and 28,261 women aged 16-84 year, with a participation rate of 53.8%. Economic hardships were measured by a combined economic hardships measure including low household income, inability to meet expenses and lacking cash reserves. Social capital was measured by social participation, interpersonal (horizontal) trust and political (vertical/institutional trust) trust in parliament. Health outcomes included; (i) self-rated health, (i) psychological distress (GHQ-12) and (iii) musculoskeletal disorders. Results from multivariate logistic regression show that both measures of economic capital and low social capital were significantly associated with poor health status, with only a few exceptions. Significant interactive effects measured as synergy index were observed between economic hardships and all various types of social capital. The synergy indices ranged from 1.4 to 2.3. The present study adds to the evidence that both economic hardships and social capital contribute to a range of different health outcomes. Furthermore, when combined they potentiate the risk of poor health.