Social inequality and healthy public policy.

For decades, health education programmes have been based on the assumption that individual behaviours (for example smoking, drug use, eating patterns) are the major risk-factors in contemporary illness. This assumption often led to interventions that subtly "blamed the victim" for his or her ill-health. In recent years the broader social conceptualization of health and illness has directed many health educators' attention towards socio-economic and environmental factors which condition and constrain lifestyle choices, and which may be directly associated with increased disease risks. While it is becoming common for government health departments and agencies to acknowledge poverty, unemployment and other forms of social inequality as potent health hazards, programmes to ameliorate such conditions are rare. Since 1983, the Toronto health department has developed programmes based upon a socio-environmental model of disease which specifically targets social systems rather than individual behaviour for change. Elements of this approach include extensive media reports on the health implications of such issues as welfare benefits, poverty, unemployment and housing; health education programmes to stimulate a critical understanding of the causes and structure of social inequality; health advocacy initiatives to influence political and legislative reforms; and a community development orientation which involves the department in broad-based coalitions working towards healthy social change. Most recently, the department has become a resource to groups attempting to create employment and service community needs through cooperative forms of economic development. Several examples of the department's programmes in each of these areas are provided. To meet the challenge of the World Health Organization's Alma Ata Declaration, health educators must examine their own potential to act as social-change agents, and must become more sophisticated in the political analysis of their practice.     

Social inequality and child malnutrition in four Andean countries.

OBJECTIVE: To analyze the effects of socioeconomic, regional, and ethnic conditions on chronic malnutrition in four Andean countries of South America: Bolivia, Colombia, Ecuador, and Peru. METHODS: The study was based on Demographic and Health Surveys (DHS) for Colombia (1995), Peru (1996), and Bolivia (1997), and on a Living Standard Measurement Survey for Ecuador (1998). We developed an index of household socioeconomic status using categorical principal components analysis. We broke down the prevalence of stunting by socioeconomic status (SES), ethnicity, place of residence (large cities, small cities, towns, and countryside), and region (highland region versus other areas of the country). We applied smoothed regression curves and linear functions to analyze SES effects on stunting, with specific models for Bolivia, Ecuador, and Peru. RESULTS: Bolivia, Ecuador, and Peru have similar characteristics, with high stunting prevalences overall; higher stunting prevalences in their highland areas, particularly among indigenous populations; and strong socioeconomic disparities. Colombia, in contrast, has a lower stunting prevalence and smaller regional disparities. The socioeconomic gradient of stunting is strong in all four countries, with prevalence rates in the poorest deciles at least three times as high as those in the top decile. DISCUSSION: The sharp contrast between the conditions found in Bolivia, Ecuador, and Peru and those in Colombia may be the result of specific ethnic factors affecting indigenous groups; a particular diet profile in the highland areas, with low protein and micronutrient intake; and differences in the long-term economic and social development paths that the countries have taken. Along with the strong socioeconomic gradient in all the countries, the weight of ethnic and regional factors suggests the need to reduce inequality as well as to comprehensively improve education and housing, better target health and nutrition programs, and implement participatory programs integrated into indigenous cultures.     

Social capital, income inequality, and mortality.

OBJECTIVES: Recent studies have demonstrated that income inequality is related to mortality rates. It was hypothesized, in this study, that income inequality is related to reduction in social cohesion and that disinvestment in social capital is in turn associated with increased mortality. METHODS: In this cross-sectional ecologic study based on data from 39 states, social capital was measured by weighted responses to two items from the General Social Survey: per capita density of membership in voluntary groups in each state and level of social trust, as gauged by the proportion of residents in each state who believed that people could be trusted. Age-standardized total and cause-specific mortality rates in 1990 were obtained for each state. RESULTS: Income inequality was strongly correlated with both per capita group membership (r = -.46) and lack of social trust (r = .76). In turn, both social trust and group membership were associated with total mortality, as well as rates of death from coronary heart disease, malignant neoplasms, and infant mortality. CONCLUSIONS: These data support the notion that income inequality leads to increased mortality via disinvestment in social capital.     

Social inequality and children's growth in Guatemala

This paper is an investigation of the effects of social inequality in Guatemala on children's health and nutritional status as measured by attained height. Guatemala remains a highly stratified and poor society. We examine the association of land distribution, land tenure, occupation, and other aspects of family social and economic status with children's height between the ages of three months and 36 months, using data from a cross-sectional survey. An important consequence of the poverty and poor living conditions of the majority of the Guatemalan population is substantial deficits in children's growth. Our results suggest that children's growth is affected by ethnicity, their father's occupation, land distribution in the area where they live, and maternal education. Substantial growth deficits are observed among children living at altitudes above 1500 metres; we hypothesize that this is because, in Guatemala, higher altitude is associated with land scarcity, poorer agricultural conditions, and greater remoteness from transport networks and other public services.     

Social inequality and healthy public policy

For decades, health education programmes have been based onthe assumption that individual behaviours (for example smoking,drug use, eating patterns) are the major risk-factors in contemporaryillness. This assumption often led to interventions that subtly"blamed the victim" for his or her ill-health. In recent yearsthe broader social conceptualization of health and illness hasdirected many health educators' attention towards socio-economicand environmental factors which condition and constrain lifestylechoices, and which may be directly associated with increaseddisease risks. While it is becoming common for government healthdepartments and agencies to acknowledge poverty, unemploymentand other forms of social inequality as potent health hazards,programmes to ameliorate such conditions are rare. Since 1983, the Toronto health department has developed programmesbased upon a socio-environmental model of disease which specificallytargets social systems rather than individual behaviour forchange. Elements of this approach include extensive media reportson the health implications of such issues as welfare benefits,poverty, unemployment and housing; health education programmesto stimulate a critical understanding of the causes and structureof social inequality; health advocacy initiatives to influencepolitical and legislative reforms; and a community developmentorientation which involves the department in broad-based coalitionsworking towards healthy social change. Most recently, the departmenthas become a resource to groups attempting to create employmentand service community needs through cooperative forms of economicdevelopment. Several examples of the department's programmesin each of these areas are provided. To meet the challenge of the World Health Organization's AlmaAta Declaration, health educators must examine their own potentialto act as social-change agents, and must become more sophisticatedin the political analysis of their practice.     

Social sexual inequality and sex difference in cancer incidence

Socioeconomic factors play many roles in influencing health including overall health status, lifestyle and occupational exposures, and access to preventive, diagnostic and treatment services. This paper reviews evidence on the geographical distribution of the sex differences in cancer incidence and life expectancy. The analyses reported are at the regional (Italy), continental (Europe), and world-wide scales. In agreement with other contributions on the social epidemiology of cancer, these results indicate that there is a close link between the health of the populations, and socioeconomic and cultural factors, and support the notion that environment contributes strongly to total cancer incidence. Thus, the emphasis for reducing cancer incidence needs to focus more on reducing environmental contributions. In order to improve the health status of the populations, not only applications of the present etiologic knowledge are necessary (for example, it is estimated that around up to 50% of cancers are nowadays technically preventable), but also further research on environmental topics should be stimulated. Within this perspective the indicators of health differences between genders-which are demonstrated to be very sensitive to socioeconomic and cultural factors--can play a very useful role for monitoring environmental factors, and for health planning by agencies and governments.     

Social inequality in deaths in Great Britain and in France

In this paper data are compared on differential mortality for working men in the United Kingdom and France, for the years 1970-1972 (U.K.) and 1966-1971 (F). Differential mortality in the United Kingdom is described in 'occupational mortality' published by O.P.C.S.; mortality according to 'Catégories socio-professionnelles' has been studied for a large cohort by INSEE (National Institute of Statistics and Economic Studies). The comparison between those two sets of data leads to the following conclusions: social differences in death rates seem to be larger in France than in United Kingdom. the main causes of death responsible for these inequalities differ in the two countries: respiratory diseases are the main cause in U.K.; in France, accidents and alcohol-related death lead to the largest inequalities. We discuss the difficulties of comparison between countries: some of the apparent differences may relate to the fact that, in France, mortality data concerns a cohort followed since 1954, while British data comes from a transversal survey. Another point of difference is the fact that foreigners are not included in the French study. In every country where data exist on the subject, inequalities in health are found. The reasons why these inequalities exist, and what should be done to reduce them, is a matter for discussion. The purpose of this paper is to contribute to the debate, by throwing light on some aspects of the observed differences.     

Social inequality and ethnic differences in smoking in New Zealand

This study tests a generalisation of the 'Wilkinson' thesis that the greater a nation's income inequality, the poorer the average national health status. We consider the effect of socio-economic inequality upon ethnic variations in smoking in New Zealand. Analysis of Maori and Pakeha (New Zealanders of European descent) smoking rates from the 1996 Census is conducted for 73 Territorial Local Authority areas in New Zealand, disaggregated by gender and rural-urban location. Partial correlation is used to control for absolute levels of deprivation and examine the independent effect of ethnic social inequality upon smoking rates. The level of social inequality between Maori and Pakeha has an independent effect on Maori smoking rates. Pakeha smoking rates by contrast are more sensitive to variations in absolute rather than relative deprivation. The effect of inequality is greatest for Maori women, especially among urban residents. By contrast, among Maori men the effects are greatest in rural areas. The results provide some qualified support for the Wilkinson thesis and suggest that policies which address fundamental issues of social inequality will play a small, but significant, role in helping to reduce high smoking rates amongst Maori.     

Going upstream: Social inequality and children's health

This study explores the impact of income inequality on the health of children. We examine the direct effects of income inequality and the mediating effects of income inequality via poverty concentration at local levels. We use a multilevel study design incorporating individual level data from the 1988 Child Health Supplement to the National Health Interview Survey supplemented with aggregate data from the 1990 Census of Population STF3A economic/ demographic files. Measures of income inequality are constructed at the county level and poverty concentration at the county and neighbourhood level. Multiple indicators are used to examine child health including physiologic, functional status, and psychological measures and behavior and school problems. The association between income inequality and child health was examined using logistic regression models. Direct effects of income inequality were observed for school suspension and indirect effects for chronic conditions, learning disabilities, emotional and behavior problems, school suspension, health status and seeing a counsellor/psychiatrist. To assess whether income inequality works through challenging the integrity of local economic institutions, we also examine whether inequality and poverty concentration at the neighbourhood level or the larger administrative unit influence children's access to health insurance. Income inequality was found to exert both a direct and an indirect effect on children's health insurance status. These findings specifically provide evidence of the effects of income inequality on children's health, and more generally demonstrate that higher level contextual factors need to be incorporated into research in order to enhance our understanding of the determinants of children's health.     

Infant mortality Social inequality in a Swedish city

Infant mortality rates for geographical areas of Göteborg(Gothenburg), Sweden, were studied for 78,357 infants livingin Göteborg from 1971 to 1985. During this time 637 infantdeaths occurred. The 32 parishes of Göteborg were dividedinto three groups referred to as high, medium and low incomeareas. The difference in infant mortality among the areas wasstatistically significant and increased over time. The relativerisk of Infant death was 1.8 in the medium and 2.0 in the lowcompared to the high income areas in 1981–1985. The infantmortality rate varied from 3.8 to 7.6/1000. The high incomeareas had lower death rates overall, in congenital malformationsand in perinatal conditions. The low income areas had a significantlyhigher rate of sudden infant death syndrome than the other groups.Political and administrative decentralization was implementedin Sweden in the 1980s. Local area research thus has a directrelevance for policy, planning and provision of services. Theresults reflect the social segregation, associated not onlywith economic stratification but also with differences in lifestylesand cultural environment. Further analyses are necessary toprovide Information on preventable risk factors In order todecrease the observed socio-economic differences. The resultscan, however, be used for targeting infant mortality levelsand for the allocation of resources.     

Social inequality in the use and comprehensiveness of dental services

Abstract: Fair access is a value enshrined through universal insurance for health care in Australia. However, dentistry is not included in this system. As a consequence, there is a strong likelihood of inequalities in access to dental services among adults. Data from the 1989–90 National Health Survey were analysed to determine sociodemographic factors related to use and comprehensiveness of dental services. Age, income, age of leaving school and occupation were independently associated with the use of dental services, and occupation was associated with an indicator of comprehensiveness of care: self-reported extraction at the last visit. In different adult age groups these sociodemographic factors had different effects, with the disparities in use of dental services greater in older age groups. Planning of dental services in the 1990s and beyond should include not only the removal of financial barriers to dental services among adults but also attention to the specific barriers experienced by the elderly.     

Social inequality in fetal and perinatal mortality in the Nordic countries

AIM: The aim of this study is to review the epidemiological literature from the past 27 years on social inequality in fetal and perinatal mortality in the Nordic countries in order to examine whether social inequalities in fetal and perinatal mortality exist, and whether there are differences between the countries. METHODS: The databases MEDLINE and EMBASE were searched for Nordic epidemiological studies published between January 1980 and August 2007 about the association between social indicators and the outcomes spontaneous abortion, stillbirth or perinatal mortality. Thirty-five studies that fulfilled the inclusion criteria were identified for this review. RESULTS: Social differences in stillbirth and perinatal mortality were found in all of the identified Finnish and Norwegian studies and in the majority of studies from Denmark, whereas in the Swedish studies the findings were less consistent. As only a small number of studies on spontaneous abortion were identified (n=3), no conclusions were drawn with regard to this outcome. CONCLUSIONS: There seems to be a reasonable body of evidence that social inequality in stillbirth and perinatal mortality exists in Norway, Finland and Denmark, whereas the conclusions regarding Sweden are more uncertain. A number of methodological problems complicate the comparison of the findings. Nordic collaborative analyses of social gradients in spontaneous abortion, stillbirth and perinatal mortality, which take these methodological concerns into account, are needed in order to draw inferences across countries.     

Social inequality and homicide rates in Sao Paulo City, Brazil

OBJECTIVE: The relation between income and mortality due to violence has been studied in recent years. The Synthesis of Social Indicators of 2002 [Sintese de Indicadores Sociais, 2002], published by The Brazilian Institute of Geography and Statistics (IBGE), states that one of the most outstanding characteristic of Brazilian society is inequality. The proposal of this ecological study was to test the association between homicide rates, and some health and socioeconomic indicators. METHODS: This is an ecological cross-sectional study. Data regarding Sao Paulo City, Brazil in the year 2000 was analyzed. The association between homicide coefficients and the following five indicators were tested: infant mortality rates, monthly average income of household heads, percentage of adolescents aged 15 to 17 years not attending school, proportion of pregnant adolescent women aged 14 to 17 years and demographic density. Pearson's correlation coefficient and a multiple linear regression model were utilized to test these associations. RESULTS: The municipal homicide rate was 57.3/100,000. The correlation between homicide rates and average monthly income was strong and negative (r=-0.65). Higher homicide rates were found in the districts whose inhabitants had lower incomes and lower rates were found in those districts whose inhabitants had higher incomes. The correlation between homicide rates and proportion of adolescents not attending school was positive and strong (r=0.68). The correlation between homicide rates and the proportion of pregnant adolescent women was positive and strong (r=0.67). The correlation between homicides and the rate of infant mortality was r=0.24 (for all: p<0.05). The correlation between demographic density and homicides was not significant. Although the univariate regression was positive for four indicators, the multivariate regression test was only significant for average monthly income (negative) and proportion of adolescents not attending school (positive) (for both indicators: p<0.01). CONCLUSIONS: The findings highlight the problem of homicides and socioeconomic disparities in S. Paulo City. Economic development and reducing socioeconomic inequality may have an impact on the rates of mortality due to violence.     

Social inequality in perceived oral health among adults in Australia

OBJECTIVE: To establish population estimates of self-assessed tooth loss and subjective oral health and describe the social distribution of these measures among dentate adults in Australia. METHODS: Self-report data were obtained from a nationally representative sample of 3,678 adults aged 18-91 years who participated in the 1999 National Dental Telephone Interview Survey and completed a subsequent mail survey. Oral health was evaluated using (1) self-assessed tooth loss, (2) the 14-item Oral Health Impact Profile, and (3) a global six-point rating of oral health. RESULTS: While the absolute difference in tooth loss across household income levels increased at each successive age group (18-44 years, 45-64 years, 65+ years) from 0.7 teeth to 6.1 teeth, the magnitude of the difference was approximately twofold at each age group. For subjective oral health measures, the magnitude of difference across income groups was most pronounced in the 18-44 years age group. In multivariate analysis, low household income, blue-collar occupation, and high residential area disadvantage were positively associated with social impact from oral conditions and pathological tooth loss. Speaking other than English at home (relative to English), low household income (relative to high income), and vocational relative to tertiary education were each associated with more than twice the odds of poor self-rated oral health. CONCLUSIONS: Significant social differentials in perceived oral health exist among dentate adults. Inequalities span the socio-economic hierarchy. IMPLICATIONS: In addition to improving overall levels of oral health in the adult community, goals and targets should aim to reduce social inequalities in the distribution of outcomes.     

Social class differences in health and care in the year before death.

STUDY OBJECTIVE--The aim was to identify any social class differences in health and care in the year before death emerging from a wider study of life before death. DESIGN AND SETTING--Data were collected at interviews, mainly of close relatives, with those who knew most about the people's lives in the year before they died. The sample was a random sample of adult (15 and over) deaths in 10 areas of England in 1987. SUBJECTS--Information was obtained about 639 persons, 80% of the initial sample of 800 deaths. MAIN RESULTS--While middle class people die at an older age, the symptoms and physical restrictions reported for middle class and working class people were similar, and middle class people were reported to have a better quality of life before death. More working class people were felt to be in financial need. CONCLUSIONS--Money and class contribute to the quality of life before death as well as postponing death.     

Social capital and inequality in health between single and couple parents in Sweden

AIMS: To study whether social capital is associated with health among parents and if so, whether existing inequalities in health between single and couple parents could be better understood by introducing social capital as a possible mechanism for how health is distributed. MATERIAL AND METHODS: At total of 2,500 parents with children in the age range of 4-16 years were randomized from existing national registers and asked to participate in a nationally distributed postal questionnaire; 1,589 parents participated (277 single and 1,312 couple), giving a response rate of 64%. The questionnaire contained questions regarding sociodemographic and socioeconomic characteristics, self-rated health, emotional and instrumental social support, civic and social participation, and trust. Social capital was measured by different levels of civic and social participation and trust. A multivariate analysis was used in order to find possible associations between social capital and health, when adjusted for social support, sociodemographic and socioeconomic characteristics. RESULTS: A low level of social capital (both social participation and trust), when adjusted for social support, socioeconomic and sociodemographic variables, was clearly and positively associated with less than good self-rated health. Social capital was unevenly distributed between single and couple mothers. CONCLUSIONS: Social capital is positively associated with self-rated health, at an individual level. The uneven distribution of social capital between single and couple mothers may be of some importance when trying to further understand and possibly alter the inequality in health that exists between single and couple parents.     

Social inequality and health: the role of social capital

The aim of the article is to examine whether and to what degree the unequal distribution of social capital in the population explains the relationship between socioeconomic position and health in Norway. Theoretical insight and empirical evidence seem to suggest that social capital mediates the effect of socioeconomic position on health outcomes. However, only a few studies have addressed this question and those that have done so have used few and simple indicators of social capital. This study is based on a nationwide cross-sectional survey (N = 3190) commissioned by Statistics Norway. The survey was designed to cover a comprehensive set of variables measuring different aspects of the theoretical construct of social capital. Two health outcomes, self-perceived health and longstanding illness, were analysed. The results showed that the mediating role of social capital between socioeconomic position and health was negligible for both health outcomes. After controlling for socio-demographic variables and socioeconomic position, only neighbourhood satisfaction and generalised trust showed a significant association with self-perceived health, whereas none of the social capital variables had any significant association with longstanding illness. Some theoretical and methodological implications of the results are discussed.