This conference reports on work on the integration of social determinants of health – socioeconomic and structural factors – into immigrant health research and policy. A cross-national framework was used to consider issues of place, migration and health. In addition to public health, it drew upon the fields of economics, sociology of immigration, and social epidemiology, and incorporated three theoretical frameworks: the life-course framework from social epidemiology, the ‘push-pull’ factor theories from geography and economics, and transnational theory from sociology. It built upon recent academic literature, including a Social Sciences and Medicine (SSM) supplement on immigration and health, to formulate areas where more research is needed and to recommend potentially fruitful program interventions and policy changes. It integrated work with North American Latino immigrants, Asian and South Asian immigrants, African and Afro-Caribbean immigrants, and Arab immigrants, and research linking the migration to Europe of Arab, Turks and other populations, and to the Middle East of immigrants from Africa.
Equity in Health
The objective of this paper was to determine how social and economic factors contribute to disability differences between older men and women. Researchers analysed World Health Survey data from 57 countries drawn from all income groups, including in their final sample a total of 63,638 respondents aged 50 and older, of whom 28,568 were males and 35,070 females. The researchers computed disability prevalence for males and females by socio-demographic factors, and estimated the adjusted effects of each social determinant on disability for males and females. Results indicated that prevalence of disability among women compared with men aged 50+ years was 40.1% vs. 23.8%. Lower levels of education and economic status were associated with disability in women and men. Approximately 45% of the sex inequality in disability could be be attributed to differences in the distribution of socio-demographic factors, while approximately 55% of the inequality resulted from differences in the effects of the determinants. The authors call 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.
Paula Braveman, Department of Family & Community Medicine, University of California, USA; Eleuther Tarimo, Consultant, Ministry of Health and Child Welfare, Harare, Zimbabwe. Available online at the Social Science & Medicine website. While interest in social disparities in health within affluent nations has been growing, discussion of equity in health with regard to low- and middle-income countries has generally focused on north-south and between-country differences, rather than on gaps between social groups within the countries where most of the world's population lives. This paper aims to articulate a rationale for focusing on within- as well as between-country health disparities in nations of all per capita income levels, and to suggest relevant reference material, particularly for developing country researchers. explicit concerns about equity in health and its determinants need to be placed higher on the policy and research agendas of both international and national organizations in low-, middle-, and high-income countries. International agencies can strengthen or undermine national efforts to achieve greater equity. The Primary Health Care strategy is at least as relevant today as it was two decades ago; but equity needs to move from being largely implicit to becoming an explicit component of the strategy, and progress toward greater equity must be carefully monitored in countries of all per capita income levels. Particularly in the context of an increasingly globalized world, improvements in health for privileged groups should suggest what could, with political will, be possible for all.
Economic indicators suggest that there are adequate global resources to guarantee the essential needs of all of the world's seven billion inhabitants. Nevertheless more than 850 million people in the world are undernourished, according to this new report by Social Watch. To monitor trends in global deprivation, Social Watch developed a basic capabilities index (BCI), which combines infant mortality rates, the number of births attended by trained personnel and enrolment rates in primary school. These indicators are considered as a ‘minimum social floor’. Nevertheless the report notes that the world is far from achieving these basic targets. The BCI rose only seven points between 1990 and 2010, and progress was faster in the first decade than the second. This trend is the opposite for trade and income, both of which grew faster after the year 2000 than in the decade before. The authors warn that the global financial crisis is likely to worsen this inverse trend. The reason for the divergence between the trends in economic and social indicators is posited to be the growing inequality within and between countries.
The linkage between the socio-economic inequality and HIV outcomes was analysed using data from a population-based household survey that employed multistage-stratified sampling, to help refocus attention on how HIV is linked to inequalities. A socio-economic index (SEI) score, derived using multiple correspondence analysis of measures of ownership of durable assets, was used to generate three SEI groups: Low (poorest), Middle, and Upper (no so poor). Distribution of HIV outcomes (i.e. HIV prevalence, access to HIV/AIDS information, level of stigma towards HIV/AIDS, perceived HIV risk and sexual behaviour) across the SEI groups, and other background characteristics was assessed using weighted data. Univariate and multivariate logistic regression was used to assess the covariates of the HIV outcomes across the socio-economic groups. More women than men were found in the poor SEI. HIV prevalence was highest among the poor and declined as SEI increased. Individuals in the upper SEI reported higher frequency of HIV testing compared to the low SEI. Only 21% of those in poor SEI had good access to HIV/AIDS information compared to 80% in the upper SEI. A higher percentage of the poor had a stigmatizing attitude towards HIV/AIDS and personal HIV risk perception compared to those in the upper SEI. Our findings underline the disproportionate burden of HIV disease and HIV fear among the poor and vulnerable in South Africa, who are further disadvantaged by lack of access to HIV information and HIV and AIDS services.
This study compared socioeconomic differentials in self-rated health and happiness in five sub-Saharan countries. Using the 2010/2014 World Values Survey, the authors obtained a sample of 9,869 participants of age 16 and above from five sub-Saharan countries. Socioeconomic inequalities were quantified using the concentration index. Poor self-rated health ranges from approximately 9% in Nigeria to 20% in Zimbabwe, whereas unhappiness was lower in Rwanda and higher in South Africa. Poor self-rated health and unhappiness were excessively concentrated among the poorest socioeconomic strata. Although magnitudes differ across countries, however, the major contributor to wealth-related inequality in poor self-rated health is satisfaction with financial situation whereas for unhappiness the major contributors are level of income and satisfaction with financial situation. This study underscores an association between wealth related inequalities and poor self-rated health and unhappiness in the context of sub-Saharan countries. Improving equity in health may be useful in fighting against the unfair distribution of resources. The authors suggest that knowledge about the self-rating of health and happiness can serve as proxy estimates for understanding the distribution of health care access and economic resources for well-being.
Previous studies have reported large socioeconomic inequalities in mortality from conditions amenable to medical intervention, but it is unclear whether these can be attributed to inequalities in access or quality of health care, or to confounding influences such as inequalities in background risk of diseases. In this study, researchers hypothesised that, as compared to non-amenable causes, inequalities in mortality from amenable causes are more strongly associated with inequalities in health care use and less strongly with inequalities in common risk factors for disease such as smoking. Cause-specific mortality data for people aged 30-74 years were obtained for 14 countries, and were analysed by calculating age-standardised mortality rates and relative risks comparing a lower with a higher educational group. In most countries and for most amenable causes of death substantial inequalities in mortality were observed, but inequalities in mortality from amenable causes did not vary between countries in patterns that are different from those seen for inequalities in non-amenable mortality. As compared to non-amenable causes, inequalities in mortality from amenable causes are not more strongly associated with inequalities in health care use. Inequalities in mortality from amenable causes are also not less strongly associated with common risk factors such as smoking. The authors call for further research to find the causes of socio-economic inequalities in mortality from amenable conditions.
In this study, researchers quantified prevalence of current daily smoking, low fruit and vegetable consumption, physical inactivity, and heavy episodic alcohol drinking and compared them across wealth and education levels in low- and middle-income countries. The study included self-reported data from 232,056 adult participants in 48 countries, derived from the 2002-2004 World Health Survey. Smoking and low fruit and vegetable consumption were found to be significantly higher among lower socioeconomic groups. The highest wealth-related inequality was seen in smoking among men in low- income countries. Physical inactivity was less prevalent in populations of low socioeconomic status, especially in low-income countries. Mixed patterns were found for heavy drinking.
The aim of this study was to assess if a positive gradient in smoking can also be observed in low and middle income countries in other regions of the world. The authors used data of the World Health Survey from 49 countries and a total of 233,917 respondents. Multilevel logistic regression was used to model associations between individual level smoking and both individual level and country level determinants. the results were stratified by education, occupation, sex and generation (younger vs. older than 45). Countries were grouped based on GDP and region. In Sub-Saharan Africa and Latin America no clear gradient was observed: inequalities were relatively small. Among men, no positive gradients were observed, and the strongest negative gradients were seen in South-East Asia and East Asia.
Noncommunicable diseases are an increasing health concern worldwide, but particularly in low- and middle-income countries. This study quantified and compared education- and wealth-based inequalities in the prevalence of five noncommunicable diseases (angina, arthritis, asthma, depression and diabetes) and comorbidity in low- and middle-income country groups, using 2002-04 World Health Survey data from 41 low- and middle-income countries. Wealth and education inequalities were more pronounced in the low-income country group than the middle-income country group. Both wealth and education were inversely associated with angina, arthritis, asthma, depression and comorbidity prevalence, with strongest inequalities reported for angina, asthma and comorbidity. Diabetes prevalence was positively associated with wealth and, to a lesser extent, education. Adjustments for confounding variables tended to decrease the magnitude of the inequality.