Measurement and explanation of socioeconomic inequality in health with longitudinal data

This paper presents a method for the measurement of changes in health inequality and income-related health inequality over time in a population.For pure health inequality (as measured by the Gini coefficient) andincome-related health inequality (as measured by the concentration index),we show how measures derived from longitudinal data can be related tocross section Gini and concentration indices that have been typicallyreported in the literature to date, along with measures of health mobilityinspired by the literature on income mobility. We also show how thesemeasures of mobility can be usefully decomposed into the contributions ofdifferent covariates. We apply these methods to investigate the degree ofincome-related mobility in the GHQ measure of psychological well-being inthe first nine waves of the British Household Panel Survey (BHPS). Thisreveals that dynamics increase the absolute value of the concentrationindex of GHQ on income by 10%.

Modeling usage of medical care services: the medical expenditure panel survey data, 1996-2000

We explore the determinants of usage of six different types of health care services, using the Medical Expenditure Panel Survey data, years 1996-2000. We apply a number of models for univariate count data, including semiparametric, semi-nonparametric and finite mixture models. We find that the complexity of the model that is required to fit the data well depends upon the way in which the data is pooled across sexes and over time, and upon the characteristics of the usage measure. Pooling across time and sexes is almost always favored, but when more heterogeneous data is pooled it is often the case that a more complex statistical model is required.

Health and income: a robust comparison of Canada and the US

This paper uses sequential stochastic dominance procedures to compare the joint distribution of health and income across space and time. It is the First application of which we are aware of methods to compare multidimensional distributions of income and health using procedures that are robust to aggregation techniques. The paper's approach is more general than comparisons of health gradients and does not require the estimation of health equivalent incomes. We illustrate the approach by contrasting Canada and the US using comparable data. Canada dominates the US over the lower bidimensional welfare distribution of health and income, though not generally in terms of the uni-dimensional distribution of health or income. The paper also finds that welfare for both Canadians and Americans has not unambiguously improved during the last decade over the joint distribution of income and health, in spite of the fact that the uni-dimensional distributions of income have clearly improved during that period.

Health care utilization among immigrants and native-born populations in 11 European countries. Results from the Survey of Health, Ageing and Retirement in Europe

Objective: This study examines health care utilization of immigrants relative to the native-born populations aged 50 years and older in eleven European countries. Methods. We analyzed data from the Survey of Health Aging and Retirement in Europe (SHARE) from 2004 for a sample of 27,444 individuals in 11 European countries. Negative Binomial regression was conducted to examine the difference in number of doctor visits, visits to General Practitioners (GPs), and hospital stays between immigrants and the native-born individuals. Results: We find evidence those immigrants above age 50 use health services on average more than the native-born populations with the same characteristics. Our models show immigrants have between 6% and 27% more expected visits to the doctor, GP or hospital stays when compared to native-born populations in a number of European countries. Discussion: Elderly immigrant populations might be using health services more intensively due to cultural reasons.

Health intervention and decline in infant mortality rates. Milk depots in Spain (1900-1936)

The role of public health has been a central topic on the classical debate about the historical mortality decline in Europe. One of these health initiatives were the Milk Depots. Spain set up those centres from the late 19th century until the beginning of the Civil War. The goal of this paper is to evaluate the effect of this health intervention on the infant mortality decline during this period. This study works out three kinds of sources: Statistical Yearbooks, Official documents and local records produced by the same Milk Depot. It analyses data available for all the country and one local case such as the Barcelona’s Milk Depot (1904-1935). The main methodological issue deals with the measurement of the effect of the Milk Depot activities on the pattern of changes of infant mortality. Results suggest that Milk Depots have a positive but quite moderate effect on the improving of overall levels of child survival.

Work, risk and health: differences between immigrants and natives in Spain

We analyze the impact of working and contractual conditions, particularly exposure to job risks, on the probability of acquiring a disability. We postulate a model in which this impact is mediated by the choice of occupation, with a level of risk associated to it. We assume this choice is endogenous, and that it depends on preferences and opportunities in the labour market, both of which may differ between immigrants and natives. To test this hypothesis we use data from the Continuous Sample of Working Lives of the Spanish SS system. It contains individual, job and firm information of over a million workers, including a representative sample of immigrants. We find that risk exposure increases the probability of permanent disability by 5.3%; temporary employment also influences health. Migrant status -with differences among regions of origin- significantly affects both disability and the probability of being employed in a risky occupation. Most groups of immigrants work in riskier jobs, but have lower probability of becoming disabled. Nevertheless, our theoretical hypothesis that disability and risk are jointly determined is not valid for immigrants: i.e. for them working conditions is not a matter of choice in terms of health.

Neither Private nor Public: The Effects of Communal Provision of Water on Child Health in Peru

The literature on local services has focused on the effects of privatization and, if anything, has compared the effects of private and mixed public-private systems versus public provision. However, alternative forms of provision such as cooperatives, which can be very prevalent in many developing countries, have been completely ignored. In this paper, we investigate the effects of communal water provison (Comités Vecinales and Juntas Administrativas de Servicios de Saneamiento) on child health in Peru. Using detailed survey data at the household- and child-level for the years 2006-2010, we exploit the cross-section variability to assess the differential impact of this form of provision. Despite controlling for a wide range of household and local characteristics, the municipalities served by communal organizations are more likely to have poorer health indicators, what would result in a downward bias on the absolute magnitude of the effect of cooperatives. We rely on an instrumental variable strategy to deal with this potential endogeneity problem, and use the personnel resources and the administrative urban/rural classi fication of the municipalities as instruments for the provision type. The results show a negative and signi cant effect of comunal water provision on diarrhea among under- five year old children. Keywords: water utilities, cooperatives, child health, regulation, Peru. JEL Classi fication Numbers: L33; L50; L95

Intermediary and structural determinants of early childhood health in Colombia: exploring the role of communities

This study examines how structural determinants influence intermediary factors of child health inequities and how they operate through the communities where children live. In particular, we explore individual, family and community level characteristics associated with a composite indicator that quantitatively measures intermediary determinants of early childhood health in Colombia. We use data from the 2010 Colombian Demographic and Health Survey (DHS). Adopting the conceptual framework of the Commission on Social Determinants of Health (CSDH), three dimensions related to child health are represented in the index: behavioural factors, psychosocial factors and health system. In order to generate the weight of the variables and take into account the discrete nature of the data, principal component analysis (PCA) using polychoric correlations are employed in the index construction. Weighted multilevel models are used to examine community effects. The results show that the effect of household’s SES is attenuated when community characteristics are included, indicating the importance that the level of community development may have in mediating individual and family characteristics. The findings indicate that there is a significant variance in intermediary determinants of child health between-community, especially for those determinants linked to the health system, even after controlling for individual, family and community characteristics. These results likely reflect that whilst the community context can exert a greater influence on intermediary factors linked directly to health, in the case of psychosocial factors and the parent’s behaviours, the family context can be more important. This underlines the importance of distinguishing between community and family intervention programmes.

Time-series regression models to study the short-term effects of environmental factors on health

Time series regression models are especially suitable in epidemiology for evaluating short-term effects of time-varying exposures on health. The problem is that potential for confounding in time series regression is very high. Thus, it is important that trend and seasonality are properly accounted for. Our paper reviews the statistical models commonly used in time-series regression methods, specially allowing for serial correlation, make them potentially useful for selected epidemiological purposes. In particular, we discuss the use of time-series regression for counts using a wide range Generalised Linear Models as well as Generalised Additive Models. In addition, recently critical points in using statistical software for GAM were stressed, and reanalyses of time series data on air pollution and health were performed in order to update already published. Applications are offered through an example on the relationship between asthma emergency admissions and photochemical air pollutants

Social Determinants of Child Health in Colombia: Can Community Education Moderate the Effect of Family Characteristics?

Contextual effects on child health have been investigated extensively in previous research. However, few studies have considered the interplay between community characteristics and individual-level variables. This study examines the influence of community education and family socioeconomic characteristics on child health (as measured by height and weight-for-age Z-scores), as well as their interactions. We adapted the Commission on Social Determinants of Health (CSDH) framework to the context of child health. Using data from the 2010 Colombian Demographic and Health Survey (DHS), weighted multilevel models are fitted since the data are not self-weighting. The results show a positive impact of the level of education of other women in the community on child health, even after controlling for individual and family socioeconomic characteristics. Different pathways through which community education can substitute for the effect of family characteristics on child nutrition are found. The interaction terms highlight the importance of community education as a moderator of the impact of the mother’s own education and autonomy, on child health. In addition, the results reveal differences between height and weight-for-age indicators in their responsiveness to individual and contextual factors. Our findings suggest that community intervention programmes may have differential effects on child health. Therefore, their identification can contribute to a better targeting of child care policies.

Health inequalities among the elderly in western Europe

Background: This paper analyses gender inequalities in health status and in social determinants of health among the elderly in Western Europe. Methods: Data came from the first wave of the “Survey of Health, Ageing and Retirement in Europe” (SHARE, 2004). For the purposes of this study a subsample of community-residing people aged 65-85 years with no paid work was selected (4218 men and 5007 women). Multiple logistic regression models separated by sex and adjusted for age and country were fitted. Results: Women were more likely to report poor health status, limitations in mobility and poor mental health. Whereas in both sexes educational attainment was associated with the three health indicators, household income was only related to poor self-rated health among women. The relationship between living arrangements and health differed by gender and was primarily associated with poor mental health. In both sexes, not living with the partner but living with other people and being the household head was related to poor mental health status (aOR=2.14; 95% CI=1.11-4.14 for men and aOR=1.75; 95% CI=1.12-2.72 for women). Additionally, women living with their partner and other(s) and those living alone were more likely to report poor mental health status (aOR=1.67; 95% CI=1.17-2.41 and aOR=1.58; 95% CI=1.26-1.97, respectively). Conclusions: Health inequalities persist among the elderly. Women have poorer health status than men and in both sexes the risk of poor health status increases among those with low educational attainment. Living arrangements are primarily associated with poor mental health status with patterns that differ by gender.

Gender inequality in health among elderly people in a combined framework of socioeconomic position, family characteristics and social support

This study analyses gender inequalities in health among elderly people in Catalonia (Spain) by adopting a conceptual framework that globally considers three dimensions of health determinants : socio-economic position, family characteristics and social support. Data came from the 2006 Catalonian Health Survey. For the purposes of this study a sub-sample of people aged 65–85 years with no paid job was selected (1,113 men and 1,484 women). The health outcomes analysed were self-perceived health status, poor mental health status and long-standing limiting illness. Multiple logistic regression models separated by sex were fitted and a hierarchical model was fitted in three steps. Health status among elderly women was poorer than among the men for the three outcomes analysed. Whereas living with disabled people was positively related to the three health outcomes and confidant social support was negatively associated with all of them in both sexes, there were gender differences in other social determinants of health. Our results emphasise the importance of using an integrated approach for the analysis of health inequalities among elderly people, simultaneously considering socio-economic position, family characteristics and social support, as well as different health indicators, in order fully to understand the social determinants of the health status of older men and women.

Invisible work, unseen hazards: the health of women immigrant household service workers in Spain

Backgroud: Household service work has been largely absent from occupational health studies. We examine the occupational hazards and health effects identified by immigrant women household service workers. Methods: Exploratory, descriptive study of 46 documented and undocumented immigrant women in household services in Spain, using a phenomenological approach. Data were collected between September 2006 and May 2007 through focus groups and semi-structured individual interviews. Data were separated for analysis by documentation status and sorted using a mixed-generation process. In a second phase of analysis, data on psychosocial hazards were organized using the Copenhagen Psychosocial Questionnaire as a guide. Results: Informants reported a number of environmental, ergonomic and psychosocial hazards and corresponding health effects. Psychosocial hazards were especially strongly present in data. Data on reported hazards were similar by documentation status and varied by several emerging categories: whether participants were primarily cleaners or carers and whether they lived in or outside of the homes of their employers. Documentation status was relevant in terms of empowerment and bargaining, but did not appear to influence work tasks or exposure to hazards directly. Conclusions:Female immigrant household service workers are exposed to a variety of health hazards that could be acted upon by improved legislation, enforcement, and preventive workplace measures, which are discussed.

Self-reported social class in adolescents: validity and relationship with gradients in self-reported health

Background: Analyzing social differences in the health of adolescents is a challenge. The accuracy of adolescent's report on familial socio-economic position is unknown. The aims of the study were to examine the validity of measuring occupational social class and family level of education reported by adolescents aged 12 to 18, and the relationship between social position and self-reported health.Methods: A sample of 1453 Spanish adolescents 12 to 18 years old from urban and rural areas completed a self-administered questionnaire including the Child Health and Illness Profile-Adolescent Edition (CHIP-AE), and data on parental occupational social class (OSC) and level of education (LE). The responsible person for a sub-sample of teenagers (n = 91) were interviewed by phone. Kappa coefficients were estimated to analyze agreement between adolescents and proxy-respondents, and logistic regression models were adjusted to analyze factors associated with missing answers and disagreements. Effect size (ES) was calculated to analyze the relationship between OSC, LE and the CHIP-AE domain scores.Results: Missing answers were higher for father's (24.2%) and mother's (45.7%) occupational status than for parental education (8.4%, and 8.1% respectively), and belonging to a non-standard family was associated with more incomplete reporting of social position (OR = 4,98; 95%CI = 1,3–18,8) as was agreement between a parent and the adolescent. There were significant social class gradients, most notably for aspects of health related to resilience to threats to illness.ConclusionAdolescents can acceptably self-report on family occupation and level of education. Social class gradients are present in important aspects of health in adolescents.

A sequential model for older workers' labor transitions after a health shock

In this work we study older workers'(50-64) labor force transitions after a health/disability shock. We find that the probability of keeping working decreases with both age and severity of the shock. Moreover, we find strong interactions between age and severity in the 50-64 age range and none in the 30-49 age range. Regarding demographics we find that being female and married reduce the probability of keeping work. On the contrary, being main breadwinner, education and skill levels increase it. Interestingly, the effect of some demographics changes its sign when we look at transitions from inactivity to work. This is the case of being married or having a working spouse. Undoubtedly, leisure complementarities should play a role in the latter case. Since the data we use contains a very detailed information on disabilities, we are able to evaluate the marginal effect of each type of disability either in the probability of keeping working or in returning back to work. Some of these results may have strong policy implications.