Welfare regimes modify the association of disadvantaged adult-life socioeconomic circumstances with self-rated health in old age

BACKGROUND

Welfare regimes in Europe modify individuals' socioeconomic trajectories over their life-course, and, ultimately, the link between socioeconomic circumstances (SECs) and health. This paper aimed to assess whether the associations between life-course SECs (early-life, young adult-life, middle-age and old-age) and risk of poor self-rated health (SRH) trajectories in old age are modified by welfare regimes (Scandinavian [SC], Bismarckian [BM], Southern European [SE], Eastern European [EE]).

METHODS

We used data from the longitudinal SHARE survey. Early-life SECs consisted of four indicators of living conditions at age 10. Young adult-life, middle-age, and old-age SECs indicators were education, main occupation and satisfaction with household income, respectively. The association of life-course SECs with poor SRH trajectories was analysed by confounder-adjusted multilevel logistic regression models stratified by welfare regime. We included 24 011 participants (3626 in SC, 10 256 in BM, 6891 in SE, 3238 in EE) aged 50 to 96 years from 13 European countries.

RESULTS

The risk of poor SRH increased gradually with early-life SECs from most advantaged to most disadvantaged. The addition of adult-life SECs differentially attenuated the association of early-life SECs and SRH at older age across regimes: education attenuated the association only in SC and SE regimes and occupation only in SC and BM regimes; satisfaction with household income attenuated the association across regimes.

CONCLUSIONS

Early-life SECs have a long-lasting effect on SRH in all welfare regimes. Adult-life SECs attenuated this influence differently across welfare regimes.

[Infant mortality in the European Union: A time trend analysis of the 1994-2015 period]

BACKGROUND

Infant mortality is an indicator of child health, and an explanatory variable to reflect the socioeconomic development of a country. We aimed to examine the changes and trends of infant mortality in the European Union (EU) and its 28 member states in the 1994-2015 period.

METHODS

We extracted data of deaths in children aged less than one year between 1994 and 2015 from the Eurostat database. We analysed secular variation in the EU overall, by country and by geographical region using joinpoint regression analysis. We conducted additional analyses to examine neonatal and early neonatal mortality trends.

RESULTS

Infant mortality in the EU has declined significantly from 8,3 to 3,6 per 1,000 live births (annual percent change=-3,8%; 95% confidence interval, -4,1 to -3,6). Among EU countries, we found the highest mortality rates throughout the study period in Romania and Bulgaria, and the lowest rates in Scandinavian countries (Finland, Sweden). There were significant decreasing trends in every country of the EU, which were most pronounced in former Soviet Baltic states and Eastern European countries, and least pronounced in Western European countries. Mortality rates have increased significantly in Greece in the last years, and plateaued in the United Kingdom and Ireland.

CONCLUSIONS

Our findings, which are based on official data, provide consistent evidence that infant mortality has declined steadily in the EU and its member states in the past decades, most markedly in Eastern European countries and former Soviet Baltic states. However, rates have risen or levelled off in some western countries in the past few years.

Early childhood development in Iran and its provinces: Inequality versus average

BACKGROUND

Early childhood development is influenced by family socioeconomic status in such a way that socioeconomic deprivation might be accompanied with adverse outcomes in early development of a child. This study aimed to assess early childhood development based on average and also based on the distribution of socioeconomic inequality in Iran and its provinces.

METHODS

Using data from provincially representative Multiple Indicator Demographic and Health Survey (2010), we developed a suitable latent class approach to construct a proxy of socioeconomic status. A composite index of early childhood development was used. We assessed inequality in early childhood development using the concentration index method.

RESULTS

At province level (n = 30), the highest and lowest averages of early childhood development were 13.60 (SD = 2.99) and 5.81 (SD = 3.29), respectively. Concentration indices indicated pro-rich inequality in early childhood development at national and provincial level. The concentration index of early childhood development was 0.087 (95% CI = 0.085-0.0098) in Iran. Moreover, the consistent positive values of the concentration indices revealed that early childhood development inequality favored best-off children in all provinces. However, early childhood development was disproportionally distributed among provinces and rated 0.016 to 0.149.

CONCLUSIONS

Iranian children in more prosperous households reported higher early childhood development compared with those in poor households at national and provincial level. It is vital to consider inequality in addition to average level of childhood development across Iranian provinces to reach a more comprehensive understanding of childhood development for public policy action in the country.

The relationships between income inequality, welfare regimes and aggregate health: a systematic review

Background

: When analysing the relationships between income inequality, welfare regimes and aggregate health at the cross-national level, previous primary articles and systematic reviews reach inconsistent conclusions. Contrary to theoretical expectations, equal societies or the Social Democratic welfare regime do not always have the best aggregate health when compared with those of other relatively unequal societies or other welfare regimes. This article will shed light on the controversial subjects with a new decomposition systematic review method. The decomposition systematic review method breaks down an individual empirical article, if necessary, into multiple findings based on an article's use of the following four components: independent variable, dependent variable, method and dataset. This decomposition method extracts 107 findings from the selected 48 articles, demonstrating the dynamics between the four components. 'The age threshold effect' is recognized over which the hypothesized relations between income inequality, welfare regimes and aggregate health reverse. The hypothesis is supported mainly for younger infant and child health indicators, but not for adult health or general health indicators such as life expectancy. Further three threshold effects (income, gender and period) have also been put forward. The negative relationship between income inequality and aggregate health, often termed as the Wilkinson Hypothesis, was not generally observed in all health indicators except for infant and child mortality. The Scandinavian welfare regime reveals worse-than-expected outcomes in all health indicators except infant and child mortality.

Health Care Public Sector Share and the U.S. Life Expectancy Lag: A Country-level Longitudinal Study

Growing research on the political economy of health has begun to emphasize sociopolitical influences on cross-national differences in population health above and beyond economic growth. While this research investigates the impact of overall public health spending as a share of GDP ("health care effort"), it has for the most part overlooked the distribution of health care spending across the public and private spheres ("public sector share"). I evaluate the relative contributions of health care effort, public sector share, and GDP to the large and growing disadvantage in U.S. life expectancy at birth relative to peer nations. I do so using fixed effects models with data from 16 wealthy democratic nations between 1960 and 2010. Results indicate that public sector share has a beneficial effect on longevity net of the effect of health care effort and that this effect is nonlinear, decreasing in magnitude as levels rise. Moreover, public sector share is a more powerful predictor of life expectancy at birth than GDP per capita. This study contributes to discussions around the political economy of health, the growth consensus, and the American lag in life expectancy. Policy implications vis-à-vis the U.S. Affordable Care Act are discussed.

Political determinants of progress in the MDGs in Sub-Saharan Africa

Sub-Saharan Africa (SSA) lagged furthest behind in achieving targets for the millennium development goals (MDG). We investigate the hypothesis that its slow progress is influenced by political factors. Longitudinal data on three health MDG indicators: under-five mortality, maternal mortality and HIV prevalence rates were collated from 1990 to 2012 in 48 countries. Countries were grouped into geo-political and eco-political groups. Groupings were based on conflict trends in geographical regions and the International Monetary Fund's classification of SSA countries based on gross national income and development assistance respectively. Cumulative progress in each group was derived and main effects tested using ANOVA. Correlation analysis was conducted between political variables - POLITY 2, fragile state index (FSI), voter turnout rates, civil liberty scores (CLS) and the health variables. Our results suggest a significant main effect of eco-political and geo-political groups on some of the health variables. Political conflict as measured by FSI and political participation as measured by CLS were stronger predictors of slow progress in reducing under-five mortality rates and maternal mortality ratios. Our findings highlight the need for further research on political determinants of mortality in SSA. Cohesive effort should focus on strengthening countries' political, economic and social capacities in order to achieve sustainable goals beyond 2015.

The rate of country-level improvements of the infant mortality rate is mainly determined by previous history

BACKGROUND

Studies of country-level determinants of health have produced conflicting results even when the analyses have been restricted to high-income counties. Yet, most of these studies have not taken historical, country-specific developments into account. Thus, it is appropriate to separate the influence of current exposures from historical aspects.

METHODS

Determinants of the infant mortality rate (IMR) were studied in 28 OECD countries over the period 1990-2012. Twelve determinants were selected. They refer to the level of general resources, resources that specifically address child health and characteristics that affect knowledge dissemination, including level of trust, and a health related behaviour: the rate of female smoking.

RESULTS

Bivariate analyses with the IMR in year 2000 as outcome and the 12 determinants produced six statistically significant models. In multivariate analyses, the rate of decrease in the IMR was investigated as outcome and a history variable (IMR in 1990) was included in the models. The history variable alone explained 95% of the variation. None of the multivariate models, with the 12 determinants included, explained significantly more variation.

CONCLUSION

Taking into account the historical development of the IMR will critically affect correlations between country-level determinants and the IMR.

Comprehensive peace agreement implementation and reduction in neonatal, infant and under-5 mortality rates in post-armed conflict states, 1989-2012

Background

Previous studies suggest that countries with a higher child mortality rate are more susceptible to armed conflict onset as well as recurrence. Studies do not explain conditions under which child mortality declines among post-armed conflict states. This article argues that where armed conflict is terminated through negotiation and implementation of comprehensive peace agreements (CPAs), the child mortality rate declines. This is due to the implementation of provisions in CPAs, which addresses underlying grievances of the poor, underserved and marginalized segments of the population, as well as the successful reconstruction of the health sector. CPA implementation resolves hostilities between armed rivals and facilitates the return process for internally displaced persons and refugees. The CPA implementation may also encourage the return of aid workers and health professionals to conflict-affected zones.

Method

This study utilizes new data on CPA implementation and examines neonatal, infant and under-5 mortality rates among 73 post-armed conflict countries between 1989 and 2012. Multivariate cross-sectional time series correlation (fixed effect) methods are used to analyze the data.

Results

Within post-armed conflict states, a decline in neonatal, infant and under-5 mortality rates is associated with higher CPA implementation rates. Additionally, this study shows that higher GDP per capita, higher levels of democracy, and more primary school enrollment are also associated with lower child mortality rates. On the other hand, child mortality rates increase following a rebel victory in armed conflict.

Conclusion

Ongoing armed conflicts are responsible for massive displacements and the destruction of economic, healthcare and human infrastructure, thus hindering improvements in child survival. For better health outcomes in post-armed conflict countries, ongoing armed conflict must cease through the signing and implementation of a CPA. Short-term and long-term public health issues are discussed in concluding comments.

Electronic supplementary material

The online version of this article (doi:10.1186/s12914-015-0066-7) contains supplementary material, which is available to authorized users.

Burden and cost of neurological diseases: a European North-South comparison

OBJECTIVES

To address the relationship between years lived with a disability (YLDs), prevalence and cost of neurological diseases, and to test whether there is a European North-South gradient for national health expenditure, disability, costs and prevalence of neurological diseases.

MATERIALS AND METHODS

Information on costs, prevalence and YLDs referred to 2010 were taken from the Study on the Cost of Disorders of the Brain and from the Global Burden of Disease study; data on health expenditure were taken from OECD reports. Selected conditions were as follows: brain tumours, stroke, dementia, Parkinson's disease, epilepsy, multiple sclerosis, migraine and tension-type headache; selected countries were from North (Denmark, Finland, Norway, Sweden) and South (Greece, Italy, Portugal, Spain) Europe. The association between the variables for each condition was tested using Spearman's correlation; Wilcoxon signed ranks test was used to test North-South Europe differences.

RESULTS

Correlations were largely non-significant (except for stroke). YLDs and cost were generally lower in South-European countries, and prevalence was lower in North-European countries, but no significant differences were found.

CONCLUSIONS

Health expenditure, YLDs, costs and prevalence of neurological conditions were generally not correlated across the eight countries. A clear North-South gradient was found for health expenditures, and partially for YLDs, costs and diseases' prevalence. We hypothesized that this is a consequence of the expansion of morbidity of neurological conditions connected to ageing, that health and welfare systems of selected countries were not prepared to face.

Understanding why children die in high-income countries

Many factors affect child and adolescent mortality in high-income countries. These factors can be conceptualised within four domains-intrinsic (biological and psychological) factors, the physical environment, the social environment, and service delivery. The most prominent factors are socioeconomic gradients, although the mechanisms through which they exert their effects are complex, affect all four domains, and are often poorly understood. Although some contributing factors are relatively fixed--including a child's sex, age, ethnic origin, and genetics, some parental characteristics, and environmental conditions--others might be amenable to interventions that could lessen risks and help to prevent future child deaths. We give several examples of health service features that could affect child survival, along with interventions, such as changes to the physical or social environment, which could affect upstream (distal) factors.

Geographic analysis of infant mortality in New Zealand, 1995-2008: an ethnicity perspective

OBJECTIVE

To detect spatial clusters of high infant mortality rates in New Zealand for Māori and non-Māori populations and verify if these clusters are stable over a certain time period (1995-2008) and similar between the two populations.

METHOD

We applied the Kulldorff's spatial scan statistics on data collected by New Zealand Ministry of Health (1995 to 2008) at the territorial local authorities (TLA) level. Kappa coefficient was used to assess the concordance between clusters obtained for Māori and non-Māori populations. T-test analyses were conducted to identify associations between spatial clusters and two predictors (population density and deprivation score).

RESULTS

There are some significant spatial clusters of infant mortality in New Zealand for both Māori and Non-Māori. The concordance of the cluster locations between the two populations is strong (kappa=0.77). Unsurprisingly, infant mortality clusters for both Māori and Non-Māori are associated with the deprivation score. The population density predictor is only significantly and positively associated with clusters obtained for the non-Māori population. After controlling for deprivation the presence of spatial clusters is all but eliminated.

CONCLUSIONS

Infant mortality patterns are geographically similar for both Māori and Non-Māori. However, there are differences geographically between the two populations after accounting for deprivation.

IMPLICATIONS

Health services that can affect infant mortality should be aware of the geographical differences across NZ. Deprivation is an important factor in explaining infant mortality rates and policies that ameliorate its effects should be pursued, as it is the major determinant of the geographical pattern of infant mortality in NZ.

US infant mortality and the President's party

BACKGROUND

Infant mortality rates in the US exceed those in all other developed countries and in many less developed countries, suggesting political factors may contribute.

METHODS

Annual time series on overall, White and Black infant mortality rates in the US were analysed over the 1965-2010 time period to ascertain whether infant mortality rates varied across presidential administrations. Data were de-trended using cubic splines and analysed using both graphical and time series regression methods.

RESULTS

Across all nine presidential administrations, infant mortality rates were below trend when the President was a Democrat and above trend when the President was a Republican. This was true for overall, neonatal and postneonatal mortality. Regression estimates show that, relative to trend, Republican administrations were characterized by infant mortality rates that were, on average, 3% higher than Democratic administrations. In proportional terms, effect size is similar for US Whites and Blacks. US Black rates are more than twice as high as White, implying substantially larger absolute effects for Blacks.

CONCLUSIONS

We found a robust, quantitatively important association between net of trend US infant mortality rates and the party affiliation of the president. There may be overlooked ways by which macro-dynamics of policy impact microdynamics of physiology, suggesting the political system is a component of the underlying mechanism generating health inequality in the USA.