Determinants of health inequalities by income from the 1980s to the 1990s in Finland

Income-related health inequalities in the Nordic countries: examining the role of education, occupational class, and age

Numerous studies have concluded that people's socioeconomic position is related to mortality and morbidity, but that the strength of this association varies considerably both within and between European regions. This has spurred several researchers to more closely examine educational and occupational gradients in health in the Nordic countries to clarify the causes of cross-national differences. However, comparable studies using income as an indicator of socioeconomic position are still lacking. This study uses recent and highly comparable data to fill this gap. The aim of this study is threefold. First, we ask to what extent there is an income gradient in health in the Nordic countries, and to what extent the association differs between these countries. Second and third, we examine whether differences in the attenuation of the income gradient by education and occupational class, and age-specific differences between countries, may act as explanations for differences in the income gradient between the Nordic countries. The data source are three waves of the European Social Survey (ESS, 2002/2004/2006), which included 17,801 people aged 25 and over from Denmark, Finland, Norway, and Sweden. Two subjective health measures (physical/mental self reported health and limiting longstanding illness) were analysed by means of logistic regression. The results show that, in all countries, people reported significantly better health and were less likely to suffer from longstanding illness as they had a higher income. This association is strongest in Norway and Finland and weakest in Denmark. The income gradient in health, but not country differences in this gradient, is partly explained by education and occupational class. Additionally, the strength of the income gradient in health varies between age groups. The relatively high health inequalities between income groups in Norway and Finland are already visible in the youngest age groups. The results imply that the socioeconomic gradient in health will arguably not be strongly reduced in the near future as a result of cohort replacement, as has been suggested in previous studies. Health policy interventions may be particularly important five to ten years prior to retirement and in early adulthood.

Interrelationships between education, occupational class, income and sickness absence

BACKGROUND

Socio-economic position measures, such as education, occupational class and income, are well-known determinants of health. However, previous studies have not paid attention to mutual interrelationships between these socio-economic position measures and medically confirmed sickness absence.

METHODS

The study is a register-based study. The participants were municipal employees of the City of Helsinki aged 25-59 years in 2003. There were 21,599 women and 5841 men participants. Three socio-economic position measures were used, namely three-level education, four-level occupational class and gross individual income quartiles. Main outcome measure was medically confirmed sickness absence spells of 4 days or longer. Inequality indices were calculated using Poisson regression analysis.

RESULTS

High education, occupational class and individual income were all consistently associated with lower sickness absence rates among both women and men. After mutual adjustment, education and occupational class remained independent determinants of sickness absence. The association of individual income with sickness absence was practically explained by temporally preceding education and occupational class.

CONCLUSIONS

Our results indicate that education and occupational class-rather than income-are strong determinants of sickness absence. Education, occupational class and income are complementary socio-economic position measures. To better inform sickness absence policy, future studies should aim to establish whether the observed socio-economic differences reflect broader differences in ill-health, lifestyle and working conditions.

Socioeconomic inequalities in early childhood malnutrition and morbidity: modification of the household-level effects by the community SES

This paper examines variations among communities in childhood malnutrition and diarrhea morbidity, explores the influences of socioeconomic status (SES) on child health, and investigates how the SES of families and that of communities interact in this process. Using multilevel modelling and data from Demographic and Health Surveys of five African countries, it shows evidence of contextual effects and a strong patterning in childhood malnutrition and morbidity along SES lines, with community SES having an independent effect in some instances. It also reveals that living in poorest conditions increases the odds of suffering from both malnutrition and diarrhea, as opposed to experiencing only one of the two outcomes. Importantly, community SES significantly modifies the effects of the household SES, suggesting that measures to improve access of mothers and children to basic community resources may be necessary preconditions for higher levels of familial socioeconomic situation to contribute to improved child health.

Social inequalities in mortality: changes in the relative importance of income, education and household size over a 27-year period

BACKGROUND

The aim of this paper was to measure socio-economic inequalities in mortality over a 27-year period, and estimate the simultaneous effects of education and income adjusted for changing proportions and potential confounders.

METHODS

Census data in 1970, 1980 and 1990 with information about income, educational level and household size were linked to mortality records at the individual level and analysed with absolute mortality rates, Poisson regression (univariate and multivariate) and Relative Index of Inequality (RII).

RESULTS

Mortality differences increased between income quartiles and educational groups as well as between singles and non-singles. RII between income quartiles increased from 1.6 to 3.6 for men and 1.7 to 2.7 for women while RII between the educational groups increased from 1.6 to 2.8 for men and 1.5 to 2.1 for women. However, RII derived from the adjusted multivariate regression analysis was 1.8 (men) and 1.9 (women) between the income groups in 1990 and 2.2 (men) and 1.7 (women) between the educational groups. In the 1990s current income was more important than previous income, and the rate ratios (RR) increased for groups dropping into the lowest income quartile between two censuses.

CONCLUSION

Low education and single status have become relatively more important risk factors for mortality over time. Confounder effects of education and household size could partly explain the seemingly large increase in inequalities between income groups. Results may also indicate a stronger reverse causation (poor health causing low income) over time.

Does high income buffer the association between adverse working conditions and ill health?

AIM

A study was undertaken to analyse the possible interaction between work environment and income for the probability of self-rated health being less than good.

METHODS

Data from the Swedish Survey of Living Conditions for the years 1998 and 1999 were analysed. Employed 20- to 64-year-olds with a registered wage were included (n=5982). The synergy index (SI) was applied, using odds ratios from logistic regressions for men, women, and all. Low and high levels of physical demands, decision authority, skill discretion and psychological demands were separately combined with low- and high-wage income (median split). Full-time work and four sociodemographic factors were controlled for.

RESULTS

Significant synergy was found for women when they were exposed to low income and a low level of skill discretion (SI=1.46 [1.01-2.13]), although this was attenuated by education level (SI=1.47 [0.96-2.25]). In general (both sexes), poor health caused by low income and unfavourable work is additive rather than multiplicatively exaggerating the risk among the jointly exposed.

CONCLUSION

Work exposures in the form of high physical load, low levels of decision authority and skill discretion, or a high level of psychological demands were significantly related to poor health also when income was high, suggesting that high income does not seem to buffer the detrimental effects of adverse working conditions. As nearly half of employed women were found to be in circumstances marked by synergy, it seems a relevant public health issue to improve these women's conditions at work, by simultaneously increasing, for example, job variety and wages.

Health inequalities by wage income in Sweden: the role of work environment

The main aim of this study was to explore the mediating role made by work environment to health inequalities by wage income in Sweden. Gender differences were also analysed. Data from the Swedish Survey of Living Conditions for the years 1998 and 1999 were analysed. Employed 20-64-year olds with a registered wage were included (nearly 6000 respondents). Sex-specific logistic regressions in relation to global self-rated health were applied. Those in the lowest income quintile had 2.4 times (men) and 4.3 times (women) higher probability of less than good health than did those in the highest quintile (adjusted for age, family status, country of birth, education level, smoking and full-time work). The mediating contribution of work environment factors to the health gradient by income was 25 per cent (men) and 29 per cent (women), respectively. This contribution was observed mainly from ergonomic and physical exposure, decision authority and skill discretion. Psychological demands did not contribute to such inequalities because mentally demanding work tasks are more common in high income as compared with low income jobs. Using sex-specific income quintiles, instead of income quintiles for the entire sample, gave very similar results. In conclusion, work environment factors can be seen as important mediators for the association between wage income and ill health in Sweden. A larger residual effect of income on health for women as compared with men suggests that one's own income from work is a more important determinant of women's than men's ill health in Sweden.

The shape of the relationship between income and self-assessed health: an international study

BACKGROUND

The relationship between income and health is usually thought to be curvilinear, but previous studies have yielded inconsistent results. We therefore examined the shape of the relationship between household equivalent income and self-assessed health in seven European countries.

METHODS

Data were obtained from nationally representative health, level of living, or similar surveys in Belgium, Denmark, England, Finland, France, The Netherlands, and Norway and applied to men and women aged 25 years and older in the 1990s. Smooth nonparametric curves were fitted to the data, as well as a spline regression function with three linear pieces connected by two knots.

RESULTS

A higher household equivalent income is associated with better self-assessed health among men and women in all countries, particularly in the middle-income range. In the higher income ranges, the relationship is generally curvilinear and characterized by less improvement in self-assessed health per unit of rising income. In the lowest income ranges, the relationship is found to be curvilinear in four countries (Belgium, Finland, The Netherlands, and Norway), where the usual deterioration of health associated with lower incomes levels off or even reverses into an improvement.

CONCLUSIONS

Further research is necessary to investigate the background of differences between countries in the shape of the relationship between income and self-assessed health, and should focus on both methodological and substantive explanations. Assuming causality, the results of our study lend some support to the notion of decreasing marginal health returns of a unit increase in income at the higher income ranges.

Self-esteem, stress and self-rated health in family planning clinic patients

Background

The independent effects of stress on the health of primary care patients might be different for different types of clinic populations. This study examines these relationships in a low-income female population of patients attending a family planning clinic.

Methods

This study investigated the relevance of different sources of personal stress and social support to self-rated health, adjusting for mental health, health behavior and demographic characteristics of subjects. Five hundred women who attended family planning clinics were surveyed and 345 completed the form for a response rate of 72 percent.

Results

Multiple logistic regression analysis revealed that liking oneself was related to good self-rated health (Odds ratio = 7.11), but stress or support from children, parents, friends, churches or spouses were not significant. White non-Hispanic and non-white non-Hispanic respondents had lower odds of reporting good self-rated health than Hispanic respondents (odds ratios were 2.87 and 2.81, respectively). Exercising five or more days per week also was related to good self-rated health. Smoking 20 or more cigarettes per day, and obese III were negatively related to good self-rated health (odds ratios were .19 and .22, respectively with corresponding p-values equal to .0043 and .0332).

Conclusions

Among younger low-income women, addressing low self-esteem might improve health status.

Unsafe neighborhoods, social group activity, and self-rated health

The purpose of this project was to assess the importance of stressors and social supports in influencing self-rated health in a community sample so that public health programs could be designed to address the root causes of poor health. The municipal health department in Amarillo, Texas, contracted for a Behavioral Risk Factor Surveillance survey in 2002. The dependant variable for the study was self-rated health. Results suggest that programs targeted at improving neighborhood safety and increasing involvement in organized social groups are needed. Public health agencies may need to collaborate with other governmental agencies in order to craft effective policies.

How did Finland's economic recession in the early 1990s affect socio-economic equity in the use of hospital care?

The study evaluates the changes in socio-economic equity in the use of general hospital care in Finland from the late 1980s to the mid 1990s. In the early 1990s the Finnish economy plunged into a deep recession which slashed over 10% of GDP and resulted in a 12% decrease in national health expenditure. At the same time, the administration and financing of specialised health services were reformed. The impact on general hospital care was controversial: budgets were reduced but better productivity increased the supply of many services. According to the study, data, based on individual linkage of nationwide hospital registers to disposable family income data in population censuses, overall acute general hospital admission rates among Finns aged 25-74 increased by over 10% from 1988 to 1996. For some surgical procedures, such as cataract, coronary revascularisation and some orthopaedic operations, rates more than doubled. In both years, lower-income groups generally used hospital care more than the better-off. However, there was a slight shift towards a pro-rich distribution, mainly due to a larger increase in surgical care among the high-income groups. In 1988 the lowest income quintile used 8% and in 1996 15% fewer operations than the highest. For individual procedures and surgical diagnostic categories, the general trends of increasing disparities were similar. Despite cuts in expenditures in the early 1990s, the Finnish general hospital system based on public funding and provision managed to increase the supply of services. However, this increase coincided with widening socio-economic discrepancies in the use of surgical services. The paper proposes that these increasing inequities were due to certain features of the Finnish health care system which create social discrepancies in access to hospital care. These include the high profile of the private sector in specialised ambulatory care and in the supply of some elective procedures, and semi-private public hospital services requiring supplementary payments from patients.