Health and the Social Rights of Citizenship: Integrating Welfare-State Theory and Medical Sociology

Unemployed + Sick = More Deserving? A Survey Experiment on How the Medicalization of Unemployment Affects Public Opinion

The literature on the social legitimacy of welfare benefits has shown that sick persons are perceived more deserving than unemployed individuals. However, these studies examine sick and unemployed persons as distinct groups, while unemployment and sickness are in fact strongly related. Policymakers across Europe have been increasingly concerned with discouraging a medicalization of unemployment and activating sick unemployed persons. Therefore, it is crucial to understand welfare attitudes toward this group. Using a factorial survey fielded with a representative sample of German-speaking adults (N=2,621), we investigate how sickness affects attitudes toward a hypothetical unemployed person on three dimensions: benefit levels, conditions, and sanctions. Respondents allocated similar benefit levels to unemployed persons regardless of whether they have an illness. Yet, they were more hesitant to apply existing conditions (e.g., active job search, job training) or sanction benefits when the unemployed person was also sick. This is except for conditions that tie benefits to obligatory health services (back training or psychological counseling) which was supported by the majority of respondents. Our research shows that the German public is not more generous and only partially more lenient toward sick unemployed persons as there is strong support for conditions targeted at overcoming ill health for this group. The findings underscore that sickness matters for how unemployed persons are perceived, but the impact varies across different dimensions of welfare attitudes.

Cancer Screening Participation and Gender Stratification in Europe

The current study examines whether the extent of macrolevel gender inequality affects the association between women's educational attainment and their participation in cervical and breast cancer screening and how this relationship is moderated by a country's cancer screening strategy (organized vs. opportunistic). A multilevel design with women (N_cervical = 99,794; N_breast = 55,021) nested in 30 European countries was used to analyze data from the European Health Interview Survey (2013-2015). Results of multilevel logistic regression models demonstrate that higher macrolevel gender inequality is associated with (a) a lower overall likelihood that women have had a mammography and Pap smear and (b) a larger gap in participation between women with low and high levels of education, regardless of a country's screening strategy (i.e., no moderation by a country's screening strategy was found). We conclude that macrolevel gender stratification should not be neglected when designing cancer screening policy.

Political Institutions and the Comparative Medicalization of Abortion

Comparative-historical research on medicalization is rare and, perhaps for that reason, largely ignores political institutions, which tend to vary more across countries than within them. This article proposes a political-institutional theory of medicalization in which health care policy legacies, political decentralization, and constitutionalism shape the preferences, discourses, strategies, and influence of actors that seek or resist medicalization. The theory helps explain why abortion has been more medicalized in Britain than the United States. The analysis finds that the American medical profession, unlike its British counterpart, focused on defending private medicine rather than protecting its power to "diagnose" the medical necessity of abortions; that American political decentralization aided the establishment of abortion on request by encouraging strategic innovation and learning that shaped social movement strategies, medical issue avoidance, and the growth of nonhospital clinics; and finally, that constitutionalism promoted rights discourses that partially crowded out medical ones.

Institutions, Incorporation, and Inequality: The Case of Minority Health Inequalities in Europe

Scholars interested in the relationship between social context and health have recently turned attention further "upstream" to understand how political, social, and economic institutions shape the distribution of life chances across contexts. We compare minority health inequalities across 22 European countries ( N = 199,981) to investigate how two such arrangements-welfare state effort and immigrant incorporation policies-influence the distribution of health and health inequalities. We examine two measures of health from seven waves of the European Social Survey. Results from a series of multilevel mixed-effects models show that minority health inequalities vary across contexts and persist after accounting for socioeconomic differences. Cross-level interaction results show that welfare state effort is associated with better health for all groups but is unrelated to levels of inequality between groups. In contrast, policies aimed at protecting minorities from discrimination correlate with smaller relative health inequalities.

Gendered health inequalities in mental well-being? The Nordic countries in a comparative perspective

Aims: The aims of this study were to: (a) compare gender differences in mental well-being in the Nordic countries with gender differences in 28 other countries around the world; and (b) evaluate whether gender differences in the Nordic countries remain when other social and lifestyle factors are taken into account. Methods: Data were obtained from 32 countries around the world that participated in the 2011 health module of the International Social Survey Programme. Ordered logit regression models were used to evaluate whether gender differences remained significant when other social and lifestyle factors were considered. Results: Gender differences in mental well-being in the Nordic countries are not particularly small and the four countries do not cluster together. The gender differences remain when other social and lifestyle factors are taken into account. Conclusions: There appears to be a similar Nordic health paradox for mental well-being outcomes as for physical health outcomes. Although there may be multiple reasons for this, continued gender equality, including sex segregation in the labour market and gendered expectations, are considered to play a part.

Rethinking the relationship between socio-economic status and health: Making the case for sociological theory in health inequality research

AIM

The aim of this study is to analyse previous explanations of social inequality in health and argue for a closer integration of sociological theory into future empirical research.

METHODS

We examine cultural-behavioural, materialist, psychosocial and life-course approaches, in addition to fundamental cause theory. Giddens' structuration theory and a neo-materialist approach, inspired by Bruno Latour, Gilles Deleuze and Felix Guattari, are proposed as ways of rethinking the causal relationship between socio-economic status and health.

CONCLUSIONS

Much of the empirical research on health inequalities has tended to rely on explanations with a static and unidirectional view of the association between socio-economic status and health, assuming a unidirectional causal relationship between largely static categories. We argue for the use of sociological theory to develop more dynamic models that enhance the understanding of the complex pathways and mechanisms linking social structures to health.

Path Dependency and the Politics of Socialized Health Care

Rich democracies exhibit vast cross-national and historical variation in the socialization of health care. Yet, cross-national analyses remain relatively rare in the health policy literature, and health care remains relatively neglected in the welfare state literature. We analyze pooled time series models of the public share of total health spending for eighteen rich democracies from 1960 to 2010. Building on path dependency theory, we present a strategy for modeling the relationship between the initial 1960 public share and the current public share. We also examine two contrasting accounts for how the 1960 public share interacts with conventional welfare state predictors: the self-reinforcing hypothesis expecting positive feedbacks and the counteracting hypothesis expecting negative feedbacks. We demonstrate that most of the variation from 1960 to 2010 in the public share can be explained by a country's initial value in 1960. This 1960 value has a large significant effect in models of 1961-2010, and including the 1960 value alters the coefficients of conventional welfare state predictors. To investigate the mechanism whereby prior social policy influences public opinion about current social policy, we use the 2006 International Social Survey Programme (ISSP). This analysis confirms that the 1960 values predict individual preferences for government spending on health. Returning to the pooled time series, we demonstrate that the 1960 values interact significantly with several conventional welfare state predictors. Some interactions support the self-reinforcing hypothesis, while others support the counteracting hypothesis. Ultimately, this study illustrates how historical legacies of social policy exert substantial influence on the subsequent politics of social policy.

Healthcare Systems in Comparative Perspective: Classification, Convergence, Institutions, Inequalities, and Five Missed Turns

This essay reviews and evaluates recent comparative social science scholarship on healthcare systems. We focus on four of the strongest themes in current research: (1) the development of typologies of healthcare systems, (2) assessment of convergence among healthcare systems, (3) problematization of the shifting boundaries of healthcare systems, and (4) the relationship between healthcare systems and social inequalities. Our discussion seeks to highlight the central debates that animate current scholarship and identify unresolved questions and new opportunities for research. We also identify five currents in contemporary sociology that have not been incorporated as deeply as they might into research on healthcare systems. These five "missed turns" include an emphasis on social relations, culture, postnational theory, institutions, and causal mechanisms. We conclude by highlighting some key challenges for comparative research on healthcare systems.

Health Inequalities in Global Context

The existence of social inequalities in health is well established. One strand of research focuses on inequalities in health within a single country. A separate and newer strand of research focuses on the relationship between inequality and average population health across countries. Despite the theorization of (presumably variable) social conditions as "fundamental causes" of disease and health, the cross-national literature has focused on average, aggregate population health as the central outcome. Controversies currently surround macro-structural determinants of overall population health such as income inequality. We advance and redirect these debates by conceptualizing inequalities in health as cross-national variables that are sensitive to social conditions. Using data from 48 World Values Survey countries, representing 74% of the world's population, we examine cross-national variation in inequalities in health. The results reveal substantial variation in health inequalities according to income, education, sex, and migrant status. While higher socioeconomic position is associated with better self-rated health around the globe, the size of the association varies across institutional context, and across dimensions of stratification. There is some evidence that education and income are more strongly associated with self-rated health than sex or migrant status.

Contextualizing Disparities: The Case for Comparative Research on Social Inequalities in Health

PURPOSE

Research on healthcare disparities is making important descriptive and analytical strides, and the issue of disparities has gained the attention of policymakers in the US, other nation-states, and international organizations. Still, disparities scholarship remains US-centric and too rarely takes a cross-national comparative approach to answering its questions. The US-centricity of disparities research has fostered a fixation on race and ethnicity that, although essential to understanding health disparities in the United States, has truncated the range of questions researchers investigate. In this article, we make a case for comparative research that highlights its ability to identify the institutional factors may affect disparities.

METHODOLOGY/APPROACH

We discuss the central methodological challenges to comparative research. After describing current solutions to such problems, we use data from the World Values Survey to show the impact of key social fault lines on self-assessed health in Europe and the U.S.

FINDINGS

The negative impact of SES on health is more generalizable across context, than the impact of race/ethnicity or gender.

RESEARCH LIMITATIONS/IMPLICATIONS

Our analysis includes a limited number of countries and relies on one measure of health.

ORIGINALITY/VALUE OF PAPER

The paper represents a first step in a research agenda to understand health inequalities within and across societies.