Health and social inequities in Switzerland

The contribution of the foreign population to the high level of infant mortality in Switzerland: a demographic analysis

BACKGROUND

In 2011 Switzerland reported the highest infant mortality rate among Western European countries, as well as the highest percentage of foreign population (23%). The comparison of the Swiss and foreign population in terms of reproductive health has received so far insufficient attention. The aim of the present study is to analyze the infant (IMR) and neonatal mortality rates (NMR) of Swiss and foreign children over the last 30 years.

METHODS

Vital statistics from the period 1980 to 2011 were used to compute IMR and NMR according to year and/or citizenship. The main analyses were made contrasting Swiss versus foreigners as a single category, as well as by country of origin. Comparisons between groups were done using relative risks.

RESULTS

In 1980-1989, IMR was 14% higher among foreign children as compared to Swiss children, and NMR 28% higher. In 2006-2010, IMR was 18% higher among foreign children than among Swiss children, and NMR 29% higher. The highest gap of IMR was observed during the period 1990-1993 (+21%). Looking at single countries, in 2008-2010 children of migrants from Germany, Portugal, Turkey, Italy, France, Kosovo and Spain had a higher level of IMR as compared to Swiss children.

CONCLUSIONS

The analysis of vital statistics confirms that over the last 30 years the gap of IMR and NMR between Swiss and foreign children has not decreased. Whatever the combination of mechanisms, which cause the observed difference, this fundamental inequity needs to be investigated and remedied by a large scale, concerted effort.

Health Psychology in Context

Over 25 years there has been a remarkable growth of theoretical and empirical studies in health psychology. Its theoretical underpinnings have been largely derivative, its focus primarily clinical, and its subject, the individual. Relatively little attention has been paid to the cultural, sociopolitical and economic conditions which set the context for individual health experience and behaviour. Theories which do not reflect the complex interaction of these variables are unlikely to provide a satisfactory account of individual health. Multidisciplinary efforts are needed at a community level to provide effective interventions which are relevant to the exposure groups being targeted. Health psychology needs measures which are valid and relevant to the general population regardless of culture, gender, social class or age. Putting health psychology into its cultural, sociopolitical and community context is a major priority for future development.

Soziale Determinanten der aktiven Lebenserwartung

Der vorliegende Beitrag präsentiert empirische Ergebnisse zu den sozialen Determinanten der aktiven Lebenserwartung in der Bundesrepublik. Das Konzept der aktiven Lebenserwartung bezieht sich auf die Analyse der Pflegebedürftigkeit, wobei sich die Unterscheidung zwischen aktiver und inaktiver Lebenserwartung in dem vorliegenden Beitrag an der sozialen Handlungsfähigkeit orientiert. Die Analyse basiert auf Mehrzustandssterbetafeln, die mit dem Sozio-ökonomischen Panel berechnet wurden. Unter den Ergebnissen ist insbesondere von Bedeutung, daß Männer keineswegs stärker von einer Ehe profitieren als Frauen: Bei Frauen wirkt sich die Ehe sogar deutlich stärker lebensverlängernd aus als bei Männern.

Increased risk of severe maternal morbidity (near-miss) among immigrant women in Sweden: a population register-based study

OBJECTIVE

To determine if immigrant women from low-, middle- and high-income countries have an increased risk of severe maternal morbidity (near-miss) when they deliver in Sweden.

DESIGN

Population register-based study.

SETTING

Nationwide study including all singleton deliveries (≥28 weeks of gestation) between 1998 and 2007.

POPULATION

Women with a near-miss event; all women with a singleton delivery ≥28 weeks of gestation during the same period acted as reference group.

METHODS

Near-miss was defined by a combined clinical and management approach with use of International Classification of Diseases, 10th revision codes for severe maternal morbidity. A woman's country of origin was designated as low-, middle- or high-income according to the World Bank Classification of 2009. Unconditional logistic regression models were used in the analysis.

MAIN OUTCOME MEASURES

Maternal near-miss frequencies per 1000 deliveries and odds ratios with 95% confidence intervals.

RESULTS

There were 914 474 deliveries during the study period and 2655 near-misses (2.9 per 1000 deliveries). In comparison to Swedish-born women, those from low-income countries had an increased risk of near-miss (odds ratio 2.3, 95% confidence interval 1.9-2.8) that was significant in all morbidity groups except for cardiovascular diseases and sepsis. Women from middle- and high-income countries showed no increased risk of near-miss.

CONCLUSIONS

Women from low-income countries have an increased risk of maternal near-miss morbidity compared with women born in Sweden. Although the rate is low it should alert healthcare providers.

Comparing objective and subjective status: gender and space (and environmental justice?)

The environmental justice literature has described differential health effects of environmental toxins and pollutants on people of different socio-economic status (SES) that may not always reflect differing levels of exposure. We offer four questions or contentions that together may contribute to understanding this conundrum and then present an empirical exploration of one of these questions: Does the relationship between SES and self-perceived status vary in space? Utilizing data from an original questionnaire survey of randomly selected adults conducted in twenty-five communities in British Columbia, Canada, a supplementary data set containing demographic and socio-economic characteristics of the communities themselves, and multilevel modelling techniques, this article describes relationships between objective and subjective measures of social status, by gender and in space. Our analysis contributes to the development of innovative environmental justice models by bringing some spatial sensitivity to interrelationships among these aspects of status.

Mortality by education in German speaking Switzerland, 1990-1997: results from the Swiss National Cohort

BACKGROUND

The aim of this paper is to show for the first time mortality differentials by level of education for Swiss men and women. This work is of interest to public health efforts in Switzerland as well as for co-operative international research into the determinants of socioeconomic differentials in health and mortality.

METHODS

This study is based on a longitudinal data set from the Swiss National Cohort, currently incorporating a probabilistic record linkage of the 1990 Swiss census, and all subsequent deaths until the end of 1997. The study population covers all Swiss nationals aged >/=25 years living in German speaking Switzerland, with 19.7 million person-years and 296 929 deaths observed. Educational gradients were analysed using standardized mortality ratios, multiple logistic regression, and the Relative Index of Inequality (RII).

RESULTS

There were sizeable gradients in mortality by education for all age groups and both sexes. The mortality odds ratio decreased by 7.2% (95% CI: 7.0-7.5%) per additional year of education for men, and by 6.0% (95% CI: 5.6-6.3%) for women. In men, we found a steady decrease of the gradient from 13.1% (95% CI: 11.9-14.4%) in the age group 25-39 to 4.5% (95% CI: 4.0-5.0%) in the age group >/=75 years. For women in the age groups under 65 the gradients were smaller; over the age of 40 there was no decrease with increasing age. These results were fairly insensitive to variations in the parameters of record linkage.

CONCLUSIONS

Despite a comparatively low overall mortality, Swiss men in the 1990s show larger relative gradients in mortality by education than men in other European countries in the 1980s, with the possible exception of younger men in Italy. In Switzerland there is a sizeable potential for further increasing overall life expectancy by reducing the mortality of those with a lower educational level. The results presented contribute to a reliable assessment of socioeconomic mortality differentials in Europe.

Desigualdades socioespaciais na mortalidade do adulto no Município de São Paulo

O aumento da importância da mortalidade do adulto tem sido acompanhado de uma grande produção científica sobre o tema nos países centrais. Nestes estudos, as desigualdades sociais têm sido avaliadas. Nos países periféricos, apesar de também se observar o crescimento da sua importância, têm sido realizados poucos estudos, em especial no que se refere às desigualdades sociais na sua geração e distribuição. Este trabalho tem como objetivo a análise das desigualdades sociais na mortalidade do adulto no município de São Paulo, buscando-se a apreensão dessa desigualdade pelo estudo dos diferenciais no espaço urbano. Este é analisado pela definição e delimitação de áreas socioambientais homogêneas. Nos resultados observa-se distribuição desigual na mortalidade do adulto no município de São Paulo, constatada nos diferentes indicadores analisados e para a maioria das causas de morte analisadas, geralmente em prejuízo das populações vivendo em áreas de piores condições socioambientais. O padrão da mortalidade do adulto, no Município de São Paulo, mostra forte participação de doenças crônicas não transmissíveis e das decorrentes de violências. São discutidas algumas dimensões de determinação dos perfis encontrados ressaltando as distribuições diferenciadas dos fatores de risco, do acesso à assistência à saúde, da exposição a riscos no ambiente urbano e das condições econômicas e sociais da população.

[Arguments and basic principles for continuous monitoring of social differences in the health of Swiss children]

On the basis of the thesis that social inequality has increased during the nineties in all western societies, and that this development is a reason for considerable concern with respect to public health, the authors propose the establishment of a long term monitoring system within the Swiss school health services. A re-analysis of the data obtained in a Swiss epidemiological study of seven-year-olds in the eighties demonstrates that social class was an important determinant of health and development of these children also during a period of economic boom. For various health and developmental problems odds-ratios (lower class vs. upper class) between 1.7 and 6.4 were found. Social class of the parents is considered as a reliable indicator of the socio-economic situation of children also for future long term observations. The number of significant somatic health problems as well as disorders of motor and speech development of six- or seven-year-olds are proposed as indicators of health status which can be assessed repeatedly at reasonable cost and with standardised methodology. This project could be started rather easily within the newly established Swiss "Health Observatory".

No real progress towards equity: health of migrants and ethnic minorities on the eve of the year 2000

The paper reviews the available evidence on access to health care and two health outcomes, perinatal mortality and accident/disability, for migrant and ethnic minorities in selected receiving industrialized countries. The health of these communities is analyzed using the entitlement approach, which considers health as the product of both the individual's private endowments and the social environment he or she faces. Migrants, especially first and second generations, and ethnic minorities often have reduced entitlements in receiving societies. Not only are they exposed to poor working and living conditions, which are per se determinants of poor health, but they also have reduced access to health care for a number of political, administrative and cultural reasons which are not necessarily present for the native population. The paper argues that the higher rates of perinatal mortality and accidents/disability observed in many migrant groups compared to the native population are linked to their lower entitlements in the receiving societies. Policies aimed at reducing such health gaps need to be accompanied by a more general effort to reduce inequalities and to promote full participation of these groups in the mainstream of society.

Social class gradients in years of potential life lost in Switzerland

Analysis of the official Swiss mortality data have shown considerable social differences. In an earlier study of Swiss men aged 15-74 for the period 1979-1982 the social class mortality differentials have been analysed using standardized mortality ratios (SMR). The present study extends this previous work by calculating years of potential life lost (YPLL) before age 75, an additional indicator of mortality that puts more importance on deaths at younger ages. Emphasis is given on causes contributing to most years of life lost, especially to accidents and violent deaths, which result in more than 30% of total years of life lost. The distribution of years of life lost of the most important causes to social classes is illustrated also for age-specific groups. Additionally, this article presents all causes which account for more than 3% of total years of life lost. The social inequalities are shown as ratios between the social class with the highest (skilled manual workers) and the lowest risk (professionals). Most years of life are lost by skilled manual workers not only in general but also cause-specific. While the SMR from all causes of death showed a 2-fold difference between professionals and skilled manual workers, the social gradient in YPLL rate was even larger (2.5). Hence, the measure of years of potential life lost emphasizes the disadvantage of skilled manual workers to die earlier than professionals. The concept of YPLL proved to be a useful additional indicator not only of mortality in general, but also especially for monitoring causes, related to the lower social classes.

Socio-economic factors and mortality in Switzerland

This review paper is concerned with the topic of mortality differences by socio-economic group in Switzerland. After a short introduction to the topic and the pitfalls associated with it, the paper reviews work done in the course of a ten year programme investigating socio-economic mortality differentials in Switzerland. This programme was carried out by a working group at the Department of Social and Preventive Medicine of the University of Berne. The paper reviews methodological difficulties and pitfalls and relates the Swiss results to findings from other countries including England and Wales and Sweden. The disadvantages of socially isolated groups such as children of single women are shown. The relatively high mortality of groups under economic pressure, such as skilled manual workers in Switzerland, is demonstrated. The Swiss situation is interesting in that skilled manual workers have a higher mortality than the unskilled and semi-skilled groups. It is concluded that this is not an artifact but may be due to the fact that only Swiss workers were investigated and that Switzerland has a large proportion of foreign workers, especially in the less skilled groups. In addition, some results of an investigation of cancer mortality by occupation are reported too. Apart from some occupation-specific findings, there are some interesting cross-references to socio-economic differential mortality.

The Black report on socioeconomic inequalities in health 10 years on

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