Towards an epidemiological understanding of the effects of long-term institutional changes on population health: A case study of Canada versus the USA

Civil service organization as a political determinant of health: Analyzing relationships between merit-based hiring, corruption, and population health

A growing literature finds that the way governments are organized can impact the societies they serve in important ways. The same is apparent with respect to civil service organizations. Numerous studies show that the recruitment of civil servants based on their credentials rather than on nepotism or patronage reduces corruption in government. Political corruption in turn appears to harm population health. Up to this time, however, civil service organization is not a recognized determinant of health and is little discussed outside of political science disciplines. To provoke a broader conversation on this subject, the following study proposes that meritocratic recruitment of civil servants improves population health. To test this proposition, a series of regression models examines comparative data for 118 countries. Consistent with study hypotheses, meritocratic recruitment of civil servants corresponds longitudinally with both lower rates of corruption and lower rates of infant mortality. Results are similar after robustness checks. Findings with regard to life expectancy are more mixed. However, additional tests suggest meritocratic recruitment contributes to life expectancy over a longer span of time. Findings also offer more support for a direct pathway from meritocratic recruitment to population health rather than via changes in corruption levels per se, although this may depend on a country's level of economic development. Overall, this study offers first evidence that civil service organization, particularly the recruitment of civil servants based on the merits of their applications rather than on whom they happen to know in government, is a positive determinant of health. More research in this area is needed.

Correlates of the country differences in the infection and mortality rates during the first wave of the COVID-19 pandemic: evidence from Bayesian model averaging

The COVID-19 pandemic resulted in great discrepancies in both infection and mortality rates between countries. Besides the biological and epidemiological factors, a multitude of social and economic criteria also influenced the extent to which these discrepancies appeared. Consequently, there is an active debate regarding the critical socio-economic and health factors that correlate with the infection and mortality rates outcome of the pandemic. Here, we leverage Bayesian model averaging techniques and country level data to investigate whether 28 variables, which describe a diverse set of health and socio-economic characteristics, correlate with the final number of infections and deaths during the first wave of the coronavirus pandemic. We show that only a few variables are able to robustly correlate with these outcomes. To understand the relationship between the potential correlates in explaining the infection and death rates, we create a Jointness Space. Using this space, we conclude that the extent to which each variable is able to provide a credible explanation for the COVID-19 infections/mortality outcome varies between countries because of their heterogeneous features.

Looking back and moving forward: Addressing health inequities after COVID-19

We will likely look back on 2020 as a turning point. The pandemic put a spotlight on existing societal issues, accelerated the pace of change in others, and created some new ones too. For example, concerns about inequalities in health by income and race are not new, but they became more apparent to a larger number of people during 2020. The speed and starkness of broadening societal conversation, including beyond the direct effects of COVID-19, create an opportunity and motivation to reassess our understanding of health. Perhaps more importantly, it is an opportunity to reduce inequities in who has access to, who uses, and who benefits from the resources that promote health and well-being. To this end, we offer three questions to guide thinking about health and health inequities after 2020: (1) what do we mean by "health" and "health inequality and inequity"? (2) what are the structures and policies we put in place to support or promote health, and how effective are they? And (3) who has the power to shape structures and policies, and whose interests do those structures and policies serve?

The role of labour unions in explaining workers' mental and physical health in Great Britain. A longitudinal approach

OBJECTIVES

To assess whether there are mental and physical health benefits of being employed in a workplace where there is a union or staff association recognized by the management or being a member of such a union.

METHODS

Using four waves [W2 (2010-11), W4 (2012-13), W6 (2014-15), W8 (2016-18)] from Understanding Society (UKHLS), we use a propensity score matching method and apply a latent growth modeling on the original dataset and on the matched dataset to estimate the impact of change in union presence and union membership between wave 2 and wave 4 for the employed population on the change in mental health (Mental Component Summary - MCS) and physical health (Physical Component Summary - PCS), after controlling for socioeconomic characteristics, age and sector of activity.

RESULTS

Collective negotiation within the workplace plays a statistically significant role in supporting workers' mental and, to a greater degree, physical health. Being unionized does not add up significant physical health benefits but a slight positive effect on mental health is observed.

CONCLUSION

About 50 per cent of the employed population is not represented by a labour union at company level and this has negative effects on health. A major health policy issue is also about promoting collective negotiation at the workplace and more research is needed about the impact of implementing such type of negotiation. The study shows the benefits of using a longitudinal approach when analysing the impact of union presence and union membership on workers' health.

Austerity Policies and Mortality in Spain After the Financial Crisis of 2008

OBJECTIVES

To analyze mortality in Spain and the United States before and after these countries implemented divergent policies in response to the financial crisis of 2008.

METHODS

We examined mortality statistics in both countries in the years 2000 to 2015. Spain started austerity policies in 2010. We compared differences in mortality ratios, on the basis of trends and effect size analysis.

RESULTS

During 2000 to 2010, overall mortality rates (r = 0.98; P < .001; Cohen's d = -0.228) decreased in both countries. In 2011, this trend changed abruptly in Spain, where observed mortality surpassed expected mortality by 29% in 2011 and by 41% in 2015. By contrast, observed mortality surpassed expected mortality in the United States by only 8% in 2015. As the mortality statistics diverged, the effect size greatly increased (d = 7.531). During this 5-year period, there were 505 559 more deaths in Spain than the expected number, while in the United States the difference was 431 501 more deaths despite the 7-fold larger population in the United States compared with Spain.

CONCLUSIONS

The marked excess mortality in 2011 to 2015 in Spain is attributable to austerity policies.

Are there health benefits of being unionized in late career? A longitudinal approach using HRS

OBJECTIVE

To assess whether unionization prevents deterioration in self-reported health and depressive symptoms in late career transitions.

METHODS

Data come from the Health and Retirement Study (N = 6475). The change in self-perceived health (SPH) and depressive symptoms (CESD) between wave 11 and wave 12 is explained using an interaction effect between change in professional status from wave 10 to wave 11 and unionization in wave 10.

RESULTS

The odds of being affected by a negative change in CESD when unionized are lower for unionized workers remaining in full-time job (OR:0.73, CI95%:0.58;0.89), unionized full-time workers moving to part-time work (OR:0.66, CI95%:0.46;0.93) and unionized full-time workers moving to part-retirement (OR:0.40, CI95%:0.34;0.47) compared to non-unionized workers. The same conclusion is made for the change in SPH but with odds ratios closer to 1.

CONCLUSION

The reasons for the associations found in this paper need to be explored in further research.

Racial Differences in Home Dialysis Utilization and Outcomes in Canada

BACKGROUND AND OBJECTIVES

Data on racial disparities in home dialysis utilization and outcomes are lacking in Canada, where health care is universally available.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We studied patients starting maintenance dialysis between 1996 and 2012 in the Canadian Organ Replacement Register, stratified by race: white, Asian, black, Aboriginal, Indian subcontinent, and other. The association between race and treatment with home dialysis was examined using generalized linear models. Secondary outcomes assessed racial differences in all-cause mortality and technique failure using a Fine and Gray competing risk model.

RESULTS

66,600 patients initiated chronic dialysis between 1996 and 2012. Compared with whites (n=46,092), treatment with home dialysis was lower among Aboriginals (n=3866; adjusted relative risk, RR, 0.71; 95% confidence interval, CI, 0.66 to 0.76) and higher in Asians (n=4157; adjusted RR, 1.28; 95% CI, 1.22 to 1.35) and others (n=2170; adjusted RR, 1.12; 95% CI, 1.04 to 1.20) but similar in blacks (n=2143) and subcontinent Indians (n=2809). Black (adjusted hazard ratio, HR, 1.31; 95% CI, 1.16 to 1.48) and Aboriginal (adjusted HR, 1.19; 95% CI, 1.06 to 1.33) patients treated with peritoneal dialysis had a significantly higher adjusted risk of technique failure compared with whites, whereas Asians had a lower risk (adjusted HR, 0.89; 95% CI, 0.82 to 0.99). In patients on peritoneal dialysis, the risk of death was significantly lower in Asians (adjusted HR, 0.83; 95% CI, 0.75 to 0.92), blacks (adjusted HR, 0.71; 95% CI, 0.59 to 0.85), and others (adjusted HR, 0.79; 95% CI, 0.68 to 0.92) but higher in Aboriginals (adjusted HR, 1.16; 95% CI, 1.02 to 1.32) compared with whites. Among patients on home hemodialysis, no significant racial differences in patient and technique survival were observed, which may be limited by the low number of events among each subgroups.

CONCLUSIONS

With the exception of Aboriginals, all racial minority groups in Canada were as likely to be treated with home dialysis compared with whites. However, significant racial differences exist in outcomes.

Associations between race, discrimination and risk for chronic disease in a population-based sample from Canada

A major epidemiological finding emerging from studies using U.S. samples is that racial differences in experiences of discrimination are associated with racial differences in health. A newer area of research is exploring the population-level dynamics between race, discrimination, and health status in various societies. The objective of this study is to assess for the first time in a national sample from Canada: (a) racial differences in experiences of discrimination and, (b) the association between discrimination and chronic conditions and their major risk factors. Data were obtained from the 2013 Canadian Community Health Survey (n = 16,836). Race was categorized as Aboriginal, Asian, Black, or White. Discrimination was measured using the Williams Everyday Discrimination Scale. Outcomes included having any chronic condition or major risk factors (obesity, hypertension, smoking, binge drinking, infrequent physical activity, and poor self-rated health). Crude and adjusted (for age, sex, immigrant status, socioeconomics) logistic regressions modeled the association between (a) race and discrimination and, (b) discrimination and each outcome. Results indicated that Blacks were most likely to experience discrimination, followed by Aboriginals. For example, Blacks were almost twice as likely (OR: 1.92, 95% CI: 1.19-3.11), and Aboriginals 75 percent more likely (OR: 1.75, 95% CI: 1.37-2.22) to report being treated with less courtesy or respect than others. Blacks were more than four times as likely (OR: 4.27, 95% CI: 2.23-8.19), and Aboriginals more than twice as likely (OR: 2.26, 95% CI: 1.66-3.08) to report being feared by others. Asians were not statistically different from Whites. With two exceptions (binge drinking and physical activity), discrimination was associated with chronic conditions and their risk factors (OR for any chronic condition: 1.78, 95% CI: 1.52-2.08). Initial results suggest that in Canada, experience of discrimination is a determinant of chronic disease and chronic disease risk factors, and Blacks and Aboriginals are far more exposed to experiences of discrimination.

Trading Equality for Health? Evaluating the Trade-off and Institutional Hypotheses on Health Inequalities in the Global South

It has been suggested that as medicine advances and mortality declines, socioeconomic disparities in health outcomes will grow. Yet, most research on this topic uses data from affluent Western democracies, where mortality is declining in small increments. We argue that the Global South represents the ideal setting to study this issue in a context of rapid mortality decline. We evaluate two competing hypotheses: (1) there is a trade-off between population health and health inequality such that reductions in under-five mortality are linked to higher levels of social inequality in health; and (2) institutional interventions that improve under-five mortality, like the expansion of educational systems and public health expenditure, are associated with reductions in inequalities. We test these hypotheses using data on 1,369,050 births in 34 low-income countries in the Demographic and Health Surveys from 1995 to 2012. The results show little evidence of a health-for-equality trade-off and instead support the institutional hypothesis.

Hospital practices to promote breastfeeding: The effect of maternal age

BACKGROUND

Breastfeeding rates are disproportionately low among young mothers in the United States. Although the use of hospital practices to promote breastfeeding is widely supported, the extent to which these practices help explain breastfeeding disparities by maternal age is unclear. Accordingly, we aimed to explore how maternal age may affect (1) receipt of hospital practices and (2) associations between these practices and exclusive breastfeeding.

METHODS

Data were derived from participants (n = 1598) of Listening to Mothers III, a national survey administered to mothers of singleton births in United States hospitals from July 2011 to June 2012. We used multivariable logistic regression models and interaction terms to examine maternal age as an effect modifier.

RESULTS

Compared with mothers aged 30 and older, mothers aged 18-19 had lower odds of reporting that nurses helped them initiate breastfeeding when ready (OR 0.59 [95% CI 0.35-0.99]), they roomed-in with their baby (OR 0.32 [95% CI 0.19-54]) and they did not receive a pacifier (OR 0.53 [95% CI 0.32-0.90]). Many associations with breastfeeding were stronger among mothers aged 18-19 and 20-24 than mothers aged 25-29 and 30 and older. Additionally, compared with receiving a pacifier, not receiving a pacifier was associated with greater odds of exclusive breastfeeding at 1 week among mothers aged 30 and older (OR 1.47 [95% CI 1.02-2.11]) but lower odds among mothers aged 18-19 (OR 0.26 [95% CI 0.10-0.70]).

CONCLUSIONS

Hospital practices to promote breastfeeding may be differentially implemented by maternal age. Encouraging teenage mothers to room-in with their babies may be particularly important for reducing breastfeeding disparities. Pacifier use among babies of teenage mothers requires further exploration.

Economic Segmentation and Health Inequalities in Urban Post-Reform China

During economic reform, Chinese economic labor markets became segmented by state sector associated with a planned redistributive economy and private sector associated with the market economy. By considering an economic sector as a concrete institutional setting in post-reform China, this paper compares the extent to which socioeconomic status, measured by education and income, is associated with self-rated health between state sector and private sector. The sample is limited to urban Chinese employees between the ages of 18 and 55 who were active in the labor force. By analyzing pooled data from the 1991-2006 Chinese Health and Nutrition Survey, I find that there is a stronger association between income and self-rated health in the private sector than in the state sector. This study suggests that sectoral differences between market and redistributive economies are an important key to understanding health inequalities in post-reform urban China.

Equally inequitable? A cross-national comparative study of racial health inequalities in the United States and Canada

Prior research suggests that racial inequalities in health vary in magnitude across societies. This paper uses the largest nationally representative samples available to compare racial inequalities in health in the United States and Canada. Data were obtained from ten waves of the National Health Interview Survey (n = 162,271,885) and the Canadian Community Health Survey (n = 19,906,131) from 2000 to 2010. We estimated crude and adjusted odds ratios, and risk differences across racial groups for a range of health outcomes in each country. Patterns of racial health inequalities differed across the United States and Canada. After adjusting for covariates, black-white and Hispanic-white inequalities were relatively larger in the United States, while aboriginal-white inequalities were larger in Canada. In both countries, socioeconomic factors did not explain inequalities across racial groups to the same extent. In conclusion, while racial inequalities in health exist in both the United States and Canada, the magnitudes of these inequalities as well as the racial groups affected by them, differ considerably across the two countries. This suggests that the relationship between race and health varies as a function of the societal context in which it operates.

Towards an understanding of the structural determinants of oral health inequalities: A comparative analysis between Canada and the United States

Objective

To compare the magnitude of, and contributors to, income-related inequalities in oral health outcomes within and between Canada and the United States over time.

Methods

The concentration index was used to estimate income-related inequalities in three oral health outcomes from the Nutrition Canada National Survey 1970–1972, Canadian Health Measures Survey 2007–2009, Health and Nutrition Examination Survey I 1971–1974, and National Health and Nutrition Examination Survey 2007–2008. Concentration indices were decomposed to determine the contribution of demographic and socioeconomic factors to oral health inequalities.

Results

Our estimates show that over time in both countries, inequalities in decayed teeth and edentulism were concentrated among the poor and inequalities in filled teeth were concentrated among the rich. Over time, inequalities in decayed teeth increased and decreased for measures of filled teeth and edentulism in both countries. Inequalities were higher in the United States compared to Canada for filled and decayed teeth outcomes. Socioeconomic characteristics (education, income) contributed greater to inequalities than demographic characteristics (age, sex). As well, income contributed more to inequalities in recent surveys in both Canada and the United States.

Conclusions

Inequalities in oral health have persisted over the past 35 years in Canada and the United States, and are associated with age, sex, education, and income and have varied over time.

•

Highlights changes and contributors to oral health inequalities in Canada and the U.S. since 1970.

•

Provides a comparative framework for analysing income-related oral health inequalities.

•

Hypotheses-generating findings on contributors to income-related oral health inequalities.

Cross-national comparison of socioeconomic inequalities in obesity in the United States and Canada

INTRODUCTION

Prior cross-national studies of socioeconomic inequalities in obesity have only compared summary indices of inequality but not specific, policy-relevant dimensions of inequality: (a) shape of the socioeconomic gradient in obesity, (b) magnitude of differentials in obesity across socioeconomic levels and, (c) level of obesity at any given socioeconomic level. We use unique data on two highly comparable societies - U.S. and Canada - to contrast each of these inequality dimensions.

METHODS

Data came from the 2002/2003 Joint Canada/U.S. Survey of Health. We calculated adjusted prevalence ratios (APRs) for obesity (compared to normal weight) by income quintile and education group separately for both nations and, between Canadians and Americans in the same income or education group.

RESULTS

In the U.S., every socioeconomic group except the college educated had significant excess prevalence of obesity. By contrast in Canada, only those with less than high school were worse off, suggesting that the shape of the socioeconomic gradient differs in the two countries. U.S. differentials between socioeconomic levels were also larger than in Canada (e.g., PR quintile 1 compared to quintile 5 was 1.82 in the U.S. [95 % CI: 1.52-2.19] but 1.45 in Canada [95 % CI: 1.10-1.91]). At the lower end of the socioeconomic gradient, obesity was more prevalent in the U.S. than in Canada.

CONCLUSIONS

Our results suggest there is variation between U.S. and Canada in different dimensions of socioeconomic inequalities in obesity. Future research should examine a broader set of nations and test whether specific policies or environmental exposures can explain these differences.

Divergence in age patterns of mortality change drives international divergence in lifespan inequality

In the past six decades, lifespan inequality has varied greatly within and among countries even while life expectancy has continued to increase. How and why does mortality change generate this diversity? We derive a precise link between changes in age-specific mortality and lifespan inequality, measured as the variance of age at death. Key to this relationship is a young-old threshold age, below and above which mortality decline respectively decreases and increases lifespan inequality. First, we show for Sweden that shifts in the threshold's location have modified the correlation between changes in life expectancy and lifespan inequality over the last two centuries. Second, we analyze the post-World War II (WWII) trajectories of lifespan inequality in a set of developed countries-Japan, Canada, and the United States-where thresholds centered on retirement age. Our method reveals how divergence in the age pattern of mortality change drives international divergence in lifespan inequality. Most strikingly, early in the 1980s, mortality increases in young U.S. males led to a continuation of high lifespan inequality in the United States; in Canada, however, the decline of inequality continued. In general, our wider international comparisons show that mortality change varied most at young working ages after WWII, particularly for males. We conclude that if mortality continues to stagnate at young ages yet declines steadily at old ages, increases in lifespan inequality will become a common feature of future demographic change.

Challenges to promoting health in the modern welfare state: The case of the Nordic nations

Aims: Finland, Norway, and Sweden are leaders in promoting health through public policy action. Much of this has to do with the close correspondence between key health promotion concepts and elements of the Nordic welfare state that promote equity through universalist strategies and programs that provide citizens with economic and social security. The purpose of this article is to identify the threats to the Nordic welfare states related to immigration, economic globalization, and welfare state fatigue. Methods: Through a critical analysis of relevant literature and data this article provides evidence of the state of the Nordic welfare state and some of these challenges to the Nordic welfare state and its health promotion efforts. Results: There is evidence of declining support for the unconditional Nordic welfare state, increases in income inequality and poverty, and a weakening of the programs and supports that have associated with the excellent health profile of the Nordic nations. This is especially the case for Sweden. Conclusions: It is argued that the Nordic welfare states’ accomplishments must be celebrated and used as a basis for maintaining the public policies shown to be successful in promoting the health of its citizens.

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.

A life course perspective on socioeconomic inequalities in health: a critical review of conceptual frameworks

Social scientists and public health researchers have long known that social position is related to health and that socioeconomic inequalities in health persist in later life. Increasingly, a life course perspective is adopted to understand the socioeconomic position (SEP)-health dynamic. This paper critically reviews the conceptual perspectives underlying empirical research seeking to better understand socioeconomic inequalities in health in the context of the life course. I comment on the contributions of this work, but also its limitations. In particular, I note the emphasis on understanding the mechanisms linking SEP to health, to the exclusion of research on the institutional and structural factors associated with socioeconomic inequalities over the life course. I also critique the relative absence of gender in this work, and how, by not linking individual experiences to the social policy contexts that shape resources and opportunities, the proximal, rather than the structural or institutional determinants of health are emphasized. I suggest that moving forward, a return to some of the key tenets of life course theory, including contributions from the comparative welfare states literature, may better inform life course analyses of socioeconomic inequalities in health. Specific suggestions for life scholarship are discussed.

Societal context and the production of immigrant status-based health inequalities: a comparative study of the United States and Canada

BACKGROUND

We compare disparities in health status between first-generation immigrants and others in the United States (US) and Canada.

METHODS

We used data from the Joint Canada-US Survey of Health. The regression models adjusted for demographics, socioeconomic status, and health insurance (the US).

RESULTS

In both countries, the health advantage belonged to immigrants. Fewer disparities between immigrants and those native-born were seen in Canada versus the US. Canadians of every immigrant/race group fared better than US native-born Whites.

DISCUSSION

Fewer disparities in Canada and better overall health of all Canadians suggest that societal context may create differences in access to the resources, environments, and experiences that shape health and health behaviors.

A Comparative Study of Population Health in the United States and Canada during the Neoliberal Era, 1980–2008

This article draws on the vast evidence that suggests, on one hand, that socioeconomic inequalities in health are present in every society in which they have been measured and, on the other hand, that the size of inequalities varies substantially across societies. We conduct a comparative case study of the United States and Canada to explore the role of neoliberalism as a force that has created inequalities in socioeconomic resources (and thus in health) in both societies and the roles of other societal forces (political, economic, and social) that have provided a buffer, thereby lessening socioeconomic inequalities or their effects on health. Our findings suggest that, from 1980 to 2008, while both the United States and Canada underwent significant neoliberal reforms, Canada showed more resilience in terms of health inequalities as a result of differences in: ( a) the degree of income inequality, itself resulting from differences in features of the labor market and tax and transfer policies, ( b) equality in the provision of social goods such as health care and education, and ( c) the extent of social cohesiveness across race/ethnic- and class-based groups. Our study suggests that further attention must be given to both causes and buffers of health inequalities.

The role of defamilialization in the relationship between partnership and self-rated health: a cross-national comparison of Canada and the United States

Partnered individuals live longer, healthier lives. In explaining this association, processes involving both social causation (in which partnership provides health benefits to individuals) and health selection (in which those who find partners were healthier than those who do not) have been invoked. Since much of this literature is focused in the U.S., comparative studies of the potential impact of policy on the causation and selection components of this association have been scant. Using comparable data from the U.S. Panel Study of Income Dynamics (N = 25,862, followed from 1984 to 2005) and the Canadian Survey of Labour and Income Dynamics (N = 15,632, followed from 1999 to 2005), we test the selective and causal relationships evident during entrance into partnership. We use fixed change-point analysis with multilevel models to fit trajectories of change in both the U.S. and Canada. In Canada, partnership benefits were evident, while health selection was limited. In contrast, in the U.S., health selection was prominent in both men and women, but partnership benefits were not significant. We argue that the differences in the extent of defamilialization of social policy between the two countries may impact the way and extent to which people choose partners and benefit from those partnerships.

How society shapes the health gradient: work-related health inequalities in a comparative perspective

Analyses in comparative political economy have the potential to contribute to understanding health inequalities within and between societies. This article uses a varieties of capitalism approach that groups high-income countries into coordinated market economies (CME) and liberal market economies (LME) with different labor market institutions and degrees of employment and unemployment protection that may give rise to or mediate work-related health inequalities. We illustrate this approach by presenting two longitudinal comparative studies of unemployment and health in Germany and the United States, an archetypical CME and LME. We find large differences in the relationship between unemployment and health across labor-market and institutional contexts, and these also vary by educational status. Unemployed Americans, especially of low education or not in receipt of unemployment benefits, have the poorest health outcomes. We argue for the development of a broader comparative research agenda on work-related health inequalities that incorporates life course perspectives.

Unemployment and mortality: a comparative study of Germany and the United States

OBJECTIVES

We examined the relationship between unemployment and mortality in Germany, a coordinated market economy, and the United States, a liberal market economy.

METHODS

We followed 2 working-age cohorts from the German Socio-economic Panel and the US Panel Study of Income Dynamics from 1984 to 2005. We defined unemployment as unemployed at the time of survey. We used discrete-time survival analysis, adjusting for potential confounders.

RESULTS

There was an unemployment-mortality association among Americans (relative risk [RR]=2.4; 95% confidence interval [CI]=1.7, 3.4), but not among Germans (RR=1.4; 95% CI=1.0, 2.0). In education-stratified models, there was an association among minimum-skilled (RR=2.6; 95% CI=1.4, 4.7) and medium-skilled (RR=2.4; 95% CI=1.5, 3.8) Americans, but not among minimum- and medium-skilled Germans. There was no association among high-skilled Americans, but an association among high-skilled Germans (RR=3.0; 95% CI=1.3, 7.0), although this was limited to those educated in East Germany. Minimum- and medium-skilled unemployed Americans had the highest absolute risks of dying.

CONCLUSIONS

The higher risk of dying for minimum- and medium-skilled unemployed Americans, not found among Germans, suggests that the unemployment-mortality relationship may be mediated by the institutional and economic environment.

Are recessions really good for your health? Evidence from Canada

This study investigates the relationship between business cycle fluctuations and health in the Canadian context, given that a procyclical relationship between mortality rates and unemployment rates has already been well established in the U.S. literature. Using a fixed effects model and provincial data over the period 1977-2009, we estimate the effect of unemployment rates on Canadian age and gender specific mortality rates. Consistent with U.S. results, there is some evidence of a strong procyclical pattern in the mortality rates of middle-aged Canadians. We find that a one percentage point increase in the unemployment rate lowers the predicted mortality rate of individuals in their 30s by nearly 2 percent. In contrast to the U.S. data, we do not find a significant cyclical pattern in the mortality rates of infants and seniors.

Aging in a cultural context: cross-national differences in disability and the moderating role of personal control among older adults in the United States and England

OBJECTIVES

We investigate cross-national differences in late-life health outcomes and focus on an intriguing difference in beliefs about personal control found between older adult populations in the U.K. and United States. We examine the moderating role of control beliefs in the relationship between physical function and self-reported difficulty with daily activities.

METHOD

Using national data from the United States (Health and Retirement Study) and England (English Longitudinal Study on Ageing), we examine the prevalence in disability across the two countries and show how it varies according to the sense of control. Poisson regression was used to examine the relationship between objective measures of physical function (gait speed) and disability and the modifying effects of control.

RESULTS

Older Americans have a higher sense of personal control than the British, which operates as a psychological resource to reduce disability among older Americans. However, the benefits of control are attenuated as physical impairments become more severe.

DISCUSSION

These results emphasize the importance of carefully considering cross-national differences in the disablement process as a result of cultural variation in underlying psychosocial resources. This paper highlights the role of culture in shaping health across adults aging in different sociopolitical contexts.

Comparing social determinants of self-rated health across the United States and Canada

A large body of research shows that social determinants of health have significant impact on the health of Canadians and Americans. Yet, very few studies have directly compared the extent to which social factors are associated with health in the two countries, in large part due to the historical lack of comparable cross-national data. This study examines differences in the effect of a wide-range of social determinants on self-rated health across the two populations using data explicitly designed to facilitate comparative health research-Joint Canada/United States Survey of Health. The results show that: 1) sociodemographic and socioeconomic factors have substantial effects on health in each country, though the size of the effects tends to differ-gender, nativity, and race are stronger predictors of health among Americans while the effects of age and marital status on health are much larger in Canada; the income gradient in health is steeper in Canada whereas the education gradient is steeper in the U.S.; 2) Socioeconomic status (SES) mediates or links sociodemographic variables with health in both countries-the observed associations between gender, race, age, and marital status and health are considerably weakened after adjusting for SES; 3) psychosocial, behavioural risk and health care access factors are very strong determinants of health in each country, however being severely/morbidly obese, a smoker, or having low life satisfaction has a stronger negative effect on the health of Americans, while being physically inactive or having unmet health care needs has a stronger effect among Canadians; and 4) risk and health care access factors together play a relatively minor role in linking social structural factors to health. Overall, the findings demonstrate the importance of social determinants of health in both countries, and that some determinants matter more in one country relative to the other.

Canada: a land of missed opportunity for addressing the social determinants of health

The first 25 years of universal public health insurance in Canada saw major reductions in income-related health inequalities related to conditions most amenable to medical treatment. While equity issues related to health care coverage and access remain important, the social determinants of health (SDH) represent the next frontier for reducing health inequalities, a point reinforced by the work of the World Health Organization's Commission on Social Determinants of Health. In this regard, Canada's recent performance suggests a bleak prognosis. Canada's track record since the 1980s in five respects related to social determinants of health: (a) the overall redistributive impact of tax and transfer policies; (b) reduction of family and child poverty; (c) housing policy; (d) early childhood education and care; and (e) urban/metropolitan health policy have reduced Canada's capacity to reduce existing health inequalities. Reasons for this are explored and means of advancing this agenda are outlined.

Comparing population health in the United States and Canada

BACKGROUND

The objective of the paper is to compare population health in the United States (US) and Canada. Although the two countries are very similar in many ways, there are potentially important differences in the levels of social and economic inequality and the organization and financing of and access to health care in the two countries.

METHODS

Data are from the Joint Canada/United States Survey of Health 2002/03. The Health Utilities Index Mark 3 (HUI3) was used to measure overall health-related quality of life (HRQL). Mean HUI3 scores were compared, adjusting for major determinants of health, including body mass index, smoking, education, gender, race, and income. In addition, estimates of life expectancy were compared. Finally, mean HUI3 scores by age and gender and Canadian and US life tables were used to estimate health-adjusted life expectancy (HALE).

RESULTS

Life expectancy in Canada is higher than in the US. For those < 40 years, there were no differences in HRQL between the US and Canada. For the 40+ group, HRQL appears to be higher in Canada. The results comparing the white-only population in both countries were very similar. For a 19-year-old, HALE was 52.0 years in Canada and 49.3 in the US.

CONCLUSIONS

The population of Canada appears to be substantially healthier than the US population with respect to life expectancy, HRQL, and HALE. Factors that account for the difference may include access to health care over the full life span (universal health insurance) and lower levels of social and economic inequality, especially among the elderly.

Self-reported hypertension prevalence and income among older adults in Canada and the United States

Hypertension is one of the most common chronic conditions worldwide. There is strong evidence that low socioeconomic status is associated with elevated rates of blood pressure-related cardiovascular disease. Few studies have examined the association between socioeconomic circumstances and hypertension among people aged 65 years and older. The purpose of this study was to examine the relationship between household income and self-reported hypertension prevalence among persons aged 65 and older in the United States and Canada. Data were obtained from the 2002-2003 Joint Canada/United States Survey of Health for 755 Canadian and 1151 US adults aged 65 and older. Aggregate hypertension prevalence rates in the United States and Canada were generally similar (53.8% versus 48.0%). We found a significant inverse linear relationship between household income and the hypertension prevalence rate in the United States, but no evidence of such a relationship in Canada. In Canada, unlike the United States, the burden of hypertension is approximately equal for socioeconomically advantaged and disadvantaged older adults. It is important to consider these findings in the context of long-term and broader institutional policies. Social disparities and barriers to health care access and primary prevention among non-elderly persons in the United States may play a role in the higher hypertension prevalence rate among low-income older adults.

Socioeconomic inequalities in health dynamics: a comparison of Britain and the United States

Drawing on theory and research on the fundamental causes of health, the life course, and the welfare state, we investigate social inequalities in dynamic self-rated health for working-aged Britons and Americans. We use data from the British Household Panel Survey and Panel Study of Income Dynamics (1990-2004) and a mixture latent Markov model to test a theoretical model of health as a discrete state that may remain stable or change over time. Our contributions are threefold. First, our finding of three distinctive types of health processes (stable good health, stable poor health, and a "mover" health trajectory) represents a more differentiated profile of long-term health than previously shown. Second, we characterize health trajectories in structural terms by suggesting who was more likely to experience what type of health trajectory. Third, our more differentiated picture of dynamic health leads to a more nuanced understanding of comparative health: Although the health advantage of Britons was confirmed, our results also indicate that they were more likely to experience health change. Moreover, the socioeconomic gradient in long-term health was steeper in the US, raising provocative questions about how state policies and practices may affect population health.

Income-related health inequalities in Canada and the United States: a decomposition analysis

OBJECTIVES

We examined income-related inequalities in self-reported health in the United States and Canada and the extent to which they are associated with individual-level risk factors and health care system characteristics.

METHODS

We estimated income inequalities with concentration indexes and curves derived from comparable survey data from the 2002 to 2003 Joint Canada-US Survey of Health. Inequalities were then decomposed by regression and decomposition analysis to distinguish the contributions of various factors.

RESULTS

The distribution of income accounted for close to half of income-related health inequalities in both the United States and Canada. Health care system factors (e.g., unmet needs and health insurance status) and risk factors (e.g., physical inactivity and obesity) contributed more to income-related health inequalities in the United States than to those in Canada.

CONCLUSIONS

Individual-level health risk factors and health care system characteristics have similar associations with health status in both countries, but they both are far more prevalent and much more concentrated among lower-income groups in the United States than in Canada.

Community-based participatory research from the margin to the mainstream: are researchers prepared?

Despite an increasing arsenal of effective treatments, there are mounting challenges in developing strategies that prevent and control cardiovascular diseases, and that can be sustained and scaled to meet the needs of those most vulnerable to their impact. Community-based participatory research (CBPR) is an approach to conducting research by equitably partnering researchers and those directly affected by and knowledgeable of the local circumstances that impact health. To inform research design, implementation and dissemination, this approach challenges academic and community partners to invest in team building, share resources, and mutually exchange ideas and expertise. CBPR has led to a deeper understanding of the myriad factors influencing health and illness, a stream of ideas and innovations, and there are expanding opportunities for funding and academic advancement. To maximize the chance that CBPR will lead to tangible, lasting health benefits for communities, researchers will need to balance rigorous research with routine adoption of its conduct in ways that respectfully, productively and equally involve local partners. If successful, lessons learned should inform policy and inspire structural changes in healthcare systems and in communities.

Shaping public policy and population health in the United States: why is the public health community missing in action?

Renewed international interest in the structural determinants of health manifests itself in a focus on the social determinants of health and the public policy antecedents that shape their quality. This increased international interest in public policy in support of the structural determinants of health has had little traction in the United States. This should be surprising since the United States presents one of the worst population health profiles and public policy environments in support of health among wealthy developed nations. The U.S. position as a health status and policy outlier results from long-term institutional changes that are shaped by political, economic, and social forces. U.S. public health researchers' and workers' neglect of these structural and public policy issues conforms to the dominant ideological discourses that serve to justify these changes. The author presents some means by which public health researchers and workers can challenge these dominant discourses.

The fall and rise of US inequities in premature mortality: 1960-2002

BACKGROUND

Debates exist as to whether, as overall population health improves, the absolute and relative magnitude of income- and race/ethnicity-related health disparities necessarily increase-or decrease. We accordingly decided to test the hypothesis that health inequities widen-or shrink-in a context of declining mortality rates, by examining annual US mortality data over a 42 year period.

METHODS AND FINDINGS

Using US county mortality data from 1960-2002 and county median family income data from the 1960-2000 decennial censuses, we analyzed the rates of premature mortality (deaths among persons under age 65) and infant death (deaths among persons under age 1) by quintiles of county median family income weighted by county population size. Between 1960 and 2002, as US premature mortality and infant death rates declined in all county income quintiles, socioeconomic and racial/ethnic inequities in premature mortality and infant death (both relative and absolute) shrank between 1966 and 1980, especially for US populations of color; thereafter, the relative health inequities widened and the absolute differences barely changed in magnitude. Had all persons experienced the same yearly age-specific premature mortality rates as the white population living in the highest income quintile, between 1960 and 2002, 14% of the white premature deaths and 30% of the premature deaths among populations of color would not have occurred.

CONCLUSIONS

The observed trends refute arguments that health inequities inevitably widen-or shrink-as population health improves. Instead, the magnitude of health inequalities can fall or rise; it is our job to understand why.

Socioeconomic status and health-related quality of life among elderly people: results from the Joint Canada/United States Survey of Health

The objective of this study was to assess the independent effect of income on health-related quality of life (HRQL) among older adults in Canada and the United States. Data were obtained from the 2002-2003 Joint Canada/United States Survey of Health. The sample consisted of 755 Canadians and 1,151 Americans aged 65 years or older. HRQL was measured with the multidimensional Health Utilities Index Mark 3 (HUI3). The results indicated that in the elderly population, HRQL was significantly associated with household income in the United States but not in Canada, controlling for sociodemographic and health indicators. Various explanations for the positive linear relationship between HRQL and income in the elderly population are discussed, including the roles of access to health care and socioeconomic inequalities in the United States and Canada.

Comparing the health of low income and less well educated groups in the United States and Canada

Background

A limited number of health status and health-related quality of life (HRQL) measures have been used for inter-country comparisons of population health. We compared the health of Canadians and Americans using a preference-based measure.

Methods

The Joint Canada/United States Survey of Health (JCUSH) 2002–03 conducted a comprehensive cross-sectional telephone survey on the health of community-dwelling residents in Canada and the US (n = 8688). A preference-based measure, the Health Utilities Index Mark 3 (HUI3), was included in the JCUSH. Health status was analyzed for the entire population and white population only in both countries. Mean HUI3 overall scores were compared for both countries. A linear regression determinants of health model was estimated to account for differences in health between Canada and the US. Estimation with bootstraps was used to derive variance estimates that account for the survey's complex sampling design of clustering and stratification.

Results

Income is associated with health in both countries. In the lowest income quintile, Canadians are healthier than Americans. At lower levels of education, again Canadians are healthier than Americans. Differences in health among subjects in the JCUSH are explained by age, gender, education, income, marital status, and country of residence.

Conclusion

On average, population health in Canada and the US is similar. However, health disparities between Canadians and Americans exist at lower levels of education and income with Americans worse off. The results highlight the usefulness of continuous preference-based measures of population health such as the HUI3.