Does income inequality harm health? New cross-national evidence

Social transition, socioeconomic status and self-rated health in China: evidence from a national cross-sectional survey (CGSS)

Background

Social transition is one of the multi-level mechanisms that influence health disparities. However, it has received less attention as one of the non-traditional social determinants of health. A few studies have examined China's social transition and its impact on health inequality in self-rated health (SRH). Therefore, this study explores the impact of China's market-oriented reforms-social transition and socioeconomic status (SES)-on residents' SRH.

Methods

Using the cross-sectional data from the Chinese General Social Survey (CGSS) in 2017, we analyzed the effects of social transition and SES on the SRH of Chinese residents using the RIF (Recentered influence function) method. The RIF decomposition method investigated health differences among different populations and their determinants.

Results

Social transition and SES have significant positive effects on the SRH of Chinese residents. The correlation between SES and the SRH of Chinese residents is moderated by social transition, implying that social transition can weaken the correlation between SES and the SRH of Chinese residents. The impacts of SES and social transition on SRH vary across populations.

Conclusion

Promoting social transition and favoring disadvantaged groups with more resources are urgently needed to promote equitable health outcomes.

Determinants of life-expectancy and disability-adjusted life years (DALYs) in European and Organisation for Economic Co-operation and Development (OECD) countries: A longitudinal analysis (1990-2019)

•We relate 68 factors to population health observed in 61 countries over 30 years.•Using random forests, multiple imputation and generalized estimating equations.•GDP per capita and demographics are key; income inequality is not.•Health and social expenditure are more influential than freedom and corruption.•On the macro-level, life-style effects appear to be mediated by cultural context.

Essentials to Improve the Effectiveness of Healthy Aging Programming: Consideration of Social Determinants and Utilization of a Theoretical Model

Older adult health, while partially determined by genetics, is mostly determined by behavioral and lifestyle choices. Researchers and interventionists develop and administer behavioral health interventions with older adults, and interventions are advertised in any number of settings, for example, by providers in healthcare settings and by activity directors in senior centers or assisted living facilities. However, previous studies and metanalyses indicate that many interventions targeting older adults are unsuccessful in recruitment or in retention. While providers and activity directors may assume older adults are unwilling to participate in behavioral change, in reality, low participation may be caused by erroneous design and administration. The objective of this manuscript is to recommend to creators and implementers of behavioral interventions for older adults that they focus on two critical considerations: the contextual perspective pertaining to healthy aging as well as an appropriately employed theoretical model that most effectively informs program design and implementation. In this commentary, we discuss how Prochaska and DiClemente's Transtheoretical Model of Health Behavior Change may lead to more desirable outcomes as it considers that a person may be at any one of six stages of change, from pre-contemplation to maintenance. Currently, many behavioral interventions are targeted at individuals who are poised for action or in maintenance phases, ignoring those in earlier phases, resulting in limited overall success. Regarding viewing healthy aging in a contextual manner, determinants external to the individual may remain unnoted and unconsidered when designing or recruiting for a behavioral intervention. In conclusion, the integration of an intrapersonal health behavior model such as the Transtheoretical Model of Health Behavior Change, coupled with clearer considerations of the interplay of contextual factors operating in the lives of older adults, may allow for more effective design and implementation, as well as resulting in higher participation in behavioral interventions targeted toward older adults.

Does income inequality increase status anxiety? Not directly, the role of perceived upward and downward mobility

Status anxiety theory posits that higher income inequality leads people to attribute more importance to their socioeconomic status and to worry about the position they occupy on the social ladder. We investigated through two experimental studies (N = 1117) the causal effect of economic inequality on status anxiety and whether expected upward and downward mobility mediates this effect. In Study 1, perceived economic inequality indirectly increased status anxiety through lesser expected upward mobility. In Study 2, perceived economic inequality decreased both expected upward and downward mobility, with opposite indirect effects on status anxiety. This suggests that the relationship between inequality and status anxiety is not straightforward, and could implicate the presence of multiple processes working at the same time-whereas lower expected downward mobility could suppress the effect of inequality, lower expected upward mobility could exacerbate it.

Income Inequality and Population Health: Examining the Role of Social Policy

Studies of the relationship between income inequality and life expectancy often speculate about the role of policy, but direct empirical research is limited. Drawing on the neo-materialist perspective, we examine whether the longitudinal association between income inequality and life expectancy is mediated and moderated by policy liberalism in U.S. states (2000-2014). More liberal policy contexts are characterized by greater efforts to regulate the economy, redistribute income, and protect vulnerable groups and lesser efforts to penalize deviant social behavior. We find that state-level income inequality is inversely associated with policy liberalism and life expectancy. The association between income inequality and life expectancy was not mediated by policy liberalism but was moderated by it. The association is attenuated in states with more liberal policy contexts, supporting the neo-materialist perspective. This finding illustrates how states like New York and California (with liberal policy contexts) can exhibit high income inequality and high life expectancy.

A test of the predictive validity of relative versus absolute income for self-reported health and well-being in the United States

BACKGROUND

A classic debate concerns whether absolute or relative income is more salient. Absolute values resources as constant across time and place while relative contextualizes one's hierarchical location in the distribution of a time and place.

OBJECTIVE

This study investigates specifically whether absolute income or relative income matters more for health and well-being.

METHODS

We exploit within-person, within-age, and within-time variation with higher-quality income measures and multiple health and well-being outcomes in the United States. Using the Panel Study of Income Dynamics and the Cross-National Equivalent File, we estimate three-way fixed effects models of self-rated health, poor health, psychological distress, and life satisfaction.

RESULTS

For all four outcomes, relative income has much larger standardized coefficients than absolute income. Robustly, the confidence intervals for relative income do not overlap with zero. By contrast, absolute income mostly has confidence intervals that overlap with zero, and its coefficient is occasionally signed in the wrong direction. A variety of robustness checks support these results.

CONCLUSIONS

Relative income has far greater predictive validity than absolute income for self-reported health and well-being.

CONTRIBUTION

Compared to earlier studies, this study provides a more rigorous comparison and test of the predictive validity of absolute and relative income that is uniquely conducted with data on the United States. This informs debates on income measurement, the sources of health and well-being, and inequalities generally. Plausibly, these results can guide any analysis that includes income in models.

Austerity by Design Comment on "Ensuring Global Health Equity in a Post-pandemic Economy"

Several scholars across many disciplines argue that neoliberal, free-market economic conditions drive inequalities, generating poverty and misery due to unfair austerity, ultimately affecting human health. Professor Labonté's prescription is that we jettison these policies targeting economic growth and development for generating greater fairness for the world's poor. This rejoinder argues contrarily that the criticism of neoliberal policies are misplaced, and that degrowth is really "self-imposed austerity," which will not benefit the poor. This rejoinder scrutinizes some simple stylized fact and assesses the soundness of the broader arguments. The evidence suggests clearly that becoming wealthy and following prudent economic policies is the best path to improving population health, equity, and other progressive outcomes. Badly required growth for the poor comes from free markets and good governance, and equity for the sake of fairness neither results in better health outcomes, nor an improved environment.

Knowledge mapping of population health: A bibliometric analysis

In recent years, population health has aroused great interest, especially after the outbreak of Covid-19. The related research increases substantially year by year. There are many kinds of research about population health, but few scholars use the bibliometric method to discuss them. Motivated by keeping abreast of emerging trends and critical turns in population health, this study adopts the bibliometric method to analyze the development history and status quo of population health, providing a summary description for it. This study adopts CiteSpace to conduct a bibliometric analysis of publications related to population health in Web of Science from 1971 to 2021. The most productive countries, authors, institutions, and research direction changes are analyzed. The research results show that: First, the number of publications and citations related to population health increases for years, especially in Canada, the United States, the United Kingdom, and Australia. Second, the number of publications by different countries or institutions in population health varies greatly, and they cooperate closely. Third, the co-occurrence of disciplines and keywords in population health is displayed. Finally, this study reveals the primary research force, the major themes, significant milestones, landmarks, and the evolution of the hot fronts. In all, the comprehensive analysis of this study would provide some enlightenment for future research.

Health Outcomes, Income and Income Inequality: Revisiting the Empirical Relationship

In this paper we revisit the relationship between health outcomes, income, and income inequality by applying alternative panel methodologies to a dataset of high-income countries spanning the time period 1980-2017. In this direction, we adopt alternative methodological frameworks in order to provide a) meaningful results by taking into account standard errors that alleviate problems of cross-sectional (spatial) and temporal dependence, and b) insights into the underlying relationships at several points of the conditional distribution of the health outcomes dependent variables. The evidence strongly supports the significant role that income plays in determining health outcomes. The findings relating to income inequality and nonlinear terms are more fragmented in that their significance and sign-direction depend on the functional form and the respective quantiles of the distribution the relationships are evaluated.

Inequality in Place: Effects of Exposure to Neighborhood-Level Economic Inequality on Mortality

This study contributes to the debate on whether income inequality is harmful for health by addressing several analytical weaknesses of previous studies. Using the Panel Study of Income Dynamics in combination with tract-level measures of income inequality in the United States, we estimate the effects of differential exposure to income inequality during three decades of the life course on mortality. Our study is among the first to consider the implications of income inequality within U.S. tracts for mortality using longitudinal and individual-level data. In addition, we improve upon prior work by accounting for the dynamic relationship between local areas and individuals' health, using marginal structural models to account for changes in exposure to local income inequality. In contrast to other studies that found no significant relation between income inequality and mortality, we find that recent exposure to higher local inequality predicts higher relative risk of mortality among individuals at ages 45 or older.

Income inequality and non-communicable disease mortality and morbidity in Brazil States: a longitudinal analysis 2002-2017

Background

Income inequality can negatively affect population health by increasing social stress and conflict, and reducing trust, public goods and healthcare access. However there is limited evidence from low and middle-income countries (LMICs) with high levels of inequality. This study investigates the association between income inequality, morbimortality and risk factors of non-communicable diseases (NCDs) in 26 Brazilian states from 2002 to 2017.

Methods

Data was acquired for men and women from the Global Health Data Exchange, the Brazilian Institute of Geography and Statistics, and the Brazilian Ministry of Health, totalling 416 state-year observations. Disability-adjusted life years (DALYs) and risk factors of NCDs were the dependent variables. Gini Index was the main independent variable. Multivariate linear panel regressions were performed, controlling for state and time fixed effects, gross domestic product per capita, population ageing, poverty and access to healthcare.

Findings

A 1% increase in the Gini Index was associated with increases in alcohol abuse (of 923•4 DALYs per 100,000 people, 95%CI 217•6 to 1629•0) and diabetes mellitus morbidity (of 893•3 DALYs per 100,000 people, 95%CI 127•7 to 1659•0), and decreases in morbidity from attention disorder (of -4•0 DALYs per 100,000 people, 95%CI -7•4 to -0•5) and autism spectrum (of -2•4 DALYs per 100,000 people, 95%CI -4•3 to -0•5). These associations were greater for men, further supported by associations with alcohol use as a risk factor.

Interpretation

This study provides evidence from a highly unequal LMIC, Brazil, of negative associations between income inequality and NCDs, and the importance of addressing wider social determinants of health.

Funding

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brazil (CAPES) - Finance Code 001 as a Brazilian CAPES scholarship to AZD and by the São Paulo Research Foundation (FAPESP), grant 2020/15944-8 to RSG.

The health effects of wage setting institutions: How collective bargaining improves health but not because it reduces inequality

Do wage-setting institutions, such as collective bargaining, improve health and, if so, is this because they reduce income inequality? Wage-setting institutions are often assumed to improve health because they increase earnings and reduce inequality and yet, while individual-level studies suggest higher earnings improve well being, the direct effects of these institutions on mortality remains unclear. This paper explores both the relationship between wage-setting institutions and mortality rates whether income inequality mediates this relationship. Using 50 years of data from 22 high-income countries (n ~ 825), I find mortality rates are lower in countries with collective bargaining compared to places with little or no wage protection. While wage-setting institutions may reduce economic inequality, these institutions do not appear to improve health because they reduce inequality. Instead, collective bargaining improves health, in part, because they increase average wage growth. The political and economic drivers of inequality may not, then, be correlated with health outcomes, and, as a result, health scholars need to develop more nuanced theories of the political economy of health that are separate from but in dialogue with the political economy of inequality.

From income inequality to social inequity: impact on health levels in an international efficiency comparison panel

BACKGROUND

Health equity, although addressed in several publications dealing with health efficiency analysis, is not easily translated into the operationalization of variables, mainly due to technical difficulties. Some studies provide evidence that it does not influence health outcomes; others demonstrate that its effect is an indirect one, with the hegemony of material living conditions over its social connotation. The aim of this article is to evaluate the role of health equity in determining health outcomes, in an international comparative analysis of the effectiveness and efficiency of health systems.

METHOD

Fixed Effects Model Panel and Data Envelopment Analysis, a dynamic and network model, in addition to comparative analysis between methods and health impacts. The effect variables considered in the study were life expectancy at birth and infant mortality, in 2010 and 2015, according to the sociocultural regions of the selected countries. Inequity was assessed both economically and socially. The following dimensions were considered: physical and financial resources, health production (access, coverage and prevention) and intersectoral variables: demographic, socioeconomic, governance and health risks.

RESULTS

Both methods demonstrated that countries with higher inequity levels (regarding income, education and health dimensions), associated or not with poverty, are the least efficient, not reaching the potential for effective health outcomes. The outcome life expectancy at birth exhibited, in the final model, the following variables: social inequity and per capita health expenditure. The outcome infant mortality comprehended the level of education variable, in association with the following healthcare variabels: care seeking due to diarrhea in children under five, births attended by skilled health professionals and the reduction in the incidence of HIV.

CONCLUSION

The dissociation between the distribution of health outcomes and the overall level of health of the population characterizes a devastating political choice for society, as it is associated with high levels of segregation, disrespect and violence from within. Countries should prioritize health equity, adding value to its resources, since health inequties affect society altogether, generating mistrust and reduced social cohesion.

Socioeconomic inequality in psychological distress among older adults in India: a decomposition analysis

BACKGROUND

Older people coming from a lower wealth gradient are more vulnerable to have stressful life events further adding more risk for common mental health disorders and psychological distress situations. The present study explores the associations between socioeconomic and health-related variables and psychological distress among older adults in India and the contribution of such factors to the inequalities in psychological distress.

METHODS

A cross-sectional survey of 9181 older adults conducted as 'Building a Knowledge Base on Population Ageing in India' was assessed. Logistic regression and decomposition models were used to analyze the data. Psychological distress was measured from General Health Questionnaire (GHQ-12). The value of Cronbach's alpha was 0.90. It was having a scale of 0 to 12 on the basis of experiencing stressful symptoms and was re-coded as 0 (representing 6+ stressful symptoms) and 1 (representing 5 and fewer symptoms).

RESULTS

Older adults from the poored, suffering from multi-morbidity, disabled, with low activities of daily living and low instrumental activities of daily living and poor cognitive ability were suffering from high psychological distress in India. Further, factors such as religion, caste, education, living arrangements, and self-worth in the family were major contributors to the concentration of psychological distress in older adults from poor households (concentration index: - 0.23).

CONCLUSION

The study suggests that among older people, there is a wide disparity of experiencing psychological distress across different socio-economic groups with significant factors being responsible for inequality in psychological distress. There is a need to build a "win-win" circumstance across sectors, including a broad spectrum of health, social and economic benefits to the vulnerable older population.

Decomposition analysis of the compositional and contextual factors associated with poor-non-poor inequality in diarrhoea among under-five children in low- and middle-income countries

OBJECTIVES

The aim of the study was to assess the magnitude of wealth inequalities in the development of diarrhoea among under-five children in low- and middle-income countries (LMICs) and to identify and quantify contextual and compositional factors' contribution to the inequalities.

DESIGN

This is a cross-sectional study.

METHODS

We used cross-sectional data from 57 Demographic and Health Surveys conducted between 2010 and 2018 in LMICs. Descriptive statistics were used to understand the gap in having diarrhoea between the children from poor and non-poor households and across the selected covariates using Fairlie decomposition techniques with multivariable binary logistic regressions at P = 0.05.

RESULTS

Of the 57 countries, we found a statistically significant pro-poor odds ratio in only 29 countries, 7 countries showed pro-non-poor inequality and others showed no statistically significant inequality. Among the countries with statistically significant pro-poor inequality, the risk difference was largest in Cameroon (94.61/1000), whereas the largest pro-non-poor risk difference in diarrhoea was widest in Timor-Leste (-41.80/1000). Important factors responsible for pro-poor inequality varied across countries. The largest contributors to the pro-poor inequalities in having diarrhoea are maternal education, access to media, neighbourhood socio-economic status, place of residence, birth order and maternal age.

CONCLUSION

Diarrhoea remains a major challenge in most LMICs, with a wide range of pro-poor inequalities. These disparities were explained by both compositional and contextual factors, which varied widely across the countries. Thus, multifaceted geographically specific economic alleviation intervention may prove to be a potent approach for addressing the poor and non-poor differentials in the risk of diarrhoea with policies tailored to country-specific risk factors. There is a need for further investigation of factors that drive pro-non-poor inequalities found in 9 of the LMICs.

Inequality amplifies the negative association between life expectancy and air pollution: A cross-national longitudinal study

Ambient air pollution, in the form of fine particulate matter (PM_2.5), poses serious population health risks. We estimate cross-national longitudinal models to test whether the negative relationship between life expectancy and PM_2.5 concentration is larger in nations with higher levels of income inequality. The dependent variable is average life expectancy at birth, and the focal predictor variables include PM_2.5 concentration, income inequality, and the two-way interaction between them. We also estimate the average marginal effects of PM_2.5 concentration from low to high values of income inequality, and the predicted values of life expectancy from low to high values of PM_2.5 concentration and income inequality. Results indicate that the negative relationship between life expectancy and PM_2.5 concentration is larger in nations with higher levels of income inequality, and the reductions in predicted life expectancy are substantial when both PM_2.5 concentration and income inequality are high. We suggest that the theoretical principles of Power, Proximity, and Physiology help explain our findings. This study underscores the importance in considering the multiplicative impacts of environmental conditions and socioeconomic factors in the modeling of population health.

Economic growth, income inequality and life expectancy in China

China had made dramatic health gains before its economic reform that began in 1978 produced rapid economic growth in the ensuing years. Since the economic reform, China's income inequality has substantially increased, and health gains have stagnated. This article investigates the extent to which China's health stagnation may be attributable to the rise in income inequality in China. By simulating the improvement in life expectancy that could have resulted if, ceteris paribus, income inequality had stayed constant at the lowest level after the founding of the People's Republic of China in 1949, we find that the sharply increasing income inequality in China has contributed to life loss in China's population, about 0.6 years for men and 0.4 years for women. These findings suggest that redistribution of income from rich to poor may be one of the most important policy levers for improving population health in China.

The Associations of Income, Education and Income Inequality and Subjective Well-Being among Elderly in Hong Kong-A Multilevel Analysis

Background: Higher income and education and lower income inequality in a neighbourhood have been shown to be related to better mental health outcome in developed countries. However, it is not clear whether these factors would affect the subjective well-being of the elderly, especially in a setting with recent rapid economic development. Methods: This study was conducted in 80 community centres with a total of 7552 community-dwelling elderly (mean age 75.9 years (SD = 7.79), 79% female) in Hong Kong. Income at individual level was measured as perceived disposable income. Education level was also collected. At district level, income was measured by district median household income and education was measured as the proportion of the population with no formal schooling. Income inequality was quantified using Gini coefficients. Low subjective well-being was defined as any one or a combination of the following: not satisfied with life, no meaning of life and being unhappy (Likert scale ≤ 2). Multilevel logistic regression was used to assess the association of income, education and income inequality and low subjective well-being. Results: We found that 15.3% (95% confidence interval (CI): 14.5 to 16.1) of the elderly have low subjective well-being. Compared with elderly who reported a very adequate disposable income, those who reported a very inadequate disposable income are at increased risk of low subjective well-being (OR=5.08, 95%CI: 2.44 to 10.59). Compared with elderly with tertiary education, those with no formal schooling were at higher risk (OR=1.60, 95%CI 1.22 to 2.09). Income inequality was not related to subjective well-being. Conclusions: Elderly with inadequate disposable income and lower education level are more likely to suffer from low subjective well-being. At the neighbourhood level, income inequality was not related to subjective well-being. However, the relationships between neighbourhood income and education level and individuals’ subjective well-being are not clear.

Effect of Income Inequality on Health in Quebec: New Insights from Panel Data

We investigated the relationship between income inequality and all-cause mortality in 87 regional county municipalities (RCMs) of Quebec (Canada) while accounting for time lags and effects of other socioeconomic variables. We presumed to be true that income inequality entails stress and depression. Thus, these phenomena were tested as mediating factors. The data used consist of eight (8) area-based chronological variables: mortality rate, Gini index, disposable income, criminality rate, number of physicians, density of population, and the proportion of people reporting feeling stressed or depressed. The association between income inequality and mortality was analyzed using the generalized method of moments (GMM) approach with local fixed effects to control unobservable characteristics. Our results show that higher income inequality led to a significant increase of mortality rate with a time lag of 5 years when socioeconomic characteristics were held constant. As expected, households’ disposable income and mortality rate were negatively associated. Moreover, mortality rate was positively associated with population density and negatively associated with the number of physicians. Finally, only depression showed the potential to act as a mediating factor. Based on our findings, we suggest that, over time, income inequality, by amplifying depression phenomena, increases the mortality rate in Quebec’s RCMs.

Globalization and health equity: The impact of structural adjustment programs on developing countries

Among the many drivers of health inequities, this article focuses on important, yet insufficiently understood, international-level determinants: economic globalization and the organizations that spread market-oriented policies to the developing world. One such organization is the International Monetary Fund (IMF), which provides financial assistance to countries in economic trouble in exchange for policy reforms. Through its 'structural adjustment programs,' countries around the world have liberalized and deregulated their economies. We examine how policy reforms prescribed in structural adjustment programs explain variation in health equity between nations-approximated by health system access and neonatal mortality. Our empirical analysis uses an original dataset of IMF-mandated policy reforms for a panel of up to 137 developing countries between 1980 and 2014. We employ regression analysis to evaluate the relationship between these reforms and health equity, taking into account the non-random selection and design of IMF programs. We find that structural adjustment reforms lower health system access and increase neonatal mortality. Additional analyses show that labor market reforms drive these deleterious effects. Overall, our evidence suggests that structural adjustment programs endanger the attainment of Sustainable Development Goals in developing countries.

Reframing inequality? The health inequalities turn as a dangerous frame shift

Background

Politicians in many countries have embraced the notion that health inequalities derive from socioeconomic inequalities, but European governments have for the most part failed to enact policies that would reduce underlying social inequalities.

Methods

Data are drawn from 84 in-depth interviews with policy-makers in four European countries between 2012 and 2015, qualitative content analysis of recent health inequalities policy documents, and secondary literature on the barriers to implementing evidence-based health inequalities policies.

Results

Institutional and political barriers are important barriers to effective policy. Both policy-making institutions and the ideas and practices associated with neoliberalism reinforce medical-individualist models of health, strengthen actors with material interests opposed to policies that would increase equity, and undermine policy action to tackle the fundamental causes of social (including health) inequalities.

Conclusions

Medicalizing inequality is more appealing to most politicians than tackling income and wage inequality head-on, but it results in framing the problem of social inequality in a way that makes it technically quite difficult to solve. Policy-makers should consider adopting more traditional programs of taxation, redistribution and labor market regulation in order to reduce both health inequalities and the underlying social inequalities.

Socioeconomic Differences and the Potential Role of Tribes in Young People's Food and Drink Purchasing Outside School at Lunchtime

Socioeconomic deprivation has been linked to food consumption practices, but studies investigating the food environment around schools provide mixed findings. Peer influence and marketing cues are considered important influencers of young people's behaviors. This study used a tribal theory lens to investigate the factors affecting pupils' purchasing and consumption of food/drinks outside schools at lunchtime. A survey was conducted with 243 pupils from seven UK secondary schools of differing socioeconomic status (SES). A purchasing recall questionnaire (PRQ) was developed and administered online at the participating schools to capture food and drink purchasing, intake, and expenditure. No significant differences were found in terms of energy and nutrients consumed or food/drink expenditure between pupils from schools of lower and higher SES. Enjoyment of food shopping with friends was linked with higher food energy intake and spend. Higher susceptibility to peer influence was associated with greater influence from food advertising and endorsements. Without ignoring the impact that SES can have on young people's food choices, we suggest that tribal theory can be additionally used to understand pupils' eating behaviors and we present implications for social marketers and policy makers.

Income Inequality and Population Health: A Global Gradient?

Cross-national empirical research about the link between income inequality and population health produces conflicting conclusions. We address these mixed findings by examining the degree to which the income inequality and health relationship varies with economic development. We estimate fixed-effects models with different measures of income inequality and population health. Results suggest that development moderates the association between inequality and two measures of population health. Our findings produce two generalizations. First, we observe a global gradient in the relationship between income inequality and population health. Second, our results are consistent with income inequality as a proximate or conditional cause of lower population health. Income inequality has a 139.7% to 374.3% more harmful effect on health in poorer than richer countries and a significantly harmful effect in 2.1% to 53.3% of countries in our sample and 6.6% to 67.6% of the world's population but no significantly harmful effect in richer countries.

Objective and Subjective Socioeconomic Status, Their Discrepancy, and Health: Evidence from East Asia

Socioeconomic status (SES) is largely understood to be a fundamental determinant of health. Recently, subjective socioeconomic status (SSS) has emerged as a potentially important predictor of health above and beyond traditional (i.e., objective) SES indicators (OSS). The current study adds to this emerging body of research by examining the potentially important role of status discrepancies for health outcomes. We used nationally representative data from three East Asian countries (China, Japan, and South Korea) (2010 East Asian Social Survey) and a non-linear statistical technique (i.e., diagonal mobility model) to simultaneously model the independent contributions of OSS and SSS and their discrepancy for three health outcomes. Findings showed that SSS does, in fact, explain additional variation in health net of OSS in most cases, and status discrepancy is not associated with any of the three health outcomes. While status discrepancy was not found to be a driving factor in determining the predictive power of SSS net of OSS (at least in East Asia), the present study adds robustness to the accumulating evidence that challenges the social inequality hypothesis and provides a basis from which future research can build and contribute further to the understanding surrounding socioeconomic status and health outcomes.

Mental distress and perceived wealth, justice and freedom across eight countries: The invisible power of the macrosystem

Health and well-being have been related to macro-level factors such as income, income inequality or socioeconomic status. With regard to the increasing burden of disease due to mental disorders worldwide, the association between the macrosystem and mental distress should be further explored, too. In this context, the subjective evaluation of the macrosystem might play an important role. In the present exploratory study, we assessed symptoms of depression, anxiety and stress as well as perceived wealth, justice and freedom in population-based surveys in Spain, France, Germany, Poland, Russia, Sweden, the United Kingdom and the United States of America (n ≈ 1000 per country). The Swedish sample presented the lowest symptom ratings of depression, anxiety and stress and the highest self-rated health. The results also indicated that the subjective evaluation of the macrosystem matters in respect to mental distress. The complete model, including the control variables country, gender, age and education, and perceived wealth, justice and freedom predicted depression, anxiety and stress symptoms explained 8% of the variance of each symptom cluster. The present results encourage research to consider the macrosystem, and the subjective evaluation of macro-level factors, as a relevant component in biopsychosocial models of mental distress.

The link between income inequality and health in Europe, adding strength dimensions of primary care to the equation

Income inequality has been clearly associated with reduced population health. A body of evidence suggests that a strong primary care system may mitigate this negative association. The aim of this study is to assess the strength of the primary care system's effect on the inverse association between income inequality and health in Europe. Health is operationalised using four cross-sectional outcomes: self-rated health, life expectancy, mental well-being, and infant mortality. Strength of the primary care system is measured using the framework of the Primary Health Care Activity Monitor Europe, and income inequality by the Gini coefficient. Multiple regression models with interaction terms were used. The results confirm that especially the structure and continuity dimension of primary care strength can buffer the inverse association between income inequality and health. European policymakers should therefore focus on strengthening primary care systems in order to reduce inequity in health.

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

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

Bring out your dead!: A study of income inequality and life expectancy in the United States, 2000-2010

We test whether income inequality undermines female and male life expectancy in the United States. We employ data for all 50 states and the District of Columbia and two-way fixed effects to model state-level average life expectancy as a function of multiple income inequality measures and time-varying characteristics. We find that state-level income inequality is inversely associated with female and male life expectancy. We observe this general pattern across four measures of income inequality and under the rigorous conditions of state-specific and year-specific fixed effects. If income inequality undermines life expectancy, redistribution policies could actually improve the health of states.

Health of midlife and older adults in China: the role of regional economic development, inequality, and institutional setting

Objectives

To document the association between economic development, income inequality, and health-related public infrastructure, and health outcomes among Chinese adults in midlife and older age.

Methods

We use a series of multi-level regression models with individual-level baseline data from the China Health and Retirement Longitudinal Survey (CHARLS). Provincial-level data are obtained both from official statistics and from CHARLS itself. Multi-level models are estimated with different subjective and objective health outcomes.

Results

Economic growth is associated with better self-rated health, but also with obesity. Better health infrastructure tends to be negatively associated with health outcomes, indicating the likely presence of reverse causality. No supportive evidence is found for the hypothesis that income inequality leads to worse health outcomes.

Conclusions

Our study shows that on top of individual characteristics, provincial variations in economic development, income inequality, and health infrastructure are associated with a range of health outcomes for Chinese midlife and older adults. Economic development in China might also bring adverse health outcomes for this age group; as such specific policy responses need to be developed.

Electronic supplementary material

The online version of this article (doi:10.1007/s00038-017-0970-9) contains supplementary material, which is available to authorized users.

Social Network and Mental Health Among Older Adults in Rural Uttar Pradesh, India: A Cross-Sectional Study

The rapid growth of the older population in India draws attention to the factors that contribute to their changing health realities. However, there has hardly been any study in India that has looked at the effects of specific social networks with children, relatives, friends and confidant on depression among older adults. The objective of the study is to investigate the association between social network and depression among the rural elderly. The study population comprised over 630 older adults (aged 60 and above) from the rural areas of Varanasi, Uttar Pradesh. We adopted Berkman's theoretical model of the impact of social relations on depression among the elderly in the Indian context. Results of the Confirmatory Factor Analysis (CFA) demonstrated that the four specific social network types: children, relatives, friends and confidant were tenable. The results showed that a better social network with 'friends/neighbours' was protective against depression among the rural elderly. This clearly points to the need for more social network centres for older adults, so that they can interact with friends within the community or between communities and participate in group activities.

Societal Inequality and individual subjective well-being: Results from 68 societies and over 200,000 individuals, 1981-2008

Income inequality has been contentious for millennia, a source of political conflict for centuries, and is now widely feared as a pernicious "side effect" of economic progress. But equality is only a means to an end and so must be evaluated by its consequences. The fundamental question is: What effect does a country's level of income inequality have on its citizens' quality of life, their subjective well-being? We show that in developing nations inequality is certainly not harmful but probably beneficial, increasing well-being by about 8 points out of 100. This may well be Kuznets's inverted "U": In the earliest stages of development some are able to move out of the (poorly paying) subsistence economy into the (better paying) modern economy; their higher pay increases their well-being while simultaneously increasing inequality. In advanced nations, income inequality on average neither helps nor harms. Estimates are from random-intercept fixed-effects multi-level models, confirmed by over four dozen sensitivity tests. Data are from the pooled World Values/European Values Surveys, Waves 1 to 5 with 169 representative national samples in 68 nations, 1981 to 2009, and over 200,000 respondents, replicated and extended in the European Quality of Life Surveys.

The Health Effects of Income Inequality: Averages and Disparities

Much research has investigated the association of income inequality with average life expectancy, usually finding negative correlations that are not very robust. A smaller body of work has investigated socioeconomic disparities in life expectancy, which have widened in many countries since 1980. These two lines of work should be seen as complementary because changes in average life expectancy are unlikely to affect all socioeconomic groups equally. Although most theories imply long and variable lags between changes in income inequality and changes in health, empirical evidence is confined largely to short-term effects. Rising income inequality can affect individuals in two ways. Direct effects change individuals' own income. Indirect effects change other people's income, which can then change a society's politics, customs, and ideals, altering the behavior even of those whose own income remains unchanged. Indirect effects can thus change both average health and the slope of the relationship between individual income and health.

School life expectancy and risk for tuberculosis in Europe

OBJECTIVE

This study aims to investigate the effect of country-level school life expectancy on Tuberculosis (TB) incidence to gain further understanding of substantial variation in TB incidence across Europe.

METHODS

An ecological study examined the prospective association between baseline country-level education in 2000 measured by school life expectancy and TB incidence in 2000-2010 in 40 countries of the WHO European region using quantile regression. Subsequently, to validate the ecological associations between education and TB incidence, an individual-level analysis was performed using case-based data in 29 EU/EEA countries from the European Surveillance System (TESSy) and simulating a theoretical control group.

RESULTS

The ecological analysis showed that baseline school life expectancy had a negative prospective association with TB incidence. We observed consistent negative effects of school life expectancy on individuals' TB infections prospectively.

CONCLUSIONS

These findings suggests that country-level education is an important determinant of individual-level TB infection in the region, and in the absence of a social determinants indicator that is routinely collected for reportable infectious diseases, the adoption of country-level education for reportable infectious diseases would significantly advance the field.

Income inequality, life expectancy and cause-specific mortality in 43 European countries, 1987-2008: a fixed effects study

Whether income inequality is related to population health is still open to debate. We aimed to critically assess the relationship between income inequality and mortality in 43 European countries using comparable data between 1987 and 2008, controlling for time-invariant and time-variant country-level confounding factors. Annual data on income inequality, expressed as Gini index based on net household income, were extracted from the Standardizing the World Income Inequality Database. Data on life expectancy at birth and age-standardized mortality by cause of death were obtained from the Human Lifetable Database and the World Health Organization European Health for All Database. Data on infant mortality were obtained from the United Nations World Population Prospects Database. The relationships between income inequality and mortality indicators were studied using country fixed effects models, adjusted for time trends and country characteristics. Significant associations between income inequality and many mortality indicators were found in pooled cross-sectional regressions, indicating higher mortality in countries with larger income inequalities. Once the country fixed effects were added, all associations between income inequality and mortality indicators became insignificant, except for mortality from external causes and homicide among men, and cancers among women. The significant results for homicide and cancers disappeared after further adjustment for indicators of democracy, education, transition to national independence, armed conflicts, and economic freedom. Cross-sectional associations between income inequality and mortality seem to reflect the confounding effects of other country characteristics. In a European context, national levels of income inequality do not have an independent effect on mortality.

Recalibrating the spirit level: An analysis of the interaction of income inequality and poverty and its effect on health

The publication of The Spirit Level (Wilkinson and Pickett, 2009) marked a paramount moment in the analysis of health and inequality, quickly attracting a remarkable degree of attention, both positive and negative, both in academic and in public discourse. Following at least 20 years of research, the book proposes a simple and powerful argument: inequality per se, more specifically income inequality, is harmful to every aspect of social life. In order to confirm this idea, the authors present a series of bivariate, cross-sectional associations showing comparisons across countries and within the United States. Despite the methodological limitations of this approach, the authors advance causal claims concerning the detrimental effects of income inequality. They also rule out poverty as a plausible alternative explanation, without directly measuring it. Meanwhile, over the last decade stratification scholars have demonstrated the nonlinear effect of economic factors, especially income, on health. The results suggest that a relative approach is best for analyzing dynamics at the top of the income distribution, whereas an absolute approach seems most appropriate for studying the bottom of the distribution. Consistent with this perspective, here I reanalyze data from The Spirit Level, adding a measure of poverty, in order to control the effect of inequality and explore its interaction with poverty. The findings show that inequality and poverty-which I contend are two interdependent but nonetheless distinct phenomena-interact across countries, such that the detrimental effects of inequality are present or stronger in countries with high poverty, and absent or weaker in countries with low poverty; poverty replaces inequality as the favored explanation of health and social ills across states. The new evidence suggests that income distributions are characterized by a complex interplay between inequality and poverty, whose interaction deserves further analysis.

The link between inequality and population health in low and middle income countries: policy myth or social reality?

An influential policy idea states that reducing inequality is beneficial for improving health in the low and middle income countries (LMICs). Our study provides an empirical test of this idea: we utilized data collected by the Demographic and Health Surveys between 2000 and 2011 in as much as 52 LMICs, and we examined the relationship between household wealth inequality and two health outcomes: anemia status (of the children and their mothers) and the women' experience of child mortality. Based on multi-level analyses, we found that higher levels of household wealth inequality related to worse health, but this effect was strongly reduced when we took into account the level of individuals' wealth. However, even after accounting for the differences between individuals in terms of household wealth and other characteristics, in those LMICs with higher household wealth inequality more women experienced child mortality and more children were tested with anemia. This effect was partially mediated by the country's level and coverage of the health services and infrastructure. Furthermore, we found higher inequality to be related to a larger health gap between the poor and the rich in only one of the three examined samples. We conclude that an effective way to improve the health in the LMICs is to increase the wealth among the poor, which in turn also would lead to lower overall inequality and potential investments in public health infrastructure and services.

Do welfare regimes influence the association between disability and self-perceived health? A multilevel analysis of 57 countries

Disability is usually associated with poorer self-rated health. However, as many people with disabilities do not consider themselves unhealthy, the association may not be as straightforward as it appears. This study examines whether the relationship between disability and self-rated health is dependent on a country's welfare regime. Welfare regimes can play a significant role in securing the needs of disabled people and lessening their social exclusion. However, welfare regimes also label disabled people accordingly, before they become entitled to specific provisions and services. Being given a low status label and being dependent on welfare provisions might trigger a negative self-evaluation of health. Using data from 57 countries of the World Health Survey of 2002-2004, the multilevel regression analyses show that people with a disability tend to rate their health worse than people without any disability. Moreover, the strength of this negative association varies significantly across countries and is affected by a country's welfare regime. The association is the strongest in the various Welfare State regimes (mostly European countries) and the weakest in Informal-Security regimes (Latin-American and Asian countries) and in Insecurity regimes (African countries). Disabled people living in Welfare States regimes tend to rate their health worse than people in other regimes. These findings confirm that welfare regimes play a role in shaping the health perception of disabled people and that processes of labeling may result in unintended and negative consequences of welfare programs. Research on the nexus between disability and self-rated health that neglects this macro-social context of welfare regimes may lead to undifferentiated and even incorrect conclusions.

Cross-temporal and cross-national poverty and mortality rates among developed countries

A prime objective of welfare state activities is to take action to enhance population health and to decrease mortality risks. For several centuries, poverty has been seen as a key social risk factor in these respects. Consequently, the fight against poverty has historically been at the forefront of public health and social policy. The relationship between relative poverty rates and population health indicators is less self-evident, notwithstanding the obvious similarity to the debated topic of the relationship between population health and income inequality. In this study we undertake a comparative analysis of the relationship between relative poverty and mortality across 26 countries over time, with pooled cross-sectional time series analysis. We utilize data from the Luxembourg Income Study to construct age-specific poverty rates across countries and time covering the period from around 1980 to 2005, merged with data on age- and gender-specific mortality data from the Human Mortality Database. Our results suggest not only an impact of relative poverty but also clear differences by welfare regime that partly goes beyond the well-known differences in poverty rates between welfare regimes.

Inequalities in the distribution of pharmacists' wage-and-salary earnings: indicators and their development

BACKGROUND

Disparities in wages and salaries can be viewed as the dispersion of a statistical distribution that responds to observed and unobserved characteristics, and reflects socioeconomic phenomena such as the interplay of supply and demand, availability of information, and efficiency of markets in their search for equilibrium.

OBJECTIVES

The aim of this study was to explore the nature of inequality in the distribution of pharmacists' wage-and-salary earnings and establish the extent to which inequality primarily occurred because of variation between/among groups or within groups of pharmacists in several classifications of human-capital and job-related preference variables.

METHODS

Data were collected through the use of a survey questionnaire mailed to registered pharmacists in South Florida, USA. Five indicators of inequality (the log earnings variance, the coefficient of variation, the lower median share, the 90-10 decile ratio, and the Gini coefficient) were estimated for eight human-capital classifications and eight job-related classifications. A one-way ANOVA model was applied to the groups in each classification to compare variation between/among versus within pharmacy groups.

RESULTS

Pharmacists' wage-and-salary earnings were more evenly distributed than most income distributions discussed in the literature. They were more equitably distributed for full-time pharmacists than for all pharmacists in the data set. All five-inequality indicators behaved similarly. Notable differences were observed between/among groups within the gender, age group, marital status, number of children, academic degree, and type of primary pharmacy activity classifications.

CONCLUSION

Inequalities in wages and salaries have been identified both between/among and within pharmacist groups in several classifications using five commonly accepted indicators.

Where wealth matters more for health: the wealth-health gradient in 16 countries

Researchers have long demonstrated that persons of high economic status are likely to be healthier than persons of low socioeconomic standing. Cross-national studies have also demonstrated that health of the population tends to increase with country's level of economic development and to decline with level of economic inequality. The present research utilizes data for 16 national samples (of populations fifty years of age and over) to examine whether the relationship between wealth and health at the individual-level is systematically associated with country's level of economic development and country's level of income inequality. The analysis reveals that in all countries rich persons tend to be healthier than poor persons. Furthermore, in all countries the positive association between wealth and health holds even after controlling for socio-demographic attributes and household income. Hierarchical regression analysis leads to two major conclusions: first, country's economic resources increase average health of the population but do not weaken the tie between wealth and health; second, a more equal distribution of economic resources (greater egalitarianism) does not raise health levels of the population but weakens the tie between wealth and health. The latter findings can be mostly attributed to the uniqueness of the US case. The findings and their significance are discussed in light of previous research and theory.

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.