Fundamental causes of health disparities: stratification, the welfare state, and health in the United States and Iceland

Is Redistribution Good for Our Health? Examining the Macrocorrelation between Welfare Generosity and Health across EU Nations over the Last 40 Years

CONTEXT

Social determinants of health are finally getting much-needed policy attention, but their political origins remain underexplored. In this article, the authors advance a theory of political determinants as accruing along three pathways of welfare state effects (redistribution, poverty reduction, and status preservation), and they test these assumptions by examining impacts of policy generosity on life expectancy (LE) over the last 40 years.

METHODS

The authors merge new and existing welfare policy generosity data from the Comparative Welfare Entitlement Project with data on LE spanning 1980-2018 across 21 countries in the Organization for Economic Cooperation and Development. They then examine relationships between five welfare policy generosity measures and LE using cross-sectional differencing and autoregressive lag models.

FINDINGS

The authors find consistent and positive effects for total generosity (an existing measure of social insurance generosity) on LE at birth across different model specifications in the magnitude of an increase in LE at birth of 0.10-0.15 years (p < 0.05) as well as for a measure of status preservation (0.11, p < 0.05). They find less consistent support for redistribution and poverty reduction measures.

CONCLUSIONS

The authors conclude that in addition to generalized effects of policy generosity on health, status-preserving social insurance may be an important, and relatively overlooked, mechanism in increasing LE over time in advanced democracies.

Health among workers retiring after the state pension age: a longitudinal and comparative study

BACKGROUND

In recent decades, many countries have observed increasing labor force participation beyond the state pension age (SPA). However, there is a lack of research on employment beyond SPA and how it relates to older workers' health. Moreover, there is a need to better understand how institutional factors affect the relationship between older workers' employment and health. In this study, we examine simultaneous employment and health trajectories over 11 years in 12 countries from Europe and the Americas, and study how these trajectories differ by welfare state regime and level of old-age pension redistribution.

METHODS

We used a harmonized pooled-country dataset of 3699 older workers based on four representative panel surveys: the Survey of Health, Ageing and Retirement in Europe (SHARE), the English Longitudinal Study of Ageing (ELSA), the Health and Retirement Survey (HRS), and the Chilean Social Protection Survey (EPS). We conducted multichannel sequence analysis to estimate the types of simultaneous employment-health trajectories, and multinomial regression analysis to examine the relationship between trajectory types and institutional factors.

RESULTS

We found that late retirement was equally associated with poor and good health. There is also a higher prevalence of late retirement trajectories in combination with poor health in liberal welfare regimes and in countries with lower levels of old-age pension redistribution.

CONCLUSION

Our study indicates that nonliberal welfare regimes and redistributive old-age pension policies may be better suited to protect vulnerable workers while providing those in good health with the opportunity to work beyond the SPA.

Welfare state decommodification and population health

A generous welfare state decommodifies social relations and frees citizens from relying excessively on markets. We argue that decommodification is associated with population health in two ways: directly, as it provides better social protection to households and indirectly, as it mitigates health-damaging labour market polarization and reduces the incidence of labour market risks. Using time-series cross-sectional quantitative analysis for 21 OECD countries from 1971 to 2010, we observe a negative relationship between decommodification and the age-standardized death rate. We then analyze three correlates of decommodification—income redistribution, labour market polarization and the reduction of labour market risk incidence—and find that only the latter two are associated with population health. Higher labour market polarization, measured by the share of market income allocated to the richest decile relative to the share of the poorest decile, is associated with a higher death rate. A new measure of risk reduction, the degree to which the welfare state reduces the prevalence of large income losses, is also associated with lower death rates, especially for men. Welfare state decommodification thus contributes to population health directly, and indirectly, via the attenuation of labour market polarization and the mitigation of labour market risks.

COVID-19 amongst western democracies: A welfare state analysis

The COVID-19 pandemic has resulted in more than 282 million cases and almost 5.5 million deaths (WHO Coronavirus Disease (COVID-19) Dashboard, 2022). Its impact, however, has not been uniform. This analysis examines differences in COVID-19 cases and mortality rates amongst different welfare states within the first three waves of the pandemic using repeated measures Multivariate Analysis of Covariance (MANCOVA). Liberal states fared much better on the number of COVID-19 cases, deaths, and excess deaths than the Conservative/Corporatist welfare democracies. Social Democratic countries, in turn, did not fare any better than their Conservative/Corporatist counterparts once potential confounding economic and political variables were accounted for: countries’ economic status, healthcare spending, availability of medical personnel, hospital beds, pandemic-related income support and debt relief, electoral events, and left-power mobilization. The pandemic-related welfare responses after the first wave were similar across all three types of western democracies, but the differences in pandemic outcomes remained. The somewhat better outlook of the Liberal states could be attributed to the so-called social democratization of the Anglo-American democracies, but also to the fact that neoliberalism could have flattened the previous differences between the welfare states typologies and could have brought states closer to each other, ideologically speaking, in terms of welfare provision.

Health Power Resources Theory: A Relational Approach to the Study of Health Inequalities

Link and Phelan's pioneering 1995 theory of fundamental causes urged health scholars to consider the macro-level contexts that "put people at risk of risks." Allied research on the political economy of health has since aptly demonstrated how institutions contextualize risk factors for health. Yet scant research has fully capitalized on either fundamental cause or political economy of health's allusion to power relations as a determinant of persistent inequalities in population health. I address this oversight by advancing a theory of health power resources that contends that power relations distribute and translate the meaning (i.e., necessity, value, and utility) of socioeconomic and health-relevant resources. This occurs through stratification, commodification, discrimination, and devitalization. Resurrecting historical sociological emphases on power relations provides an avenue through which scholars can more fully understand the patterning of population health and better connect the sociology of health and illness to the central tenets of the discipline.

Global capitalism as a societal determinant of health: A conceptual framework

Recent scholarship has sought to distinguish between the deeper societal factors that shape the more proximate social determinants of health. One of these socio-structural institutions is global capitalism. While critical scholarship has advanced our understanding of the relationships between capitalist globalization and health, more work is needed to understand the transnational economic, political, and cultural practices that affect various global health issues. This paper argues that the theory of global capitalism provides an important, critical perspective for understanding different phenomena associated with global health. The theory's key concepts of transnational corporations, financialization, consumerism, transnational social classes, and transnational state comprise the conceptual framework. When applied to various global health topics, the theory advances our understanding of the health-related institutional structures of today's global economy, provides a holistic view that integrates various strands of health research, highlights various forms of health activism, and offers new questions for addressing persistent health injustice across the world.

Deprivation or discrimination? Comparing two explanations for the reverse income-obesity gradient in the US and South Korea

In high-income countries, poverty is often associated with higher average body mass index (BMI). To account for this reverse gradient, deprivation theories posit that declining economic resources make it more difficult to maintain a healthy weight. By contrast, discrimination theories argue that anti-fat discrimination in hiring and marriage sorts heavier individuals into lower-income households. This study assesses competing predictions of these theories by examining how household income in representative samples from South Korea (2007-2014, N=20,823) and the US (1999-2014, N=6395) is related to BMI in two key contrasting groups: (1) currently-married and (2) never-married individuals. As expected by anti-fat discrimination in marriage, the reverse gradient is observed among currently-married women but not among never-married women in both countries. Also consistent with past studies no evidence was found for a reverse gradient among men. These findings are consistent with anti-fat discrimination in marriage as a key cause of the reverse gradient and raise serious challenges to deprivation accounts as well as explanations based on anti-fat discrimination in labour markets.

Organized Labor and Depression in Europe: Making Power Explicit in the Political Economy of Health

Despite engagement with the construct of power relations, research on the political economy of health has largely overlooked organized labor as a determinant of well-being. Grounded in the theory of power resources, our study aims to fill this gap by investigating the link between country-level union density and mental health while accounting for the compositional effects of individual-level union membership. We use three waves of the European Social Survey (N = 52,737) and a variation on traditional random-effects models to estimate both the contextual and change effects of labor unions on depressive symptoms. We find that country-level union density is associated with fewer depressive symptoms and that this is true irrespective of union membership. We discuss our findings vis-à-vis the literatures on the political economy of health, power resources, and fundamental causes of disease.

Addressing Health Care Disparities: A Radical Perspective and Proposal

This paper begins by rethinking the sociological theory that social conditions are fundamental causes of health disparities and that controlling disease ironically increases or creates them. While usually true, the radical proposal of non-profit health care and pharmaceutical development could ameliorate health disparities if a nation like Canada or a region like the EU looked to radically different but successful models such as the Drugs for Neglected Diseases initiative. It uses what could be called entrepreneurial collaboration for public health markets and inverts intellectual property to public health IP to maximize health gain instead of profits.

Employment relations and dismissal regulations: Does employment legislation protect the health of workers?

Sociologists have long acknowledged that being in a precarious labour market position, whether employed or unemployed, can harm peoples' health. However, scholars have yet to fully investigate the possible contextual, institutional determinants of this relationship. Two institutions that were overlooked in previous empirical studies are the regulations that set minimum compensation for dismissal, severance payments, and entitlements to a period of notice before dismissal, notice periods. These institutions may be important for workers' health as they influence the degree of insecurity that workers are exposed to. Here, we test this hypothesis by examining whether longer notice periods and greater severance payments protect the health of labour market participants, both employed and unemployed. We constructed two cohorts of panel data before and during the European recession using data from 22 countries in the European Union Statistics on Income and Living Conditions (person years = 338,000). We find more generous severance payments significantly reduce the probability that labour market participants, especially the unemployed, will experience declines in self-reported health, with a slightly weaker relationship for longer notice periods.

The Institutional Determinants of Health Insurance: Moving Away from Labor Market, Marriage, and Family Attachments under the ACA

For more than a century, the American welfare state required working-age adults to obtain social welfare benefits through their linkages to employers, spouses, or children. Recent changes to U.S. healthcare policy prompted by the Patient Protection and Affordable Care Act (ACA), however, provide adults with new pathways for accessing a key form of social welfare-health insurance-decoupled from employers, spouses, and children. Taking advantage of this fundamental shift in the country's system of social welfare provision, I use data from the National Survey on Drug Use and Health (NSDUH) to explore patterns of health insurance coverage from before and after the ACA became active in 2014. The results show that the salience of labor market, marriage, and family attachments as pathways to coverage significantly declined in the first three years following passage of the ACA. By providing adults with a new route to coverage decoupled from their institutional attachments, the ACA helped narrow health insurance inequalities across gender, race and ethnicity, and education. Given the strong association between health insurance and health outcomes, the results from this study raise important questions about the centrality of institutional attachments for our knowledge of health inequalities.

Compensation Appraisals and Labor Union Membership

Given the beneficial effects of labor unions on "bread and butter issues," union members should appraise their economic circumstances more favorably than nonunion members do. Yet, research on the anomaly of the dissatisfied union worker challenges this expectation. Using the General Social Survey's Quality of Work Life module, this article examines whether union members appraise their economic circumstances less favorably than nonunion members. Results suggest that union membership is associated with more favorable appraisal of benefits but not wages. These findings may help to provide at least a partial explanation for the anomaly of the dissatisfied union worker. Because income constitutes a vital component of job satisfaction, this study contributes more broadly to our understanding of employee well-being. It also connects the study of occupational health to that on institutions, contributes to the growing literature on the political economy of health, and highlights latent effects of union security agreements.

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

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

The relationships between income inequality, welfare regimes and aggregate health: a systematic review

Background

: When analysing the relationships between income inequality, welfare regimes and aggregate health at the cross-national level, previous primary articles and systematic reviews reach inconsistent conclusions. Contrary to theoretical expectations, equal societies or the Social Democratic welfare regime do not always have the best aggregate health when compared with those of other relatively unequal societies or other welfare regimes. This article will shed light on the controversial subjects with a new decomposition systematic review method. The decomposition systematic review method breaks down an individual empirical article, if necessary, into multiple findings based on an article's use of the following four components: independent variable, dependent variable, method and dataset. This decomposition method extracts 107 findings from the selected 48 articles, demonstrating the dynamics between the four components. 'The age threshold effect' is recognized over which the hypothesized relations between income inequality, welfare regimes and aggregate health reverse. The hypothesis is supported mainly for younger infant and child health indicators, but not for adult health or general health indicators such as life expectancy. Further three threshold effects (income, gender and period) have also been put forward. The negative relationship between income inequality and aggregate health, often termed as the Wilkinson Hypothesis, was not generally observed in all health indicators except for infant and child mortality. The Scandinavian welfare regime reveals worse-than-expected outcomes in all health indicators except infant and child mortality.

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.

Infusing fundamental cause theory with features of Pierre Bourdieu's theory of symbolic power

The theory of fundamental causes is one of the more influential attempts to provide a theoretical infrastructure for the strong associations between indicators of socioeconomic status (education, income, occupation) and health. It maintains that people of higher socioeconomic status have greater access to flexible resources such as money, knowledge, prestige, power, and beneficial social connections that they can use to reduce their risks of morbidity and mortality and minimize the consequences of disease once it occurs. However, several key aspects of the theory remain underspecified, compromising its ability to provide truly compelling explanations for socioeconomic health inequalities. In particular, socioeconomic status is an assembly of indicators that do not necessarily cohere in a straightforward way, the flexible resources that disproportionately accrue to higher status people are not clearly defined, and the distinction between socioeconomic status and resources is ambiguous. I attempt to address these definitional issues by infusing fundamental cause theory with features of a well-known theory of socioeconomic stratification in the sociological literature-Pierre Bourdieu's theory of symbolic power.

Maternal Education, Changing Family Circumstances, and Children's Skill Development in the United States and UK

Among the core dimensions of socioeconomic status, maternal education is the most strongly associated with children's cognitive development, and is a key predictor of other resources within the family that strongly predict children's well-being: economic insecurity, family structure, and maternal depression. Most studies examine these circumstances in isolation of one another and/or at particular points in time, precluding a comprehensive understanding of how the family environment evolves over time and contributes to educational disparities in children's skill development and learning. In addition, very little research examines whether findings observed among children in the United States can be generalized to children of a similar age in other countries. We use latent class analysis and data from two nationally representative birth cohort studies that follow children from birth to age five to examine two questions: 1) how do children's family circumstances evolve throughout early childhood, and 2) to what extent do these trajectories account for the educational gradient in child skill development? Cross-national analysis reveals a good deal of similarity between the U.S. and U.K. in patterns of family life during early childhood, and in the degree to which those patterns contribute to educational inequality in children's skill development.

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.

Self-rated health, generalized trust, and the Affordable Care Act: A US panel study, 2006-2014

Previous research shows that generalized trust, the belief that most people can be trusted, is conducive to people's health. However, only recently have longitudinal studies suggested an additional reciprocal pathway from health back to trust. Drawing on a diverse body of literature that shows how egalitarian social policy contributes to the promotion of generalized trust, we hypothesize that this other 'reverse' pathway could be sensitive to health insurance context. Drawing on nationally representative US panel data from the General Social Survey, we examine whether the Affordable Care Act of 2010 could have had influence on the deteriorating impact of worsening self-rated health (SRH) on generalized trust. Firstly, using two-wave panel data (2008-2010, N = 1403) and employing random effects regression models, we show that a lack of health insurance coverage negatively determines generalized trust in the United States. However, this association is attenuated when additionally controlling for (perceived) income inequality. Secondly, utilizing data from two separate three-wave panel studies from the US General Social Survey (2006-10; N = 1652; 2010-2014; N = 1187), we employ fixed-effects linear regression analyses to control for unobserved heterogeneity from time-invariant factors. We demonstrate that worsening SRH was a stronger predictor for a decrease in generalized trust prior (2006-2010) to the implementation of the Affordable Care Act. Further, the negative effect of fair/poor SRH seen in the 2006-2010 data becomes attenuated in the 2010-2014 panel data. We thus find evidence for a substantial weakening of the previously established negative impact of decreasing SRH on generalized trust, coinciding with the most significant US healthcare reforms in decades. Social policy and healthcare policy implications are discussed.

An Age-Period-Cohort Analysis of Religious Involvement and Adult Self-Rated Health: Results from the USA, 1972-2008

This study conducts an age, period, cohort analysis of how religious involvement affects adult health across the life course and over time in the USA. Cross-classified random-effect models are used to examine data drawn from the General Social Survey, 1972-2008. The research shows clear life course patterns, time trends and birth cohort changes in the religious involvement and health relationship with period effects surpassing cohort effects. For the most part, the results show a loss of advantage in health with age for those who are more involved in religion. Period effects are mainly demonstrated by an overall downward trend of self-rated health (SRH) attributable to religious denominational differences and various levels of social integration. Unlike the period effects, the health disparities associated with religious denominational differences fluctuated when cohort progressed. These findings suggest that in general, the positive effect of religious involvement on SRH decreases with age and periods, but its influence on individual SRH fluctuates by cohort. It is expected that a downward trend in SRH attributable to religious involvement will carry on in future.

Can the welfare state replace parents? Children's cognition in the United States and Great Britain

We compare family and parental effects on child verbal facility, verbal achievement and mathematics achievement in the United States and Great Britain. We study 3,438 5-13 year-old children from the 1994 NLSY Child-Mother Data Set and 1429 same-aged children from the National Child Development Study, also known as the British Child. Multivariate analyses suggest that the processes through which families invest in child cognition are similar across societies, with factors including low birth weight, child health, maternal cognition, family size and children's home environments being consequential. We conclude that parental investments are equally important across the two societies. The more developed welfare state in Great Britain does not notably compensate for parental investments in that society, although it may play a greater role when parental resources are absent or stretched thin.

Socioeconomic background and high school completion: Mediation by health and moderation by national context

This study uses longitudinal data from the Norwegian Health Study linked with registry data (n = 13262) and the U.S. National Longitudinal Survey of Youth 1997 (n = 3604) to examine (1) whether adolescent health mediates the well-established relationship between socioeconomic background and successful high school completion, and (2) whether this mediated pathway of influence varies by national context. Adolescents from lower educated and lower income families reported poorer health, which negatively impacted their likelihood of graduating from high school. The partial mediational effect of adolescent health was stronger in the U.S. than in Norway. These results suggest that policies aimed at preventing high school dropout need to address adolescent health, in addition to the unequal opportunities derived from socioeconomic disadvantage.

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.

The role of income inequality and social policies on income-related health inequalities in Europe

Introduction

The aim of the paper is to examine the role of income inequality and redistribution for income-related health inequalities in Europe. This paper contributes in two ways to the literature on macro determinants of socio-economic inequalities in health. First, it widens the distinctive focus of the research field on welfare state regimes to quantifiable measures such as social policy indicators. Second, looking at income differences completes studies on socio-economic health inequalities, which often analyse health inequalities based on educational differences.

Methods

Using data from the European Values Study (2008/2009), 42 European countries are available for analysis. Country characteristics are derived from SWIID, Eurostat, and ILO and include indicators for income inequality, social policies, and economic performance. The data is analysed by using a two-step hierarchical estimation approach: At the first step—the individual level—the effect of household income on self-assessed health is extracted and introduced as an indicator measuring income-related health inequalities at the second step, the country-level.

Results

Individual-level analyses reveal that income-related health inequalities exist all across Europe. Results from country-level analyses show that higher income inequality is significantly positively related to higher health inequalities while social policies do not show significant relations. Nevertheless, the results show the expected negative association between social policies and health inequalities. Economic performance also has a reducing influence on health inequalities. In all models, income inequality was the dominating explanatory effect for health inequalities.

Conclusions

The analyses indicate that income inequality has more impact on health inequalities than social policies. On the contrary, social policies seemed to matter to all individuals regardless of socio-economic position since it is significantly positively linked to overall population health. Even though social policies are not significantly related to health inequalities, the power of public redistribution to impact health inequalities should not be downplayed. Social policies as a way of public redistribution are a possible instrument to reduce income inequalities which would in turn lead to a reduction in health inequalities.

Different contexts, different effects? Work time and mental health in the United States and Germany

This paper takes a comparative approach to the topic of work time and health, asking whether weekly work hours matter for mental health. We hypothesize that these relationships differ within the United States and Germany, given the more regulated work time environments within Germany and the greater incentives to work long hours in the United States. We further hypothesize that German women will experience greatest penalties to long hours. We use data from the German Socioeconomic Panel and the National Longitudinal Survey of Youth to examine hours effects on mental health score at midlife. The results support our initial hypothesis. In Germany, longer work time is associated with worse mental health, while in the United States, as seen in previous research, the associations are more complex. Our results do not show greater mental health penalties for German women and suggest instead a selection effect into work hours operating by gender.

Inequalities in oral impacts and welfare regimes: analysis of 21 European countries

OBJECTIVE

Very few studies have analysed the relationship between political factors and oral health inequalities, and only one study has compared the magnitude of inequalities in oral health-related quality of life (OHRQoL) across welfare state regimes. This study aimed to compare socioeconomic inequalities in oral impacts on daily life among 21 European countries with different welfare state regimes (Scandinavian, Anglo-Saxon, Bismarckian, Southern, and Eastern).

METHODS

We analysed data from the Eurobarometer 72.3, a survey carried out in 2009 among adults in European countries. Inequalities in oral impacts by education, occupational social class and subjective social status (SSS) were estimated by means of age-standardized prevalence rates, odds ratios (ORs), the relative index of inequality (RII) and the slope index of inequality (SII).

RESULTS

Educational inequalities in the form of social gradients were observed in all welfare regimes. The Scandinavian and Southern welfare regimes also showed gradients for all SEP measures. There were not significant differences in the magnitude of relative inequalities (RII) across welfare state regimes. Absolute educational inequalities were largest in the Anglo-Saxon welfare regime (SII = 17.57; 95% CI: 7.80-27.33) and smallest in the Bismarckian (SII = 3.32; 95% CI: -2.18 to 8.83).

CONCLUSIONS

A significant difference in the magnitude of inequalities across welfare regimes was found for absolute educational inequalities but not for relative inequalities. Welfare state regimes may influence the relationship between knowledge-related resources and oral impacts on daily life.

Understanding the role of welfare state characteristics for health and inequalities - an analytical review

Background

The past decade has witnessed a growing body of research on welfare state characteristics and health inequalities but the picture is, despite this, inconsistent. We aim to review this research by focusing on theoretical and methodological differences between studies that at least in part may lead to these mixed findings.

Methods

Three reviews and relevant bibliographies were manually explored in order to find studies for the review. Related articles were searched for in PubMed, Web of Science and Google Scholar. Database searches were done in PubMed and Web of Science. The search period was restricted to 2005-01-01 to 2013-02-28. Fifty-four studies met the inclusion criteria.

Results

Three main approaches to comparative welfare state research are identified; the Regime approach, the Institutional approach, and the Expenditure approach. The Regime approach is the most common and regardless of the empirical regime theory employed and the amendments made to these, results are diverse and contradictory. When stratifying studies according to other features, not much added clarity is achieved. The Institutional approach shows more consistent results; generous policies and benefits seem to be associated with health in a positive way for all people in a population, not only those who are directly affected or targeted. The Expenditure approach finds that social and health spending is associated with increased levels of health and smaller health inequalities in one way or another but the studies are few in numbers making it somewhat difficult to get coherent results.

Conclusions

Based on earlier reviews and our results we suggest that future research should focus less on welfare regimes and health inequalities and more on a multitude of different types of studies, including larger analyses of social spending and social rights in various policy areas and how these are linked to health in different social strata. But, we also need more detailed evaluation of specific programmes or interventions, as well as more qualitative analyses of the experiences of different types of policies among the people and families that need to draw on the collective resources.

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.

Oral health and welfare state regimes: a cross-national analysis of European countries

Very little is known about the potential relationship between welfare state regimes and oral health. This study assessed the oral health of adults in a range of European countries clustered by welfare regimes according to Ferrera's typology and the complementary Eastern type. We analysed data from Eurobarometer wave 72.3, a cross-sectional survey of 31 European countries carried out in 2009. We evaluated three self-reported oral health outcomes: edentulousness, no functional dentition (<20 natural teeth), and oral impacts on daily living. Age-standardized prevalence rates were estimated for each country and for each welfare state regime. The Scandinavian regime showed lower prevalence rates for all outcomes. For edentulousness and no functional dentition, there were higher prevalence rates in the Eastern regime but no significant differences between Anglo-Saxon, Bismarckian, and Southern regimes. The Southern regime presented a higher prevalence of oral impacts on daily living. Results by country indicated that Sweden had the lowest prevalences for edentulousness and no functional dentition, and Denmark had the lowest prevalence for oral impacts. The results suggest that Scandinavian welfare states, with more redistributive and universal welfare policies, had better population oral health. Future research should provide further insights about the potential mechanisms through which welfare-state regimes would influence oral health.

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.

Children's behavior problems in the United States and Great Britain

We analyze the effects of family capital on child behavior problems in the United States and Great Britain by comparing a longitudinal survey sample of 5- to 13-year-old children from the 1994 National Longitudinal Survey of Youth (N = 3,864) with a similar sample of children from the 1991 National Child Development Study "British Child" (N = 1,430). Findings suggest that in both societies, male children, those with health problems, and those whose mothers are divorced are at increased risk for behavior problems, while those with stronger home environments are at reduced risk. Family structure effects are more pervasive in Great Britain than in the United States, although some of these findings are a function of our racially diverse U.S. sample. We conclude that parents are important in both societies in promoting child social adjustment, and evidence that the more developed welfare state in Great Britain may substitute for capital at home is weak.

Informal politics and inequity of access to health care in Lebanon

INTRODUCTION

Despite the importance of political institutions in shaping the social environment, the causal impact of politics on health care access and inequalities has been understudied. Even when considered, research tends to focus on the effects of formal macro-political institutions such as the welfare state. We investigate how micro-politics and informal institutions affect access to care.

METHODS

This study uses a mixed-methods approach, combining findings from a household survey (n = 1789) and qualitative interviews (n = 310) in Lebanon. Multivariate logistic regression was employed in the analysis of the survey to examine the effect of political activism on access to health care while controlling for age, sex, socioeconomic status, religious commitment and piety.

RESULTS

We note a significantly positive association between political activism and the probability of receiving health aid (p < .001), with an OR of 4.0 when comparing individuals with the highest political activity to those least active in our sample. Interviews with key informants also reveal that, although a form of "universal coverage" exists in Lebanon whereby any citizen is eligible for coverage of hospitalization fees and treatments, in practice, access to health services is used by political parties and politicians as a deliberate strategy to gain and reward political support from individuals and their families.

CONCLUSIONS

Individuals with higher political activism have better access to health services than others. Informal, micro-level political institutions can have an important impact on health care access and utilization, with potentially detrimental effects on the least politically connected. A truly universal health care system that provides access based on medical need rather than political affiliation is needed to help to alleviate growing health disparities in the Lebanese population.

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